Responses to themed questions raised during 14 September 2021 webinar to launch ‘Pou hirihiri, Pou o te aroha | Healing...

Some questions were raised at the during 14 September 2021 webinar to launch 'Pou o te aroha | Healing and learning from harm' video but there was not enough time to answer them all. We have now provided responses to those questions.

Theme 1: Health care areas in which restorative practice and/or hohou te rongo can be used

Example question: Do you think this approach could be used in primary care?

Restorative practice and/or hohou te rongo can be used in any health care setting. Both are distinguished by an emphasis on relational principles, values, and goals. Mana enhancing relationships are integral to developing a safety climate in any health care environment and are essential for:

• effective leadership, communications and teamwork
• provision of care and compassion to patients, whānau and colleagues
• constructive resolution of interpersonal conflicts and workplace disputes
• responding positively to complaints and adverse events
• constructive disciplinary procedures and professional learning
• restoration of relationships between patients, whānau and colleagues.

Restorative approaches are most effective when they are part of a larger commitment to becoming a restorative workplace or restorative organisation rather than being a one-off intervention when all else fails. In kaupapa Māori settings, hohou te rongo enhances the existing use of kawa and tikanga.

Theme 2: Barriers to and enablers for a restorative approach

Example question: What are the main barriers within health care systems to the use of restorative practice?

• Collaboration: A national collaborative has developed appropriate resources and is building capability within the health and disability sector. Membership includes consumers, clinicians, Crown entities and kaumātua and kuia. The collaborative is co-designing several initiatives that share funding and resources, such as the film, training and district health board pilots.
  
  
• A just culture: It is widely accepted by safety scientists that most adverse events result from complex interactions between people and their environment. A just culture ensures people feel safe to speak openly about an incident without fear of shame, retributive action or blame.  A just culture should balance learning, healing and accountability.
  
  
• Bias and racism: In Aotearoa New Zealand, our history of colonisation and assimilation have embedded bias and racism that are central to the inequities in health care experienced by Māori, Pacific peoples and other minority populations. This is a key risk to the wellbeing of patients, whānau and the workforce. Restorative practice and hohou te rongo are regularly operating cross-culturally and restorative approaches can be frustrated by being unconscious about biases and racism in those interactions.
  
  
• Trust: For consumers, whanau and clinicians to be open to attending a restorative circle/meeting, they need to have trust in the process and the facilitators. To help foster this trust, having skilled, independent facilitation is essential. For clinicians, having independent facilitators might mean they are more willing to participate; for consumers, knowing that the process and facilitator are completely independent from where the harm has occurred may help them feel more reassured of the process.

Theme 3: Honouring Te Tiriti o Waitangi

Example question: How might we support our Te Tiriti partner to lead the kaupapa of hohou te rongo in our business as usual and resolve conflict at its earliest point?

Health care leaders and providers have been challenged to demonstrate their commitment to an authentic Te Tiriti partnership and accelerating equity for Māori. Te Tiriti o Waitangi provides for a special relationship with tangata whenua that includes the restoration of harm for Māori in health care settings.

Inviting our marae, hapū and iwi to partner with us to integrate hohou te rongo into business as usual requires that we support an authentic Te Tiriti partnership:

• Article 1: There is meaningful Māori representation and a prioritisation of kaitiakitanga led by Māori at all levels.
• Article 2: We support tino rangatiratanga within the health system by actively supporting kaupapa Māori partners, applying hohou te rongo in our quality and safety systems and also recognising that Māori control and authority are critical to success.
• Article 3: There is intentional systematic action to accelerate equity in the Māori patient experience health.

Theme 4: Minimising harm during the course of the investigation

Example question: Did your research include what follow-up, if any, occurred or would be useful, following the relational restorative hui?

Our research identified critical success factors that can reduce the risk of harm from the process. All these factors are established in sectors that use restorative approaches.

• Voluntary, active participation – no one can be forced into a restorative process. It must be safe for all the people involved: the consumer, health professionals and the facilitator. All those involved must be adequately prepared and consent to proceed. Confidentiality rules must be agreed at the outset and independent facilitators used. If any party does not want to participate, a restorative process is still possible if the needs of individuals and whānau can be met.
  
  
• Emotional support – offering tailored support before, during and after a restorative process is important. While many people said in the research they did not need to access formal psychosocial support, a small number of people did want specialist services or had complex needs.

  Consumers wanted access to:

  • emotional support from whānau and/or the facilitator before and during the process
  • support from community groups or other survivors
  • a navigator who can help meet their individual substantive needs
  • the option of formal psychosocial support.

The other parties wanted access to:

• • professional supervision or peer support
  • the option of formal psychosocial support.
    
    
• Co-design the outcomes – in a restorative process, the appropriate response to the harm should be co-designed by all the affected parties, as far as reasonably possible. The co-design process includes the investigation response and the actions for repair and prevention. Individuals may have different needs, but restorative practices allow for diverse options and outcomes to be explored, for example, how and to whom people want to share their experiences of a harmful event. Our research found that this can assist the restoration of trust and relationships and contribute towards a meaningful apology, if you deliver on the actions you commit to and continue to communicate with the people involved. 
  
  
• A wellbeing approach, not a health approach – restoration is a relational process, therefore transcends health care. Just as harm is not confined to clinical harm, so to restoration. Particularly for Māori, the inclusion of tikanga processes can send an important message that we understand restoration is not confined to health care practice.

Theme 5: Working in a complex system

Example question: What would you suggest as to how we can engage in a restorative process in a complex situation that involves many people, such as the exposure to anti-seizure medicines during pregnancy?

We know from the Ministry of Health project on a restorative approach to surgical mesh harm, and the subsequent evaluation, that:

• a restorative approach has the potential to meet the procedural and psychological needs of all those affected (consumers, clinicians and health care professionals) in ways that current approaches do not and should be offered alongside existing regulation and policy
• healing and learning from systemic or institutional harm requires a collaborative and multi-agency response. A restorative approach can support all the affected parties to co-design an inquiry, which in turn can heal relationships and trust. Use of a facilitator who is multi-partial is important to maintain the focus on relational values and principles.

The Health Quality & Safety Commission has established a national quality forum where the example mentioned above can be discussed with key agencies. Support of restorative approaches will be enabled through changes to the National Adverse Event Reporting Policy (currently under review). A national collaborative for restorative initiatives in health care meets monthly and is working with the agencies, communities, clinicians and consumers to develop a collective strategy. A hui hosted by the Centre for Restorative Justice will explore what relational responses might look like alongside regulation and the roles and responsibilities of all the agencies and people involved.

Theme 6: Access to skilled facilitators

Example questions: How can people access facilitation training? How would whānau access this service?

Restorative practice and hohou te rongo are emerging approaches in the health sector. The Centre for Restorative Justice is currently developing micro-credentialed courses through a co-design approach with the national collaborative, and the Commission is focused on increasing capability across the health sector over the next three years. As capability grows, the vision is that the approaches will become more widely available and embedded alongside existing regulatory approaches. Until then, consumers can still request a restorative or kaupapa Māori approach to a complaint or adverse event. Providers can access skilled facilitators and/or advice from their iwi (hohou te rongo) or the Centre for Restorative Justice (restorative practice) directly by emailing: RestorativeHealth@vuw.ac.nz.

Whānau who would like to access a kaupapa Māori approach following an adverse event should ask health providers to involve their Māori health directorate, local iwi or cultural advisor if this is not offered to them.

Theme 7: Timing

Example question: Is there a timeframe within which this methodology can be applied?

Approaching an adverse event in a relational way from the outset is essential. Restorative responses invite ‘listening to understand’ the justice needs of all those involved in a holistic, caring way. These needs can change over time, as shock, grief, trauma, moral distress and shame run their course. It is important to revisit these needs regularly, especially during long investigations or when legal processes are also occurring. The timeframe for bringing people together will be determined by the people involved and can occur alongside other forms of investigation.