Humanising harm: A realist evaluation of restorative responses to adverse events in the Aotearoa New Zealand Health and Disability System
Despite two decades of policy and improvement efforts, the global incidence of adverse events is stubbornly persistent. When harm occurs, elaborate systems respond to identify the cause(s), mitigate reoccurrence, resolve complaints, and even establish culpability. Institutions encourage independent ‘investigations’ that apply profession-specific protocols and methods to achieve their aims. In the complex adaptive health environment, the adversarial character of these responses and the efficacy of the methods applied are increasingly debated. In the aftermath of harm, and through the processes of disclosure, investigation, resolution, and change, the human impacts of the initial event are often inadequately addressed, and the experience of harm is compounded. Restorative approaches are emerging globally to address this gap. Characterised by a focus on relational principles, practices, and goals, a restorative response is guided by addressing harms, responding to needs, restoring trust, and promoting repair. As a novel approach in the Aotearoa New Zealand (NZ) health and disability system, there is tentative evidence for use, and an evidence gap exists regarding how restorative approaches work (or not), for whom and in what contexts.
Using the explanatory power of realist evaluation and the multilevel and multimethod data collection and analysis required, this thesis tests and refines theories in two phases. The focus of examination is: (1) identifying the ways in which compounded harm manifests within the context of the embedded system; (2) how resources associated with the Ministry of Health restorative response to harm from surgical mesh use were introduced into particular contexts, the emotional or cognitive responses triggered in stakeholders, and the outcomes produced; (3) the systemic conditions that facilitate, hinder, or otherwise affect a restorative response; and (4) developing middle-range theory that explains how restorative responses mitigate compounded harm and generate the outcomes stakeholders desire.
The examination surfaced different understandings about how harm emerges and should be responded to and mitigated within the complex health environment. The human experience is influenced by lived and living experience and multiplicity. In the complex adaptive health environment, a restorative response is influenced by interdependent structures, institutional practices, and dynamic conditions. Compounded harm is a complex phenomenon associated with institutional ownership of harm and violations of dignity, mutuality, consent, care, identity and responsibility. When compounded harm is amplified it can extend trauma, distress and even contribute to suicidal ideation. Understanding how colonisation and inequity influence the experience is essential. A restorative response is human-centred and relational and has the potential to generate mutually beneficial outcomes associated with mutual learning, mutual healing, collaboration and restoration. Applying an equity lens to outcome attainment enhances the potential for resolution and reconciliation.
The key contribution of the thesis is the development of eight middle-range theories, which illuminate in which contexts specific mechanisms generate a range of desired outcomes (the dignity, equity, safety, reintegration, apology and complexity theories) or contribute to compounded harm (the violation and trauma theories). Restorative responses are a nascent area of development in health systems, and sharing emerging findings with healthcare stakeholders has informed policy and practice development in NZ and beyond. Based on the assumption that interdependent institutions want to nurture restorative potential in the NZ health and disability system, the theories can guide development and mitigate the risk of compounded harm. In NZ, development should occur within a Tiriti o Waitangi framework in partnership with Māori.
