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It's OK to Break the Rules, Sometimes

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

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.

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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!