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Restorative Just Culture in Practice
Implementation and Evaluation
Sidney Dekker, Amanda Oates, Joseph Rafferty, Sidney Dekker, Amanda Oates, Joseph Rafferty
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eBook - ePub
Restorative Just Culture in Practice
Implementation and Evaluation
Sidney Dekker, Amanda Oates, Joseph Rafferty, Sidney Dekker, Amanda Oates, Joseph Rafferty
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About This Book
A restorative just culture has become a core aspiration for many organizations in healthcare and elsewhere. Whereas 'just culture' is the topic of some residual conceptual debate (e.g. retributive policies organized around rules, violations and consequences are 'sold' as just culture), the evidence base on, and business case for, restorative practice has been growing and is generating increasing, global interest. In the wake of an incident, restorative practices ask who are impacted, what their needs are and whose obligation it is to meet those needs. Restorative practices aim to involve participants from the entire community in the resolution and repair of harms.
This book offers organization leaders and stakeholders a practical guide to the experiences of implementing
and evaluating restorative practices and creating a sustainable just, restorative culture. It contains the perspectives from leaders, theoreticians regulators, employees and patient representatives. To the best of our knowledge, there is no book on the market today that can function as a guide for the implementation and evaluation of a just and learning culture and restorative practices. This book is intended to fill this gap. This book will provide, among other topics, an overview of restorative just culture principles and practices; a balanced treatment of the various implementations and evaluations of just culture and restorative processes; a guide for leaders about what to stop, start, increase and decrease in their own organizations; and an attentive to philosophical and historical traditions and assumptions that underlie just culture and restorative approaches.
The interest in 'just culture', not just in healthcare but also in other fields of safety-critical practice, has been steadily growing over the past decade. It is a trending area. In this, it has become clear that 20-year-old retributive models not only hinder the acceleration of performance and organizational improvement but have also in some cases become a blunt HR instrument, an expression of power over justice and a way to stifle honesty, reporting and learning. What is new in this, then, is the restorative angle on just culture, as it has been developed over the last few years and now is practised and applied to HR, suicide prevention, healthcareimprovement, regulatory innovations and other areas.
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Information
Chapter 1 Introduction to Restorative Just Culture
Sidney Dekker
DOI: 10.4324/9781003162582-1
Contents
The Retributive Dead End
Restorative Just Culture as a Strong Alternative
A History of Restorative Justice
The Goals of Restoration
Moral Engagement
The Many Sides of an Incident
Emotional Healing
Reintegrating the Practitioner
Organizational Learning
Into Practice
References
A just culture is a culture of trust, learning and accountability. The primary purpose of a just culture, to most people, is to respond appropriately to incidents. Their idea is that a just culture should not only enable you and your organization to learn from failure but also hold your people âaccountableâ for undesirable performance. This chapter and this book show that a just and learning culture, or a restorative just culture, is actually so much more than that. Restorative practices that build toward a just and learning culture enable people in an organization to become more involved, to speak up and to become part of the solution â independent of untoward things happening or not.
The Retributive Dead End
Most of the guidance available on just culture today â and the typical model adopted by many organizations â considers justice in retributive terms (see Dekker, 2016). It asks questions such as:
- What rule was broken?
- Who is responsible?
- How bad is the violation (honest mistake, at-risk or reckless behavior) and so what should the consequences be?
Such a âjust cultureâ is organized around shades of retribution. It focuses on the supposed âoffenderâ and asks what they have done and what they deserve. But many managers have found that simplistic guidance about pigeonholing human acts does not take them very far: how do you fairly judge, for instance, how âbadâ a supposed violation was? There will almost always be a lack of clarity, agreement or perceived fairness about who draws the line between the acceptable and the unacceptable behavior. Does this person who draws the line actually know the nuances and messy details of the practitionerâs work? If not, how can they really know what constitutes risk or risk-taking in that world? And of course, hindsight and outcome biases have been shown to have a considerable influence on how people judge the actions leading up to an outcome (LaBine & LaBine, 1996).
Knowledge, power and justice get easily muddled in this. Research shows that the more powerful people in an organizational hierarchy typically consider their organizationâs culture to be more âjustâ (von Thaden, Hoppes, Yongjuan, Johnson, & Schriver, 2006). Also, there is not always a well-developed process for appealing a decision that is made on the basis of a âjust cultureâ policy. Being âjust culturedâ is known by some employees as a good way to get yourself fired, demoted or suspended. It is probably not surprising that there is actually no convincing evidence that organizations with a retributive just culture have higher reporting rates or that they learn more of value after an incident. They may in fact create cultures of ârisk secrecyâ, of hiding evidence of wrongs and harms, of pushing blame around.
Restorative Just Culture as a Strong Alternative
A restorative just culture presents a strong and viable alternative. The principles of restorative justice are these:
- An event causes harm, and the response to that event should aim to repair that harm. This includes taking responsibility for the harm and making amends for it.
- The people most involved in, and affected by, the harm should all be able to participate in designing and deciding the restoration needed.
- The result often includes restoration of trust and a transformation of relationships between stakeholders and reintegrates participants into the community of practice.
What this means in practice is that a restorative response is organized around three very different questions (as compared to a retributive response):
- Who is impacted?
- What do they need?
- Whose obligation is it to meet those needs?
Identifying and meeting obligations is ultimately about putting right what went wrong. It is about making amends. In restorative practices, this means promoting reparation and healing for all affected by the incident. This notion of reparation, of restitution or âpaying backâ, is central to retributive justice too, of course. In restorative practices, however, everything possible is done to reintegrate the practitioner into the community, and the âpaymentâ typically gets made in a different currency. Restorative practices ask you to:
- Address the harm done to first and second victims of the incident, as well as the surrounding community.
- Address the systemic issues that helped produce the incident by asking what was responsible for it, so that other practitioners and first victims are less likely to end up in a similar situation.
For restorative practices to be meaningful and seen as just by all involved, you have to be collaborative and inclusive. Effective restoration relies on this engagement. An incident can affect many people, and its aftermath typically has many stakeholders. These might be given access to, and information about, each other. All can then be involved in deciding what justice requires in their case. This may mean an actual dialogue between parties (e.g. first and second victim) to share their accounts and arrive at an agreement on what should be done. How might the creation of restorative justice look in your organization? It will likely involve the following steps and people:
- Encounters between stakeholders. The first one is likely to be between your organization and the practitioner(s) involved in the incident. Remember your organizationâs obligations above!
- An encounter between the first and the second victim, appropriately guided, may follow. Surrogates or representatives may need to be used in some situations.
- Encouraging all stakeholders to give their accounts, ask questions, express feelings and work toward a mutually acceptable solution.
- Acknowledge the harm, restore the balance and address your future intentions.
Restorative justice has the possibility to deal effectively with both the consequences and the causes of an event. Rather than just pursuing the narrow and limited âlegalâ facts that would be necessary to secure, for example, dismissal, restorative justice facilitates a dialogue that helps identify many sides of the event. It seeks to lay out, for and with help of all participants, the complexity and diversity of an incident. This begins to display the complex causal web beneath it and can let participants in on a diversity of leverage points to make changes. It does this by:
- Getting people from the community of practice involved. These are most likely the people who understand intimately the messy details of how work is done and how success and failure are created locally. Without a deeper understanding of how success is normally assured, and how a negative event could come about, there is neither a good chance of a fair response to it nor a good chance of finding entry points for change and improvement.
- Engaging in forward-looking accountability. Forward-looking accountability deals with causes and consequences because it directs accountabilities toward prevention. It holds people accountable not by fixing blame for something past. Rather, people collaboratively fix future responsibilities for things they need to accomplish in and for the community.
And, as said in the introductory paragraph, there is more to a restorative just culture than how you respond to incidents. The best post-event processes in the world, after all, cannot do much if there is no prior relationship of confidence and trust between the people in an organization who need to figure out what to do next. Restorative practices, and how they touch everything from peopleâs interactions to human resources to processes and procedures, are made to help an organization build that confidence and that trust.
A restorative just culture doesnât mean that it is a culture without rules. But because a restorative just culture so consciously invests in the engagement and enabling of people, it generates a number of advantages that can bring work-as-imagined (as it is in all the rules) and work-as-done (as it is in actual practice) much closer together (Hollnagel, 2012):
- Involvement of those who will have to do the work enhances the legitimacy of the rules that apply to peopleâs work.
- Taking part in the process of developing the rules increases the sense of ownership the workers feel toward the rules. The rules derive from their own insights, arguments and experiences.
- Developing the rules in connection with the workers ensures that the rules are connected with reality. The standards are not designed for an ideal environment, imagined without time pressures, complicating factors and conflicting information. Instead, the written rules (and practices taught by educators) align with and support normal practice in the field.
The two forms of just culture (retributive versus restorative) also approach trust differently. Retribution builds trust by reinforcing rules and the authority of certain parties or persons to patrol and enforce them. It says that where people work to get things done, there are lines that should not be crossed. And if they are, there are consequences. Think about it like this: if you find that people âget awayâ with breaking rules or doing sloppy work, you donât have much trust in the system or in your communityâs ability to demand accountability. Your trust can be restored if you see an appropriate and assertive response to such behavior. You can once again rest assured that the system, or your community, does not accept such behavior and responds in ways that make that clear â to everyone.
Restoration, on the other hand, builds trust by repairing fiduciary relationships. Fiduciary relationships are relationships of trust between people who depend on each other to make something work. Consider the work done in your own organization. People in your organization depend on each other. Every day, perhaps every minute, they have to trust each other that certain things get done, and get done timely, appropriately, safely. They might not do these things themselves because they are not in the right place, or because they lack the expertise or authority to do them. So they depend on others. This creates a fiduciary relationship: a relationship of trust. It is this relationship that is hurt or broken when things go wrong. And it is this relationship that needs restoring (Table 1.1).