Normalization Of Deviance

Can We Passively Accept Doing The Wrong Thing?

Countless serious medical errors can occur everyday in practice despite knowing that what we are doing is wrong. Egregious errors, committed by even careful and committed professionals, may be habitual, normalized over time, and dangerous. Hospital risk management departments have embedded the belief that medical errors and mistakes are the result of a single individual doing something inconceivably stupid. However, major disasters and patient care catastophies actually require multiple people committing repeated errors which finally result in serious harm or frank catastrophe. The blueprint for harms of great magnitude requires that certain lapses, errors, and mistakes go unnoticed, unattended or unresolved for prolonged periods of time.1

What begin as deviations from standard practice or procedure become, after enough repetition, a normalized pattern of practice. These deviations can persist for years. However, institutional deviance is almost never done with criminal or malicious intent. In time, individuals become lulled into accepting the deviant practice, forgetting what they had once been taught . Complacency sets in. 2

Normalization of Deviance is a term that originated following the Shuttle Challenger disaster in 1986. Following the investigation a sociologist, Diane Vaughan, described the process as "people within the organization become so accustomed to a deviation that they don't consider it as deviant, despite the fact that they far exceed their own rules for elementary safety". 3

For twenty years, prior to the Space Shuttle Columbia tragedy, insulation debris shedding, that eventually doomed the last flight, had occurred without issues or problems on each and every previous flight. For twenty years, and the knowledge of countless technicians and engineers. Because this shedding, which could affect vulnerable areas of the shuttle, had become familiar to the flight engineers and associated specialists, this attitude evolved: "If this debris hasn't caused an accident, yet, it probably never will".4 They knew it was a problem, and it shouldn't occur, but it had become normalized.

In a hospital clinical environment, variations from recommended practice and acceptable behavior also become normalized; individuals become accustomed to altered versions of practice as normal, even though they were taught a different way to accomplish the task. It is human nature to take shortcuts or ignore boring steps involved in performing a task the right way. When there are no negative consequences, the deviation is reinforced. The next time a person performs the task, it becomes easier to accept the shortcut. Over time it no longer seems like a shortcut, and becomes the normal way to perform. Although this problem can occur in any industry, deviations from proper procedure have a significant impact on health care safety. 5

Rule violations continue to be normalized if individuals who witness them fail (or refuse) to intervene. Studies have shown that participants found it impossible to confront their colleagues. Fear of retaliation, inability to confront, belief that "it's not my job", and absent confidence that speaking up would do any good, were the major reasons for not confronting deviant behaviors. The study reported that "people don't want to make others angry or disrupt their working relationship, so they rely on others and never get back to the person". Findings of system flaws and weaknesses are frequently altered and diluted as the information ascends the chain of command (Gerstein, 2008; Vaughan, 1999).6

In these situations it is unsettling to discover that an administrator might convince herself that correcting an employee's practice deviations can be more trouble than whatever future disasters might result from those deviations. Disasters are discounted as improbable. Unfortunately, humans can be irrationally optimistic about avoiding adverse events. People tend to approach deviance by comparing their estimation of the work required to eliminate the deviance with the chances that an adverse event will actually occur. If the chances for disaster are perceived to be low, motivation to eliminate the problem is also low. Unfortunately, only a true culture of safety that openly suppports identification of shortcuts, work arounds, errors and near misses will eliminate normalization of deviance.7

Some examples of normalization of deviance in Obstetrics may include the following:

1) Vital signs in delivering women ("She has a higher heart rate because she is pregnant, no reason for worry") Extra steps to investigate the tachycardia are dismissed. The provider may know this is a dumb thing to say, but how many times will she repeat it - to herself and others?8

2) Setting alarm parameters "just a bit higher" than normal to avoid repeated trips to the patient's room to investigate or evaluate.9

3) Neglecting to find and review prenatal records on a patient's admission. Failing to perform necessary assessments and passing over important information in a patient's history. Relying on RN history and not performing your own.

4) You have inserted countless IUDs over time. You stop assessing the position of, and sounding, the uterus because you've never had a uterine perforation.

5) Ignoring a persistent Category II EFM tracing because you have rounds to make, or documentation to complete. Investigating the cause is time consuming. ACOG says it's indeterminate, so you can blow it off for a while. You will tell the nurse to call you and wait to see if it gets worse.

6) A provider becomes annoyed, and even insulting, when asked by a nurse to clarify orders that he has written down. Rather than ask him, the nurse will consult with other nurses and they, collectively, decide to decipher his scrawl. This example illustrates multiple deviations: bad handwriting that goes unaddressed, resulting in orders the nurses "guess" are correct, and someday may result in a disaster.10

7) Mis-use of oxytocin is another example of NoD. Standards of practice regarding the administration of this agent for provider convenience are often ignored. "A potentially dangerous drug is administered to hasten the completion of a physiologic process that would, if left to its own devices, usually complete itself without incurring the risk of drug administration".

In obstetrics, oxytocin administration is encouraged by the ability of many fetuses to tolerate hyperstimulation without becoming seriously hypoxic or acidotic. When a provider recalls that she has never had a problem with a particular oxytocin administration, this is hardly reassuring in light of "large-scale outcomes-based evidence or basic physiologic considerations to the contrary".11

8) From the perspective of staff nursing on labor and delivery, NoD may lead to distorted staffing ratios for women receiving oxytocin, e.g. assigning one nurse to care for two women being induced with it. A situation that is common but clearly inappropriate and unsafe.12

Over time, continued deviation from approved best practice threatens patient care and creates significant risks to the safety of your patients. Normalization of deviance may encourage shortcuts that are harmless for a long time and then, suddenly you are facing tragedy. Consider, also, that NoD represents an attitude, not just fudging the performance of tasks. If you doubt that this could affect you, I urge you to consider it possible. All of us are guilty of work-related deviance to one extent or another. Boring tasks are easy to skip and appear trivial in real time. And trial lawyers are aware of the phenomenon. In litigation, you may face questions under oath related to your knowledge of short cuts, errors, and workplace complacency.

Questions you might face: Were you aware that the defendant was taking short cuts? Did you or anyone else address the issue? Who did you tell? Did you personally confront this person? Why not? They will turn over every stone to investigate the cause of any care disaster. There may be a very small chance that this will ever happen to you. However, it might be productive for you to take a moment to contemplate your own practice and if you can identify any awareness of, or personal deviance, however minor.

1. Banja, J. The normalization of deviance. Bus Horiz. 2010;53(2): 139.

2. Ibid. Pg 1

3. NPIC. The Nomalization of Deviance and Maternal Health Outcomes. 225 Chapman Street Suite 200. Providence, RI 02905.

4. Ibid. Banja, J. pg. 8

5. Relias Media. Healthcare Risk Management. Normalization of deviance a constant risk. pg. 2, December 1, 2008.

6. Ibid. Banja, J. pg. 6

7. Ibid. pg. 6

8. Ibid. NPIC. pg. 4

9. Ibid. pg 4

10. Banja, J. pg. 6

11. Clark, S., Simpson, K.R., Knox, E et.al. Oxytocin: new perspectoves on an old drug. American Journal of Obstetrics & Gynecology. pg.35.e3

12. Ibid. pg 35.e3

http://www.midwivesontrial.com

Awareness of Legal Risk In Midwifery Practice

Nurse-Midwifery Care and Support of Patients With Fetal Loss Before 20 Weeks Gestation