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It's OK to Break the Rules, Sometimes

Alexandra Wilson Pecci, for HealthLeaders Media, September 10, 2013

A nurse leader advocates for "positive deviance" in nursing—bending or tweaking rules or guidelines in the interest of positively affecting patient care, even though there is no outcomes data to support the practice.

When Jodie Gary was working nights as a critical care nurse, she was written up by her supervisor for breaking hospital policy and letting a man spend the night holding his hospitalized wife's hand.

The two had never spent a night away from each other in their 50-year marriage. When the man left his wife's side for the evening, per hospital rules, the woman got anxious, her blood pressure rose, and she required higher doses of pain medication.

So Gary acted in what she believed was in the patient's best interest, and sure enough, when her husband returned, the woman's blood pressure lowered, she calmed down, and she didn't need as much pain medication.

"I broke visitation policy and let him stay at the bedside all night," Gary remembers. It's something that she still feels was the right decision, regardless of whether she was written up, regardless of whether she broke the rules.

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4 comments on "It's OK to Break the Rules, Sometimes"


Debbie C. (9/18/2013 at 10:25 AM)
Interesting article.. Deviation from the norm.. as leaders I feel it is important to follow "standards of practice" whenever possible.. Policies should be written in a manner that state the purpose & goal, they should be straight forward and written in a simple to follow format.. My policy - "keep it simple".Within the policy you can identify the "guidelines" which are just that "a guide". Guidelines should allow for and encourage "critical thinking skills" and be adaptable to allow for "variance" or "deviation from the norm" when addressing patient or residents needs.. it is all in the wording. This is why it is important for leadership to review policies & guidelines, with the input of those who's professional practice is most affected by the policy. It is also helpful to engage your Medical Staff in the review and recommendations regarding policies. I once had a physician tell me.. "there is more than one way to skin a cat"... (sorry about the analogy.. I love animals.. but you get the point). In my opinion.. the policy which restricted the spouse from spending the night... is completely inappropriate and hopefully has been changed... I applaud the nurse who used "common sense" and an "[INVALID]nate method of relieving pain and anxiety" for this patient. A little care and compassion can go a long way. Policies are written.. but they are not "written in stone".. they need to be reviewed, updated and changed, if appropriate. "Common sense" needs to be one of the main criteria in the review process.

Linda (9/13/2013 at 10:28 AM)
"Positive deviance" is a symptom of a systems problem [INVALID] NOT a solution. When faced with a "rule" that interferes with good practice, a nurse should have an approved route of addressing the issue. He/she should not have to "break the rule" and take unnecessary risks to do good. A procedure to authorize the better action should ALWAYS be available. Nurses should not be taught to risk rule-breaking. They should be supported by a good system that provides a suitable process for openly adapting guidelines, etc. to provide appropriate care (preferably with the consultation of others before practicing outside normal procedures.)

gs (9/13/2013 at 9:12 AM)
Such positive deviance should be exposed (even sought out) and used as a learning tool to adjust policy or procedures that may be cumbersome, inefficient and ineffective OR to reinforce the rationale of a well designed policy. Too often the process of caring for patients is framed by professionals who have been away from the bedside long enough that they are not cognizant of the many changes of everyday duties. Often policies are created for compliance only...we have a long way to go!