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Understanding the Concept of Normalization of Deviance in Healthcare

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There have been many talks of normalization of deviance over the years from different industries. It is a natural human tendency to create shortcuts to processes and procedures, which can be influenced by a multitude of factors. The subject of normalization of deviance is relatively a new focus in the health care industry.

The term “normalization of deviance” was coined by Diane Vaughan, a sociologist. She generated the term while examining the Challenger space shuttle disaster (Price & Williams, 2018). The results of the investigation presented with a design fault of an O-ring which was taken as a minor fault and an acceptable one. Never the less, this simple and minor acceptable fault resulted in the loss of 7 astronauts’ lives, deaths that could have been avoided had NASA followed the procedure by the book.

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Nature of deviance

Deviance can occur from multiple factors, leading to shortcuts and risky procedures. Terry Wilcutt, NASA’s chief of safety and mission assurance states, “there is a natural human tendency to rationalize shortcuts under pressure, especially when nothing bad happens” (Price & Williams, 2018). Where there is an absence of immediate negative outcome, the deviant behavior strengthens and makes it readily acceptable as the norm. This leads to desensitization of the perpetrators to the deviant practice leading to acceptance and no longer feels wrong to do so. The practice can be passed down to new employees and soon becomes an unwritten standard of practice at the work place. Pressures that result in deviant behavior can come in many forms.

“To err is human,” is an essay written by Alexander Pope on criticism. But few know the origins of the term, yet we have all heard and used it many times. Yes, indeed it is very human to err as we all know and accept that none of us is perfect. This sense of imperfection in being human tends to allow us to accept and justify our deviant nature at times. William Blake, an English poet and philosopher stated that mankind would settle into a normal deviance if you allow it to do so (Shaw, 2017). The nature of deviance in among us all.

Deviance in Nursing

Currently there is a shortage of nurses and this is a well-known fact. This shortage of nurses can and has led to heavier patient loads which in turn results in time constraints for providing care to those patients. Therefore, in the field of nursing, these pressures could be time, patient load or even just peer pressure. When new nurses are hired, it is standard practice to be oriented by a preceptor for a certain period of time. The new nurse will learn and follow what knowledge the preceptor imparts on them. Also, every preceptor has their own unique way to performing a task, which could become a learned process for the new nurse leading to accept it as a normal process. The statement “that’s not how we do it on our unit,” is a very frequently heard one in nursing (Price & Williams, 2018).

California is the only state that has passed a regulation regarding nurse to patient ratio. When there is an excess patient load, there is only a finite amount of time you can dedicate to the care activities of each patient. This leads to nurses creating shortcuts and sometimes, even completely ignoring procedures that may seem trivial or less harmful. Eventually this deviation can lead to becoming the new norm and even be accepted as supporting other organizational goals such as budget constraints (Price & Williams, 2018). A study presents that nurses, when faced with a problem, create a work-around 93% of the time as opposed to 7% of the time reporting the problem in the process (Price & Williams, 2018).

As the old English proverb states ‘necessity if the mother of all inventions,’ nurses can be very innovative when faced with a challenge. They are quick to find an easier and a quicker way of getting the task complete, sometimes at the cost of minor safety infringements which is overshadowed by the need to complete the task. This behavior can, unknowingly, cascade into disaster and harm.

Prevention of Deviance

Not one healthcare provider wants to be a part in the harm of a patient. Yet, this trend of normalization of deviance tend to occur all too often. Once the deviance is entrenched, it is very difficult to root out and keeping it off would create another insurmountable challenge. There needs to be a shift in focus from individuals to systems and process to the culture change in healthcare. Rich evidence can be found in multiple literatures showing that it is more productive in preventing errors to focus on system fixes instead of making humans perfect (Price & Williams, 2018). More often than not, a nurse is pushed towards deviant practices due to system processes that are not aptly created or efficient to that particular unit or field. Rather than an accusatory statement, questions should be placed as to why it happens. Process and procedures need to be constantly reviewed and changes made to adapt to the ever-changing health care practices.

Deviance occurs in the presence of something being wrong, and to focus on what that wrong is would be a more efficient way of dealing with the deviance. Sometimes bar codes are difficult to scan or is not printed well enough for the scanner to recognize so the nurse will skip the scanning process to administer the medication on time. This can lead to medication errors such as the wrong medication being given to the wrong patient. An example given in the article states a decrease in hand hygiene compliance was due to workplace design with inconveniently placed hand hygiene stations (Price & Williams, 2018). The question why is more important than who when it comes to rooting out deviant behaviors and maintaining safe practices.

Normalization of deviance is a relatively new concept in healthcare and becoming aware of such behaviors is fundamental in eliminating and preventing dangerous practices that would place a patient at harm’s way. Just as, if one of the NASA engineers working on the Challenger space shuttle had spoken out about the deviant behavior which could have led to saving those 7 lives, every healthcare worker has the responsibility to speak out and question against work-arounds when they witness it. These questions may be pivotal in keeping patients out of harm’s way while creating a positive and a productive work environment. The focus needs to be kept as to why a certain behavior happens rather than who started it or who is committing the act.

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