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It's OK to Break the Rules, Sometimes

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

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."

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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!