By Rose O. Sherman, EdD, RN, FAAN
A nurse manager recently talked with me about the bullying on a unit that she had recently assumed responsibility for. She was shocked at how the bullying behaviors seemed to be normalized and just accepted as part of the culture. The previous nurse manager had not dealt with it because it involved some of her “best” staff. She worried about losing them. The new manager was now faced with some serious challenges as she attempted to change a culture where there was a normalization of this deviant behavior.
Normalization of Deviance Defined
The normalization of deviance can be defined as a gradual process in which unacceptable practice or standards become acceptable. As deviant behavior is repeated without catastrophic results, it becomes the social norm for the unit/organization. With RN turnover at 17.2% nationwide and RN disengagement from their work on the increase, it is very problematic when small incremental deviances are tolerated 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. John Banja cites 7 factors that lead to the normalization of deviant behavior in healthcare environments:
1. Staff believes 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 believes that it is OK to break a rule for the good of the patient.
5. Staff believe that rules don’t apply to them – they have experience and can be trusted.
6. Staff fears 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 to the chain of command.
Challenging Deviant Behavior
To counter deviant behavior, nurse leaders must have a fundamental commitment to an anti-bullying environment and back up the commitment with action. 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 bullying – 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 deviant behavior. Your goal should be to create a culture of understanding that deviations may occur, but that they require swift attention. Staff also need to be taught to feel comfortable speaking up when they see deviant behavior.
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 or acting out their own stress. 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 or behavior deviations whenever they occur.”
Read Rose Sherman’s new book available now – The Nurse Leader Coach: Become the Boss No One Wants to Leave
Read to Lead
Banja, J. (2010). The normalization of deviance in healthcare delivery. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821100/
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