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When Doing Wrong Feels So Right: Normalization of Deviance

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Abstract

Normalization of deviance is a term first coined by sociologist Diane Vaughan when reviewing the Challenger disaster. Vaughan noted that the root cause of the Challenger disaster was related to the repeated choice of NASA officials to fly the space shuttle despite a dangerous design flaw with the O-rings. Vaughan describes this phenomenon as occurring when people within an organization become so insensitive to deviant practice that it no longer feels wrong. Insensitivity occurs insidiously and sometimes over years because disaster does not happen until other critical factors line up. In clinical practice, failing to do time outs before procedures, shutting off alarms, and breaches of infection control are deviances from evidence-based practice. As in other industries, health care workers do not make these choices intending to set into motion a cascade toward disaster and harm. Deviation occurs because of barriers to using the correct process or drivers such as time, cost, and peer pressure. As in other industries, operators will often adamantly defend their actions as necessary and justified. Although many other high-risk industries have embraced the normalization of deviance concept, it is relatively new to health care. It is urgent that we explore the impact of this concept on patient harm. We can borrow this concept from other industries and also the steps these other high-risk organizations have found to prevent it.
When Doing Wrong Feels So Right: Normalization
of Deviance
Mary R. Price, MSN, RN-C, NEA-BC and Teresa C. Williams, MSN, RN, NE-BC
Abstract: Normalization of deviance is a term first coined by sociologist
Diane Vaughan when reviewing the Challenger disaster. Vaughan noted
that the root cause of the Challenger disaster was related to the repeated
choice of NASA officials to fly the space shuttle despite a dangerous de-
sign flaw with the O-rings. Vaughan describes this phenomenon as occur-
ring when people within an organization become so insensitive to deviant
practice that it no longer feels wrong. Insensitivity occurs insidiously and
sometimes over years because disaster does not happen until other critical
factors line up. In clinical practice, failing to do time outs before proce-
dures, shutting off alarms, and breaches of infection control are deviances
from evidence-based practice. As in other industries, health care workers
do not make these choices intending to set into motion a cascade toward
disasterand harm. Deviation occurs because of barriers to using the correct
process or drivers such as time, cost, and peer pressure. As in other indus-
tries, operators will often adamantly defend their actions as necessary and
justified. Although many other high-risk industries have embraced the nor-
malization of deviance concept, it is relatively new to health care. It is ur-
gent that we explore the impact of this concept on patient harm. We can
borrow this concept from other industries and also the steps these other
high-risk organizations have found to prevent it.
Key Words: normalization of deviance, high-reliability
organizations, preventable harm, patient safety, medical errors
(J Patient Saf 2018;14: 12)
Normalization of deviance is a term first coined by sociologist
Diane Vaughan when reviewing the Challenger space shuttle
disaster. Vaughan
1
noted that the root cause of the Challenger
disaster was related to the repeated choice of NASA officials to
fly the space shuttle despite a dangerous design flaw with the
O-rings that failed to seal critical joints. Vaughan's
1
research
showed that this deviance from an established standard was
labeled as acceptable risk. Accepting this risk led to the Chal-
lenger exploding on a freezing morning when the cold-stiffened
O-rings allowed a critical flow of hot propellant gases to blowby
and ignite, killing 7 astronauts. Since then, normalization of devi-
ance has been found to be a factor in many other recent disasters,
includingthe Columbia space shuttle disaster, the deadly chemical
release in Bhopal, India, and nuclear-related accidents at
Chernobyl and Three Mile Island.
2
Vaughan
1
describes normalization of deviance as occurring
when people within an organization become so insensitive to
deviant practice that it no longer feels wrong. Insensitivity occurs
imperceptibly and sometimes over years because disaster does not
happen until other critical factors line up. In clinical practice,
failing to do time outs before procedures, shutting off alarms,
and breaches of infection control policies are examples of devi-
ances from standard, accepted, evidence-based practices. Although
the concept is relatively new to health care, it has tremendous appli-
cability. How many seasoned health care professionals have heard
novices state, Every preceptor I have shows me a different way
to do things.Another common statement heard from staff is,
That's not how we do it on our unit.
As in other industries, health care workers do not make these
choices intending to set into motion a cascade toward disaster
and harm. Health care providers may not see the required practice
as safer than the status quo because it has not been proven to them
to be better at preventing an adverse event. Frequently, deviation
occurs because of barriers to using the correct process or drivers
such as time, cost, and peer pressure.
2
Indeed, as in other indus-
tries, the operators will often adamantly defend their actions as
necessary and justified.
3
Eventually, the deviation becomes the
new norm. This new norm may even be justified as helping to
accomplish other important organizational goals such as customer
service and budget constraints, without seeming to compromise
safety.
4
Langewiesche
5
explained that Murphy's Law is not appli-
cable to normalization of deviance. Everything that can go wrong
usually does not, and so normalization occurs. Good people make
small changes to a process, nothing bad happens, and then the
conclusion is drawn that the deviation is acceptable. Another
incremental change is made and results in the same conclusion.
At some point, however, something that could go wrong does go
wrong, and by that time, all the accumulated deviations over time
have removed the barriers that would have prevented the error
from becoming disastrous.
James Reason's Swiss Cheese Model
6
is useful in under-
standing how normalization of deviance sets up the system
for possible failure and resulting harm. Usually, no single isolated
cause leads to an adverse event. Often, multiple factors occurring
together result in failure and harm. The holes in the Swiss cheese
represent a breach in a potential barrier to an active error or unsafe
act. An ideal process is like a piece of Swiss cheese where none
of the holes ever line up. A failing process could be visualized
as several pieces of Swiss cheese with aligning holes. The same
concept can be applied to health care; if the right circumstances
occur at the right time, the holes line up, increasing the risk for
an adverse event.
No health care provider wants to be part of patient harm, yet it
happens all too frequently. A recent study reported in the Journal
of Patient Safety
7
estimates that acts of commission, omission,
and other preventable events cause more than 400,000 patient
deaths per year in the United States. The number of patient deaths
is equivalent to 22 Boeing 777 jets with 350 passengers and crew
crashing every week with no survivors and is at least 4 times the
number used in the landmark 1999 Institute of Medicine report,
To Err Is Human.
8
Harvard's Lucian Leape, one of the authors of
the Institute of Medicine report, says that it is time to embrace this
new number because it represents the best methodology to date.
9
These numbers are not meant to discourage creativity and
change toward improvement in patient care. To avoid normaliza-
tion of deviance, change should not be freelanced, undocumented,
From the St. Elizabeth Healthcare, Florence, Kentucky.
Correspondence: Mary R. Price, MSN, RN-C, NEA-BC, Manager, Staff
Development, St. Elizabeth Healthcare, 4900 Houston Rd, Florence, KY
41042; or Teresa C. Williams, MSN, RN, NE-BC, Education Specialist,
Staff Development, St. Elizabeth Healthcare, 4900 Houston Rd, Florence,
KY 41042 (email: mary.price@stelizabeth.com or
teresa.williams@stelizabeth.com).
The authors disclose no conflict of interest.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
REVIEW ARTIC LE
J Patient Saf Volume 14, Number 1, March 2018 www.journalpatientsafety.com 1
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
and hidden. Change should be instituted with transparency using
the tools of performance improvement, evidence-based practice
change, and research. To those who disdain cookbook medi-
cine,the response should be, Thank heavens we finally have a
cookbook.
Once deviation is entrenched, rooting it out is challenging.
Keeping it out adds another challenge. Other industries have suc-
cessfully turned deviance around, providing lessons learned avail-
able for healthcare to borrow. High-risk industries such as airlines
now meet the standard of being high-reliability organizations.
Achieving this level of reliability required a culture change in
those industries, which is exactly what is going to be required in
health care.
10
A shift in focus from individual guilt to systems and processes
is central to the culture change facing health care.
11
When harm
occurs, instead of looking for a scapegoat in the form of the last
link in the chain of a faulty system or process, the investigation
should search deeper, into the system or process itself. The patient
safety literature is rich in evidence demonstrating that a focus on
system fixes rather than trying to make humans perfect is much
more productive in preventing errors.
4
Blaming an individual does
nothing to change the system that pushed the individual to deviate.
Other individuals also deviate to cope with the same imperfect
system. Our communication with that last link, that last caregiver,
should not be an accusation, but rather a question, Why did you
choose to do what you did? Was there a barrier to doing it accord-
ing to the established procedure?The very fact that a deviance
was used is a signal that something is wrong in the system/
process/work flow, and the person struggling with the imperfect
system may be able to lead us to the holes in the Swiss cheese.
A normalization of deviance, a near miss, an errorall are faint
signals that there are problems in the system
12
and should cue
practitioners to dig deeper.
A focus on systems first requires a paradigm shift in thinking.
We have a history in health care of holding ourselves to a standard
of perfection. Only when health care providers accept the impos-
sibility of perfection will we value and prioritize the work that is
necessary to f ix the processes, equipment, and work flows that
set up the errors. It is imperative that leadership at all levels learn
how to think in terms of systems and to look at how systems inter-
act with one another. Leadership involvement is often necessary
to implement patient safety changes, and the top-downaspect
is one that cannot be ignored; however, there needs to be recogni-
tion that unintended downstream consequences of leadership
decisions could affect patient safety.
13
This is not to push the
blame upstream from the frontline caregiver to leadership, be-
cause drivers and barriers also exist at the leadership level.
System fixes may involve eliminating drivers to doing things
the wrong way or removing barriers to doing things the right
way. There are opportunities for system fixes in every report of
an error or near miss. Bar codes that do not scan properly are a
driver to skip the scanning process to administer the medication
on time. Complicated procedures and poorly designed work areas
create insidious barriers to doing things the right way because we
fail to see these for the hazards they are. For example, a workplace
design with inconveniently placed hand hygiene stations has been
shown to decrease hand hygiene compliance.
14
Interpersonal fac-
tors in the system are also at play; for example, simple peer pres-
sure can drive a person to deviance, and our novice nurses are
particularly vulnerable to being easily influenced.
Increasing awareness of this phenomenon is very important for
nursing because the nurse has more direct patient contact than
anyone else on the patient care team and often stands as the last
barrier to patient harm. Deviant practices that have become normal-
ized may remove that last barrier. According to 1 study, nurses will
create a work-around 93% of the time when faced with a problem
versus only 7% of the time reporting the process problem to those
who could focus on the contributing factors.
15
Further research is
needed to determine whether this tendency is prevalent among other
health care providers.
Frontline health care workers have the opportunity to take a
lead role in preventing deviance from creeping into practice.
Health care providers can accomplish this by being aware of
the concept of normalization of deviance, by being taught how
to report process problems in a nonpunitive environment, and by
being empowered to speak up to colleagues. Health care workers
should be open to constructive feedback and thank a colleague
who questions a work-around; this question may save the care pro-
vider from inadvertently causing patient harm.
Because normalization of deviance is a relatively new concept
to health care, becoming aware of this phenomenon is fundamen-
tal to eliminating and preventing this dangerous and often incre-
mental acceptance of unacceptable risk.
1
All of health care owns
the problem, and all must be part of the solution. The next
400,000 patients at risk are waiting.
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Price and Williams J Patient Saf Volume 14, Number 1, March 2018
2www.journalpatientsafety.com © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
... While normalization of deviance can occur due to a variety of reasons, productivity pressure, defined as an increased emphasis on the quantity of services provided over the quality in the interest of generating revenue, 24 is a primary attribute. 16,20,25 Productivity pressure typically stems from managerial personnel who create a barrier to adhering to safety standards and protocols when those protocols conflict with time pressures. 20 Because of productivity pressures that are applied to personnel in the work environment, rationalization of deviant behavior thus becomes perceived as legiti-mate and necessary. ...
... 22 A primary antecedent to normalization of deviance is a generalized complacency related to the absence of adverse events. 1,20,25 The absence of negative outcomes leads personnel to perceive that adverse events will not happen, which tends to fortify behaviors associated with taking shortcuts and workarounds, bypassing safety protocols in their entirety. Furthermore, there tends to be an insensitivity to a deviant practice whereby it no longer feels wrong 1,25 or there is peer pressure to conform to unit practices that reflect normalization of deviance. ...
... 1,20,25 The absence of negative outcomes leads personnel to perceive that adverse events will not happen, which tends to fortify behaviors associated with taking shortcuts and workarounds, bypassing safety protocols in their entirety. Furthermore, there tends to be an insensitivity to a deviant practice whereby it no longer feels wrong 1,25 or there is peer pressure to conform to unit practices that reflect normalization of deviance. ...
Article
Normalization of deviance is a phenomenon demonstrated by the gradual reduction of safety standards to a new normal after a period of absence from negative outcomes, which suggests that the absence of negative outcomes tends to reinforce the behaviors associated with cutting corners, bypassing safety checklists, and ignoring alarms. While the concept was first identified within the National Aeronautics and Space Administration, it has a strong, dangerous presence within health care, holding specific peril within high-risk environments such as the operating room. The aims of this article are to (1) analyze the concept of normalization of deviance and (2) identify the role of normalization of deviance with respect to the behavior of nurses in high-risk health care environments to prevent adverse patient outcomes. The steps outlined by Walker and Avant are applied to guide the concept analysis.
... The current study found strong support for the proposed model, and the results were consistent with previous studies that highlighted the importance of leadership in shaping nurse behaviour (Malik & Dhar, 2017;Sarwar, Naseer, et al., 2020). Similarly, the critical role of organizational identification is in accordance with previous studies suggesting that nurses are inclined to exhibit prosocial rule-breaking due to loyalty to their profession and organization (Dadich et al., 2018;Gary, 2014;Price & Williams, 2018). This study is timely, as it aimed to identify the factors that can increase pro-social rule-breaking among nurses and lead to patient-centred behaviour to help bring ease to patients, the ultimate objective of caregivers (Price & Williams, 2018). ...
... Similarly, the critical role of organizational identification is in accordance with previous studies suggesting that nurses are inclined to exhibit prosocial rule-breaking due to loyalty to their profession and organization (Dadich et al., 2018;Gary, 2014;Price & Williams, 2018). This study is timely, as it aimed to identify the factors that can increase pro-social rule-breaking among nurses and lead to patient-centred behaviour to help bring ease to patients, the ultimate objective of caregivers (Price & Williams, 2018). ...
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... In this case, the moral ambiguity of responding to poor physical health among people who also have persistent and severe mental health issues, may become lost in the recurrence and enduring nature of issues and events and the social construction of 'ordinary' everyday life (Chambliss, 1996). 'Normalization of deviance' is another concept drawn from sociology, that can provide insight into some of the practices that were enacted in the social contexts of this research, see for example (Banja, 2010;Price & Williams, 2018;Wright, Polivka, Odom-Forren, & Christian, 2021). Normalization of deviance occurs when people within a specific context or organisation becomes insensitive to deviant practices (Wright et al., 2021, p. 4). ...
... Such insensitivity is described as imperceptible and developing over time, e.g. as people working in certain contexts continues to bend rules or reduce standards of their work to the point where 'a new normal' is reached over time. An important factor in normalization of deviance is that the deviant practices continue, because no negative outcome appears to follow immediately after these actions (Price & Williams, 2018;Wright et al., 2021). The trouble begins, as other critical factors line up and disasters occur (Wright et al., 2021). ...
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Aim: This research thoroughly investigated aspects of everyday life among a group of people with schizophrenia, to gain insight into how physical health issues were managed. Methods: The PhD study was designed as an ethnographic study and drew on social constructionism. Nine participants with schizophrenia were recruited at two residential facilities (n=4) and at an outpatient clinic, provid-ing treatment to younger people with newly diagnosed schizophrenia (n=5). Additionally, 27 mental health care professionals contributed with their perspectives on management of physical health in mental health services. Qualitative methods were employed, and four analyses were con-ducted to explore the data material. Findings: The participants with schizophrenia experienced debilitating physical health issues in everyday life and two ‘typical’ strategies for managing these were identified. Both management strategies were inexpedient insofar as neither strategy resulted in transition towards better health. They were used repeatedly and constituted an ongoing process in which existing physical health issues and strategies used to manage them in everyday life were sustained. The findings include an explanatory theory about the complex social pro-cesses that were enacted as part of management of physical health in everyday life. Sustaining factors were identified as interacting in complex, multi-dimensional processes in the social context of everyday life, resulting in a deadlock in which management of debilitating physical health issues with inexpedient strategies, was continuously sustained among the participants with schizophrenia. There is a need for future research that explores aspects of beneficial management of physical health issues among people with severe mental illness.
... The conceptual origin of normalization of deviance arose during investigations into NASA safety practices (Vaughan, 1996), and there is evidence of the concept within the health care industry (Price & Williams, 2018). However, there is a dearth of evidence relating to the exact nature of normalization of deviance in health care. ...
... It is characterized by employees adjusting their behavior to fit a process that is perceived to be more efficient and logical yet goes beyond the bounds of safe practice standards. Employees speciously conclude that deviation is acceptable because what can go wrong, typically, does not go wrong (Price & Williams, 2018). The exploration of this concept remains relatively new in health care, and its acknowledgment is a crucial first step to mitigating its obvious perilous and negative outcomes. ...
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Normalization of deviance is a phenomenon in which individuals and teams deviate from what is known to be an acceptable performance standard until the adopted way of practice becomes normalized. In health care, this phenomenon erodes the safety culture, and it can be particularly concerning in high-risk work environments, such as the operating room (OR). The purposes of this study were to: (a) Explore the concept of normalization of deviance in the OR; (b) Identify reasons for normalization of deviance; and (c) Identify factors that protect against normalization of deviance. This focused ethnographic study included a sample of 10 perioperative nurses who were interviewed. Our findings demonstrated that normalization exists in the OR. Reasons for normalization of deviance included productivity pressures, generalized complacency, complacency related to length of experience, social pressures, and negative acculturation. Factors that protect against normalization of deviance included nurse engagement and having supportive managerial relationships.
... "Normalization of deviance" was first described by sociologist Diane Vaughan when discussing the Space Shuttle Challenger accident. 2 In medicine this term is frequently used when speaking about deviations to standard practice which generally are small but when taken collectively over a period of time can lead to errors or harm to patients. However, this same concept can be applied to the behaviors and actions of patients. ...
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Medical Competence and Patient Safety Competence as Individual Virtue or Systems Issue? Why the Difference in Competence Assumptions? Good Doctoring and the Pursuit of Perfection Standardization and the Fear of Scientific-Bureaucratic Medicine The Expectation of Perfection versus the Inevitability of Mistake Key Points References The Problem of "Human Error" in Healthcare Numbers Are Strong The Human Factors Approach Human Error as Attribution and Starting Point "I Knew This Could Happen!" The Local Rationality Principle Key Points References Cognitive Factors of Healthcare Work Attentional Dynamics Knowledge Factors Strategic Factors Key Points References New Technology, Automation, and Patient Safety The Substitution Myth Data Overload Automation Surprises Evaluating and Testing Medical Technology Key Points References Safety Culture and Organizational Risk Safety Culture and Drifting into Failure Risk as Energy to Be Contained Risk as Complexity Risk as the Gradual Acceptance of the Abnormal Risk as a Managerial or Control Problem Key Points References Practical Tools for Creating Safety Safety Reporting and Organizational Learning Adverse Event Investigations Human Factors and Resource Management Training Briefings and Checklists Key Points References Accountability and Learning from Failure Learning and Accountability-Just Culture Criminalization of Medical Error: A Growing Problem? The Second Victim Key Points References New Frontiers in Patient Safety: Complexity and Systems Thinking Complicated versus Complex Newton, Components, and Complexity The Cartesian-Newtonian Worldview and Adverse Events Key Points References Index
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When faced with a human error problem, you may be tempted to ask 'Why didn't they watch out better? How could they not have noticed?'. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. These are all expressions of 'The Bad Apple Theory', where you believe your system is basically safe if it were not for those few unreliable people in it. This old view of human error is increasingly outdated and will lead you nowhere. The new view, in contrast, understands that a human error problem is actually an organizational problem. Finding a 'human error' by any other name, or by any other human, is only the beginning of your journey, not a convenient conclusion. The new view recognizes that systems are inherent trade-offs between safety and other pressures (for example: production). People need to create safety through practice, at all levels of an organization. Breaking new ground beyond its successful predecessor, The Field Guide to Understanding Human Error guides you through the traps and misconceptions of the old view. It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language. But it also helps you look forward. It suggests how to apply the new view in building your safety department, handling questions about accountability, and constructing meaningful countermeasures. It even helps you in getting your organization to adopt the new view and improve its learning from failure. So if you are faced by a human error problem, abandon the fallacy of a quick fix. Read this book.
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Based on 1984 data developed from reviews of medical records of patients treated in New York hospitals, the Institute of Medicine estimated that up to 98,000 Americans die each year from medical errors. The basis of this estimate is nearly 3 decades old; herein, an updated estimate is developed from modern studies published from 2008 to 2011. A literature review identified 4 limited studies that used primarily the Global Trigger Tool to flag specific evidence in medical records, such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient. Ultimately, a physician must concur on the findings of an adverse event and then classify the severity of patient harm. Using a weighted average of the 4 studies, a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm. The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed. Fully engaging patients and their advocates during hospital care, systematically seeking the patients' voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal.