Jo Wailling is a registered nurse and research associate with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington. Jo presented on restorative practice at the Commission’s mental health and addiction (MHA) quality improvement programme workshop held in Wellington on 26 June for mental health and addiction leaders for the Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project. This blog is a continuation of that presentation.
In his 2002 paper, Don Berwick published 'lessons from a novice', describing how his thinking about health care safety had evolved, stating:
‘I thought the problem is errors, I learnt the problem is harm.
‘I thought: What’s important happens before the injury.
‘I learned: What happens after the injury is equally important.’
Over the last 10 years, researchers and clinicians have increasingly documented harm to health care workers, consumers, families and whānau from several sources, including adverse events, bullying and moral distress from not being able to respond to consumers’ needs in everyday work. In such situations, people want the harm to be acknowledged and repaired, in order to restore their personal wellbeing and their trust in health care providers.
Sadly, the voices of those most harmed by an adverse event are often lost in well intentioned processes that seek to capture, measure and investigate the causes of the event and mitigate the risk of recurrence. Time and again, consumers, families, whānau and health care professionals tell us that an investigative approach does not always meet the needs of all of those directly involved, and in some cases can make things worse.
In New Zealand, stories that suggest it is time to revisit the way we respond to health care harm are evident in academic research, government reports such as He Ara Oranga and the experiences of surgical mesh patients . Berwick also emphasises the importance of learning from stories, concluding: ‘I thought: Reporting is necessary to track problems and progress. I learned: Stories are necessary to gain knowledge.’
In considering how best to respond to health care harm, it is important to remember that safety systems are made up of individuals and communities, as well as rules and processes. In everyday clinical work, safe health care occurs in the sacred relationship between vulnerable consumers and health professionals adapting to complex conditions.
Once we think about safety as a system that has to adapt to people’s needs through trusting relationships, rather than one that seeks to lessen risk and enforce regulation alone, we can consider how best to support the needs of all the people involved, both consumers, family and whānau, and health care professionals.
Restorative approaches are ideal for this purpose. Restorative approaches are underpinned by universal relational values, such as personal freedom, respect, truth, accountability and empowerment, and include ways of expressing these values in emotionally stressful situations.
You may be thinking this all sounds a little bit ‘hippy dippy’, but restorative approaches are already firmly embedded in our criminal justice and education systems and are becoming increasingly common in the workplace.
They have also been shown to be successful in improving safety culture, wellbeing and economic outcomes in a large National Health Service Trust in the United Kingdom.
Restorative approaches are particularly well suited to the Aotearoa context because they resonate with Tikanga Māori approaches. They are also aligned with the recommendation of the Cartwright Report (1988) that the Health and Disability Commission should ‘negotiate and mediate complaints and grievances, heighten health professionals understanding of patients’ rights and refer complaints to a patient advocates and boards with independent oversight.’
In clinical roles, I have successfully applied restorative approaches to promote safety culture and respond to bullying, conflict and other harmful events. The restorative justice team at Victoria University is currently working with the Ministry of Health, using a restorative approach to address the harms created by surgical mesh use (restorativehealth.net ), and we are exploring how we might support a mental health service provider to respond to suicide deaths, conflict and bullying in a restorative way.
Perhaps the increasing interest in restorative approaches reflects a recognition that open disclosure practices that include the apology: ‘We are sorry this happened to you’, do not dignify all those affected by an adverse event. To uphold dignity, we must ensure that everyone impacted feels heard, and listened to, in a way that is meaningful for them. This is the true power of restorative approaches.
Emerging research supports what we have already learned from Te Tiriti o Waitangi – that a model of shared leadership, custodianship and democratic engagement is more likely to be effective in promoting safety and dignity, than one that solely focuses on rules and regulations, or on traditional medicolegal perspectives.
Because restorative approaches promote accountability and collective responsibility, they can support the design of more effective and equitable safety systems, acknowledging that while working in isolation might result in survival, it is only by working together that safety strategies can flourish.
‘Nā tē rourou, nā taku rourou ka ora ai te iwi.
With your food basket and my food basket the people will thrive.’
Restorative approaches aim for a collective understanding, to clarify responsibilities, inform action and heal individuals and relationships. They recognise that including the voices of all those affected by health care harm is more equitable, intending to meet the justice needs an adverse event creates.
Restorative approaches identify three categories of justice needs; substantive, procedural and psychological. The substantive needs are the actual harms to be remedied and procedural needs guide how those involved in an adverse event want to communicate and make decisions to address the harms. In addition, the psychological needs establish how individuals or communities want to be acknowledged, respected and treated throughout the process. Restorative approaches adapt and respond to the adverse event accordingly, ensuring all parties can communicate differences and concerns in a safe and respectful way.
Restorative approaches are more likely to result in a meaningful apology than investigative processes that repeatedly conclude that a formal apology, training and audit are required. Being both reciprocal in nature and responding in a way that meets the needs of all those affected, restorative approaches can inform action and also heal relationships.
For example, following a suicide death, this might mean incorporating everything from individualised psychosocial support for families, whānau and health professionals, to identifying local and systemic changes and who is responsible for making them happen. The collective understanding created from restorative practice would be an ideal approach to deliver the ‘He Ara Oranga’ direction that:
'The Ministries of Justice and Health, with advice from the Health Quality & Safety Commission, and in consultation with families and whānau, review processes for investigating deaths by suicide, including the interface of the coronial process with DHB and Health and Disability Commissioner reviews'.
My parting words must be that restorative approaches are not limited to responding to harm. They can support meaningful consumer and staff participation, supporting democratic decision making in teams and communities in a way that transcends traditional engagement strategies. Interested? Please get in touch email@example.com.
- Berwick, D. (2002). Patient safety: Lessons from a novice. Advances in Neonatal Care, 2 (3), 121-2.
- An adverse event is an event with negative reactions or results that are unintended, unexpected or unplanned (often referred to as ‘incidents’ or ‘reportable events’). In practice this is most often understood as an event that results in harm to a consumer. www.hqsc.govt.nz/our-programmes/adverse-events/projects/adverse-events-reports
- Kaur, M. de Beur, R. Oates, A. Rafferty, J. Dekker, S. (2019). Restorative just culture: A study of the practical and economic effects of implementing restorative justice in an NHS Trust. MATC Web of conferences. 273. https://doi.org/10.1051/matecconf/201927301007.
- https://www.hdc.org.nz/media/2981/guidance-on-open-disclosure-policies-dec-09.pdf; https://www.hqsc.govt.nz/assets/Reportable-Events/Publications/HQS-OpenDisclosure-Feb12.pdf.
- Government Inquiry into Mental Health and Addiction. (2018). He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction, www.mentalhealth.inquiry.govt.nz/inquiry-report, p.20.
Author: Jo Wailing