Journal Club Review Article: 

Banja, J. (2010). The normalization of deviance in healthcare delivery. Business Horizons, 53(2), 139.           

Background

“The failure of health professionals to comply with standards, rules, or regulations is a fundamental cause of such breaches.”

When violations of practice standards are intentional, this can become the norm within a group of professionals or across a unit. This practice can then become normalised and compliance failures become the norm.

Just think to everyday practice, how many incidences does a nurse or doctor complete a task and bend the rules a little to get the job done? The risk is this becomes the norm and a culture of deviations is created. We end up inadvertently downgrading the policies and procedures that were created as the safety net.

Concepts & Discussion

Errors- can be active or latent (e.g. a procedure).

3.1 The rules are stupid and inefficient (pg. 4)

• Justification for breaking the rules, then you are at risk of taking the workforce along with you. Think role modelling here. 
• Nurses are skilled at getting around rules?

3.2 Knowledge is imperfect and uneven (pg. 5)

• Knowing rules, guidelines, why does the guideline exist?
• How many rules or checklists are you expected to know in your daily practice? Infection control is potentially one of the examples where practice differs. This may lead to the missing risk minimisation aspect.

3.3 The work itself, along with new technology, can disrupt work behaviours and rule compliance (pg. 5)

• It can be hard to keep up with technology changes (especially if the investment in training and education has not occurred).
• Changes well known and understood processes, this causes major disruption to the workforce.

3.4 Break the rule for the good of the patient (pg. 5)

• The justification aspect. The example used by Banja is of the health professional removing the tip of the index finger to feel for the vein, this breaks infection and safety prevention rules but is undertaken for a practical solution that helps avoid multiple attempts.

3.5 The rules don’t apply to me/you can trust me (pg. 5)

• Ownership or presuming everyone has best intentions.  Nurses having to hold one another to account. This is the difficult aspect, especially as in a workplace hierarchy and power relationships exist.

3.6 Workers are afraid to speak up (pg. 6)

• The difficulty of speaking up, holding to account, the traditional hierarchies of seniority, nurse to medical, cultural. What deviations do we accept?

3.7 Leadership withholding or diluting findings on system problems (pg. 6)

• Underreporting, pressure of figures and data, the administration of healthcare (an example report of hospital incidents and barriers).

Recommendations

• Need to pick up signals (from incident reporting, audits, feedback).
• Feedback from the workforce. Change from the traditional hierarchy and make a floor up not a top down system.
• Auditing.
• Review and test some common practice – disposing of drug errors, lack of equipment.
• Pay attention to the weak signals (Swiss cheese effect).
• Resist the urge to be optimistic.
• Create an environment and culture to feel safe to speak up.
• No blame culture, it is the system under review.

For The Educator To Consider

Think of your own habits and deviations, we all role model the behaviour in education.

When new rules to practice are introduced, think about the consequences and logistics of this practice change to all levels of staff. 

Take a copy of this article and hold a journal club discussion with your colleagues, see if this occurs in your unit, what others’ views are on this topic. It should hopefully generate some good robust discussion.

Reference

Banja, J. (2010). The normalization of deviance in healthcare delivery. Business Horizons, 53(2), 139.

Big thanks to Timbo for suggesting this article to review.