Normalization of Deviance in a Just Culture

By Rose O. Sherman, EdD, RN, FAAN

One of my nurse leader students was relating an incident that had recently happened on her unit with a young millennial nurse. The nurse was experiencing problems with the smart pump that she was using to administer an IV medication. Her solution was to reprogram the machine herself although it was clearly against medical center policy. The outcome was a medication error which fortunately was caught early and did not result in a patient injury. When the nurse leader counseled the young nurse, she did not expect the nurse to respond by telling her that she was justified in what she had done because it was clearly in the interest of the patient to get his medications on time and she was attempted to fix the machine. In further investigating the situation, the manager found that this was not the first time that one of her newer nurses had done this. Her medical center had a just culture philosophy. Under this philosophy, human error falls into three categories: 1) Human Error 2) At-Risk Behavior 3) Reckless Behavior. She struggled with the situation because she felt it fell under the Reckless Behavior category because the risk taking was intentional. An even bigger problem was that the behavior had been normalized on the unit.

Normalization of Deviance Defined

The normalization of deviance can be defined as: a gradual process in which an unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization. With medical errors now the 3rd leading cause of death in hospitals today, it is very problematic when small incremental deviances are tolerated as happened on my student’s unit and become behavioral norms.

Factors Leading to Deviance

Interestingly it has been found in research that deviant behavior is more likely to occur in experienced versus inexperienced staff. As nurses become more confident about their judgment, they are more likely to believe that they can slightly bend rules if needed. The one possible exception to this situation is Generation Y’s confidence with technology. John Banja cites 7 factors that lead to the normalization of deviant behavior in healthcare environments:

1. Staff believe that rules are stupid and inefficient – developed by those who are not in the trenches of care.

2. Staff lack of knowledge – knowledge is imperfect and uneven and some staff may not even know the reasons for the practice and procedure.

3. New technologies – can disrupt ingrained practice patterns, impose new learning demands, or force system operators to devise novel responses or accommodations to new work challenges.

4. Staff belief that it is OK to break a rule for the good of the patient.

5. Staff belief that rules don’t apply to them – they have experience and can be trusted.

6. Staff fear about speaking up when deviant behavior is observed.

7. Leadership awareness of deviant behavior or systems problems but there is a failure to bring it up the chain of command.

Challenging Deviant Behavior

To counter deviant behavior, nurse leaders must have a fundamental commitment to patient safety and this must be evident to staff. Leaders must become acutely vigilant about deviant behaviors and practices, and be ready to take aggressive steps to halt their occurrence before they achieve normalization. The best time for a nurse leader to intervene in correcting a deviant practice is early rather than later on, when righting the now-normalized deviation can be much more challenging. When you counsel staff for errors – watch for the statement “staff on this unit do this all the time – I am not the only one”. It could be a defensive response but it might also indicate the normalization of a deviant behavior. Your goal should be to create a culture of understanding that some practice deviations are likely to occur, but that they require swift attention. In a just culture, staff need to be aware that if a behavior is defined as reckless or intentional risk taking regardless of the motivation to help patients, the leadership response will need to be punitive.

Preventing the normalization of deviant behavior is an ongoing challenge for nurse leaders and requires continuing diligence. Deviations or rule violations are rarely motivated by malice or greed, but often result from nursing staff feeling intense performance pressures. Banja recommends that “reminding ourselves of the seriousness of the stakes might help leaders to steel their courage, remain vigilant, and respond aggressively to unsafe practice deviations whenever they occur.”

Read to Lead

Banja, J. (2010). The normalization of deviance in healthcare delivery. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821100/

Marx, JD Whitepaper Prepared for AHQR (2001) Patient Safety and the “Just Culture” – Just Culture AHQR 2001