When adverse events happen, the first question often asked is “who is to blame?” Many workplaces are governed by a retributive system, which seeks sanctions or punishment for the person who has allegedly caused harm.
However, some health care trusts in the UK are looking at the way they deal with work issues and implementing a paradigm shift in their culture and disciplinary procedures. The Nursing and Midwifery Council is also interested in this approach, and started its journey with this thinking back in 2018 with a commitment to a culture of openness and learning.
A just restorative culture is a learning approach to dealing with adverse events, which focuses on harm done rather than blame. The approach recognises that people make mistakes, while ensuring people are held accountable for their decisions. It aims to repair trust and relationships damaged after an incident. It allows all parties to discuss how they have been affected and collaboratively decide what should be done to repair the harm.
The widely used retributive approach aims to find out who did something wrong and how to deal with them. This neglects to look deeper into processes and learn lessons for the future, leaving organisational issues unaddressed. This approach doesn’t just inflict a sanction on the person, the process itself has a huge potential to cause harm whether the person ends up with a sanction or not.
The process leading to harm
From the moment a complaint is raised, there is the potential for harm. This could be the period of suspension a member of staff is put on while the complaint is investigated, which would isolate them from their colleagues. It can affect the person’s confidence, self-esteem, mental health, family life and relationships, to name a few.
A just restorative culture introduces the idea of multiple potential harmed parties.
Often people who have been disciplined go off sick because they can't cope with the strain of it
Importantly, this culture gives some support to the member of staff, recognising that it can be traumatic for a professional to make a mistake that leads to harm.
A restorative approach is also a powerful way to hold people to account, identifying and repairing the harm done. It encourages people to take responsibility for their actions, but by no means excuses poor behaviour or offers a get-out-of-jail-free card.
A gentler approach
While members await disciplinary hearings or capability hearings, they can often endure a fairly long period of suspension. This can be an intensely stressful and disorientating time for the member, Giles Jones, an RCN Officer for the South West Region, says.
Giles, who has been involved in helping implement a just restorative culture at Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust, says: “Often people who have been disciplined go off sick because they can't cope with the strain of it. Even if the result is that there's no case to answer, the harm has already happened the moment they're accused of something.”
Change the conversation from apportioning blame to supporting staff
Giles gives an extreme example of the harm caused: a nurse who was demoted following a suspension. Their mental health began to deteriorate rapidly, and they started drinking heavily. They were eventually admitted to the hospital with severe liver damage and died in the same ICU that they were suspended and demoted from a year previously.
“A just restorative culture is far less abrasive for members who find themselves in a disciplinary process. It’s a gentler approach and very seldom does it result in a suspension,” he explains.
Emma Hallam, a nurse at North Bristol Trust, safety rep and steward, has first-hand experience of a just restorative culture being implemented in the workplace. “If you look at any disciplinary process or policy of any organisation, it can be very exposing. However, if you get together in a room and start discussing how and why the event happened, and how to stop it happening again, it becomes a real discussion rather than feeling like the accused person is in a courtroom,” she says.
Successful implementation
The Cornwall Partnership NHS Foundation Trust started implementing a just restorative culture in 2019. This was used as a case study in a session at the RCN UK Joint Representatives autumn conference 2021.
At its worst point, the trust saw 24 suspensions in a year, and as of October 2021, there were no suspensions in progress. In 2018, the trust had 21 dismissals in one year, and in 2020, there were no dismissals.
At the time of the conference, there had been only one investigation this year, whereas the trust averaged around six per year previously.
Amanda Oates, Executive Director of Workforce at Mersey Care NHS Foundation Trust, with help from local reps, began implementing a just restorative culture in 2016. The trust fundamentally changed the way it responded to incidents, patient harm, and complaints against staff. After seeing the benefits in their own organisation, the trust partnered with Northumbria University to create a just restorative learning training package for other organisations to follow.
The trust has seen suspensions reduce by 95% and disciplinary investigations reduce by 85% since 2014. It has also seen an increase in the reporting of adverse events, as well as the number of staff who’ve sought support and those who’ve felt able to raise concerns about safety and unacceptable behaviour.
Amanda explains that at Mersey Care, there is a four-step framework used to review an incident or event and says a vital part of changing the culture is being more mindful of the language used. “Semantics change the conversation from apportioning blame to supporting staff in a restorative way. So rather than say ‘mistake’, for example, you could say ‘didn’t go as expected’. We have to be very mindful that we don't fall into our own biases and prejudice when we look at an incident,” she says.
Advice for reps
Emma has some advice for reps who are involved in helping to implement this new culture. “Be open-minded about it. Listen to what's being suggested,” she says. “Also, build relationships with your colleagues, be collaborative and have more honest, empathetic discussions.”
Once a rep understands just restorative culture, they will find that opportunities for spreading the word are endless
Amanda also has some guidance. “It's a long journey. And it's an incremental one. Sometimes you take two steps forward and one step back. It’s an evolution and it's got to organically grow within the organisation,” she explains.
How to suggest culture change where you work
There is an informal but important role for reps to play in widening the adoption of just restorative principles in the workplace either in the NHS or the independent sector.
For instance, if a rep is involved in a disciplinary process that leads to no further action or a trivial sanction, they can tell the panel how a change of focus from blame to harm would have avoided the expense and trauma of subjecting their member to the process.
They can also use the joint consultative process to raise the issue whenever policies are reviewed, or recruitment and retention are on the agenda. Giles says: “It never hurts to mention that in all the trusts where just restorative principle has been applied there has been a marked saving of expense, employment litigation and staff turnover. In fact, once a rep understands just restorative culture, they will find that opportunities for spreading the word are endless.”
Changing and reframing language in a just restorative culture
- “Why did you do that?” Change to: “Can you help me understand what happened?”
- “You didn’t follow x procedure or protocol.” Change to: “I am aware that there is a policy about this, let me share it with you. Can we discuss what it means in practice?”
- “Why didn’t you follow the procedure?” Change to: “Is this procedure followed at all?”
- “Who is responsible?” Change to: “Who has been harmed?”
- “How do we punish this person?” Change to: “How do we restore this person’s confidence and reputation with their colleagues?”
