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It's OK to Break the Rules, Sometimes

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

"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 a managing editor for HealthLeaders Media.

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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!