Managing rule breaking in clinical practice

In the late 1980s, the ferry Herald of Free Enterprise left Zeebrugge's inner harbour, took on water and capsized – killing 193 passengers and crew. A subsequent investigation of the incident found that the bow doors had not been fully closed before the ship left harbour, in order to save time.1 Around a decade later, workers at the JCO uranium processing plant in Tokai-Mura, Japan, were anxious to complete their job at the conversion building and decided to use the precipitation tank instead of a buffer column (a much smaller device) to increase their performance when purifying and homogenising uranium. The concentration of product became critical and the system exploded.1 These two incidents, cited by Amalberti et al, illustrate how conflicting pressures can ultimately lead to ‘deviant’ behaviour. In their paper, Violations and migrations in healthcare: a framework for understanding and management, the authors point out that these accidents were caused ‘not by unintended errors, but by deliberate deviations from rules and standards’.1 In both cases, accident analysis showed that the workers' deviations from normal operating procedures resulted from ‘a long progressive drift in practice’.1 Simply reprimanding those who break the rules fails to add to our understanding of why (and how) such violations and migrations occur. Instead, we need to understand the rules within the context of the ‘real world’ – along with the factors that help or hinder clinicians from following guidelines. Speaking at the Association of Perioperative Practice’s annual congress, Mark Emerton, consultant orthopaedic surgeon, Leeds Teaching Hospitals NHS Trust, examined the question: “Violation and migration – why does it happen and what can we do?” A senior fellow in Quality and Safety Improvement, at the NHS Institute, Mark Emerton is the lead clinical faculty member for the Leading Improvements in Patient Safety course, and has previously been a member of the core team for the national Patient Safety First campaign – as well as a senior clinical advisor to the National Patient Safety Agency. He asked the audience to consider: “When people do not follow policy, are they being deliberately obstructive – or are there other factors at work? If the latter is the case, we need to understand why people do not follow the rules, so that we can design systems that take this into account.”

Normalising ‘deviant’ behavior

 He drew parallels between deviations from the rules in healthcare with deviation from the national speed limit. Although the latter is designed to improve safety for road users, widespread ‘deviant’ behaviour has become the accepted norm. He asked the audience: “Who has never driven faster than 70 mph on the motorway?” The response from the audience showed that everyone had broken the speed limit at sometime – in fact, most people had driven at over 80 mph, while a large percentage had also driven above 90 mph. Mark Emerton suggested that there are many factors that lead to migration away from the safe zone: “Although we have a body of evidence on road safety and the importance of reducing speed, people ignore this in their desire to get from A to B quicker. There are pressures to go faster – ‘everyone else is doing it’. Some individuals perceive there to be less risk because the road is empty in the early hours of the morning; others may believe that the rules are only enforced by the police if they exceed 80 mph.” He pointed out that people begin to feel that this illegal speed is normal: “After driving for years at 80 mph, we get comfortable and start to push the boundaries, gradually migrating further and further away from the safe zone, set by safety experts, and entering a more risky space,” he warned. Hand hygiene is another area where the rules are broken on a large scale, he pointed out. A study conducted on a train showed that 25% of men had faecal bacteria on their hands. In healthcare, various studies have also shown disappointing rates of compliance to hand hygiene protocols. Mark Emerton asked the audience: “Who washes their hands every single time they should?” Only a small number raised their hands. “We know that it reduces infection. UK Trusts have been operating a sustained campaign over the last four years and conduct regular audits, so why do people choose not to wash their hands?” Some of the reasons offered included: time and sore hands. Furthermore, staff do not necessarily see the consequences of their violation of the rules. “We are meant to perform hand hygiene before and after every patient contact, yet people fail to see the importance. Others think that because they are wearing gloves they do not need to wash their hands. One nurse, for example, was observed going from patient to patient without washing their hands because they perceived them to be clean while wearing gloves. Glove boxes are also often placed on their side, so that the contents fall onto floor – yet people put them back into the box instead of throwing them away.”