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.
It's this kind of "positive deviance" in nursing—bending or tweaking rules or guidelines in the interest of positively affecting patient care—that Gary, Ph.D., RN, assistant professor of nursing at the Texas A&M University Health Science Center College of Nursing, discusses in her American Journal of Nursing concept analysis, "Exploring the Concept and Use of Positive Deviance in Nursing."
Positive deviance is a somewhat ambiguous-sounding term; after all, the word "deviance" carries with it negative connotations. But it's not negative in this context; quite the opposite.
"It's departing from any sport of policy, procedure, [or] routine… intentionally but honorably, using some sort of creativity," Gary tells me, and it's doing so with the intention providing patient-centered care.
"People are very gray. Not everybody fits into this black-and-white policy, so a nurse might slightly tweak something to make it better."
For instance, maybe a nurse breaks visitation rules, like Gary did. Maybe he or she administers an extra dose of pain medication without physician orders at 2:00 am or uses a bigger central line dressing—or two of them—than guidelines dictate because a patient weighs 500 pounds and the line is in his groin.
Gary believes that nurses do these sorts of thing all the time, every day in their work, but "we don't really have outcomes data on this," she says. "I think that everyone who's been a nurse can relate to it on some level."
Despite its prevalence though, positive deviance in nursing isn't often documented, for several reasons. First, nurses might not think to document such actions, especially when they're taken for granted as the kind of quick-thinking that's simply all in a day's work.
They also might not want to document rule-breaking for fear of being reprimanded. And electronic charting doesn't really allow for nuance: Users simply tick a box when a task is completed; they don't explain how it was completed.
Gary told me that she conducted a (still-to-be-published) study in which she surveyed 106 critical care nurses via the American Association of Critical-Care Nurses and asked them to describe "a time when a policy procedure or guideline didn't fit the needs of the patients and what they did about it." She found a lot of "responsible subversion," rule-bending and breaking in the interest of patients, often in emergent situations and end-of-life care.
"They're kind of doing these creative workarounds," Gary says. And, "I was surprised to hear about how many people were sneaking pets in, or children."
Of course, there are risks involved for nurses who choose to break rules in this way, sometimes more serious ones than getting written up.
"When it comes to actually adapting medication, you could lose your license," Gary says. And she's certainly not advocating for "willy-nilly" rule-breaking; nurses need to have enough clinical knowhow to know when it's appropriate to bend the rules. Besides, Gary isn't talking about nurses who are going crazily rogue, like Dr. Gregory House on "House, M.D."
"This is not the dark side of nursing," Gary says. "Nurses are doing this to provide patient-centered care."
Gary acknowledges that nurse managers have to walk a very fine line here; they don't want to blithely encourage rule-breaking, after all. But instead of rigidly following black-and-white rules, Gary says nurse leaders could perhaps be more open-minded and find a balance between a strict policy and something that's more of a guideline. Doing so would allow for the complexity of healthcare and also trust nurses to act in the patient's best interest.
"I'm not exactly asking for nurses to have more autonomy, just knowing that they can be more accountable for the care they provide," Gary says. Nurses want better guidelines to help "guide their care but not dictate it."
Alexandra Wilson Pecci is an editor for HealthLeaders.
