“The Normalization of Deviance in Healthcare Delivery”, 2010 ():
[cf. 2007] Many serious medical errors result from violations of recognized standards of practice. Over time, even egregious violations of standards of practice may become “normalized” in healthcare delivery systems.
This article describes what leads to this normalization and explains why flagrant practice deviations can persist for years, despite the importance of the standards at issue.
This article also provides recommendations to aid healthcare organizations in identifying and managing unsafe practice deviations before they become normalized and pose genuine risks to patient safety, quality care, and employee morale.
…Factors that account for the normalization of deviance: 3.4: I’m breaking the rule for the good of my patient!
This justification for rule deviation recalls the situation described in Example #5, where the rule or standard is perceived as counterproductive. The phlebotomist in the following example might similarly plead that rule-following diminished the quality of her patient care:
- Example #6: A phlebotomist in a neonatal unit would slip on her gloves to do a blood draw, but then immediately tear off the index fingertip of one of them (thus violating an infection control rule). She would use that exposed fingertip to detect the baby’s vein, which she would then stick. She claimed she had a very hard time feeling the baby’s vein through the latex glove, and she didn’t want to miss the vein and subject the baby to multiple sticks. It took 3 rather direct confrontations with her supervisor before the rule violation stopped. (Maxfield et al 200519yaa)
3.5: The rules don’t apply to me/You can trust me
While pathological narcissists who believe they are above rule-following can be found in any organization (2005, How to break bad news; 2004), a more subtle form of “the rules don’t apply to me” is when system operators believe they are not tempted to engage in the behavior that the rule or standard is supposed to deter. Thus, the rule is understood as superfluous. As in Example #5, the rule violator feels perfectly justified in performing the problematic behavior, because the deviant practice of drug diversion would never cross his or her mind.
Administrators should appreciate a psychological finding that has been replicated in various forms throughout the 20th century: most human beings perceive themselves as good and decent people, such that they can understand many of their rule violations as entirely rational and ethically acceptable responses to problematic situations. They understand themselves to be doing nothing wrong, and will be outraged and often fiercely defend themselves when confronted with evidence to the contrary (2003).