January 2021, Volume XXXIV, Number 10

cover story One

Restorative Justice

Building relationships in academic medicine

hat are the barriers to my patients accessing care during a pandemic? How can we mentor students better? How do we approach colleagues following a hurtful exchange of words? The standard approach to addressing these questions is that someone, typically an authority figure, forms a task force or committee to discuss and make a decision, often without hearing from those impacted. An authority figure may impose sanctions, separating people, when it is decided that harm occurred. Processes and approaches based in restorative justice principles provide an alternative to sanctioning and separation. Restorative approaches build communication and relationships and allow the proactive building of culture, reparation of harm, or the reintegration of a person who has been separated from a community or group.

If the goal of academic medicine is to heal, whether by discovery of new knowledge, caring for those with illnesses, teaching the next generation of healers, or providing accessible and equitable care for Minnesota communities, can academic medicine improve its ability to heal by incorporating restorative practices into the work? This is the question posed by the Association of American Medical Colleges (AAMC) who selected the University of Minnesota Medical School as one of seven colleges of medicine across the country to train a cohort of faculty and staff members in restorative justice approaches.

Restorative practices can be used to improve culture.

What is the history of restorative practices and restorative justice?

Restorative approaches are not new. They are deeply rooted in many Indigenous cultures, including the Ojibwe and Navajo people of North America and the Maori people of New Zealand. The term “restorative justice” emerged in the 1970s in the United States criminal justice system as a way to bring victims and those causing harm together to repair harm and rebuild relationships. Eventually, the restorative justice processes involved others impacted by the trauma or event, including families, friends, and the community. Restorative justice then expanded into other realms, particularly education, to address discipline issues and reintegrate students sanctioned by suspension back into school. Restorative practices are trauma-informed and can break the cycle of harm, separation, distrust, and more harm.

 Not all harmful situations are appropriate for a restorative approach. If someone does not acknowledge they committed a harm, refuses to participate in a restorative practice, or if potential participants in a circle wish to dispute a sanction and debate the facts of an incident, restorative practices are not appropriate. A restorative practice does not obviate the need for a sanctioning process and, in fact, could be used in conjunction with sanctioning.

What is actually involved in doing a restorative circle?

Many may be familiar with circle processes. Restorative circles are good for addressing issues of culture, including examining the accessibility of a clinic or exploring how to build a better mentoring program. For a restorative justice circle, there is extensive planning ahead of time. The facilitators thoroughly prepare by interviewing the participants beforehand, planning out ways for participants to connect and talk about the impacts, proposing how to build trust and community, and finally, proposing some actions for participants in the circle.

Once the circle is formed and agreements around the conduct of the circle are established, the facilitators ask a series of questions that each participant answers in turn and uninterrupted. When meeting in person, a circle would involve a talking piece, an object of significance to the group or facilitators that is passed between participants and held by those speaking. A talking piece promotes respect and equity of voice. On remote platforms, the facilitators establish a way of designating whose turn it is to speak.

Participants are encouraged to listen deeply and tell their own stories. Circles are built on a foundation of respect, integrity, fairness, and confidentiality. A concept that resonated with me is that participants should “take the learning, not the stories.” Rounds of questions eventually lead to the understanding of themes and then action items, if desired. Sometimes, circles are designed for exploring the understanding and impact of an external event and not to determine action items.

Why did the University of Minnesota Medical School do this pilot program?

Excellence in all mission areas of the U of M Medical School is based on integrity, inclusion, and teams being able to work effectively together and with communities. The focus of restorative practices is to build relationships with each other as participants, repair relationships that may have been damaged, and promote healing if relationships were harmed or build community. Restorative practices can be used to improve culture, repair harm around a specific event or action, and reintegrate a person who has been separated from their work or learning environment. The goal of the U of M Medical School’s participation for the pilot program was to explore how restorative practices could be used to improve culture across all mission areas.

Four faculty members, across the research, education, and clinical missions, and two staff members from education and human resources completed training from the AAMC in December of 2020. The group who went through the training continues to meet monthly to plan where and when restorative circles can be incorporated into the work of the U of M Medical School.

The early experiences in the conduct of circles are revelatory. A patient-experience-focused circle yielded a completely different understanding of what we “know” or what we expected. The participants and facilitators truly appreciated the stories, the insights into the perspectives of others, and the co-creation of new ideas to address the purpose of the circle.

Experiences in the conduct of circles are revelatory.

I helped facilitate a circle focused on mentoring with another participating university in the AAMC training program. The circle consisted of an administrator, faculty members, and students. After meeting for one hour, the circle proposed an action plan of individual and organizational recommendations to improve mentoring at the institution. The participants went from nervous, anxious, and curious to motivated, excited, and grateful. The participants gained a better understanding of what faculty members and students experienced as mentees and, now, as mentors. They discussed ideals and what they wanted the future to look like. They talked about barriers and obstacles. They reached a common understanding they otherwise would never have obtained. That common understanding allowed them to quickly envision changes to improve the mentoring culture.

Circles can also address specific issues of harm. People sometimes communicate things in the heat of the moment that they regret. There is the accidental reply all email, the all caps email, or the hurtful social media post where colleagues who are friends may see and feel hurt by a post. These are not infrequent events. Often the incident is buried, where it causes divisiveness, fuels factions, and perpetuates bad feelings. If the incident falls under human resources purview, a person may get “written up” or reprimanded for the behavior and threatened with sanctions.

Restorative justice provides an alternative to burying the incident. With careful preparation and facilitation, the victim can explain the impact of the comment. The person who said it can provide context for saying it, express regret and a desire to repair the damaged relationship. The victim can explain what it would look like to repair the harm. Of significance, the bystanders- those who witnessed the event, those who heard about it later, those who spread word of the incident - also get to tell their stories, describing the impact of the incident on them. People in support of the victim and for the person who caused harm can be engaged to help in rebuilding trust and in preventing future incidents. An understanding can be reached and actions agreed to, if appropriate for the situation.

Restorative justice in academic medicine can also involve reintegration of members who are separated from the school. Separation, whether due to leave, illness, or disciplinary action, can harm multiple groups of people within the separated person’s work community. The U of M Medical School hopes to one day be able to work with those separated from work to smooth re-entry.

In summary, restorative justice, practices, and approaches are not new. They will sound and feel familiar to many. Restorative practices differ from many processes currently used to address harm in that they focus on rebuilding relationships and healing instead of punitive approaches that separate people and do not build trust and community. Restorative practices are not for every situation though. The use of restorative practices in academic medicine is a valuable way to improve culture, repair harm, and reintegrate those members of the community who have been separated. Restorative practices are one way academic medicine can improve discovery, teaching, and the provision of care to better heal all those we serve.

Amanda M. Termuhlen, MD is a Professor of Pediatrics and the Associate Dean for Faculty Affairs at the University of Minnesota Medical School. Dr. Termuhlen is also a pediatric hematologist/oncologist with University of Minnesota Physicians. 

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