When poor care becomes the norm

Individuals may have different perspectives of what actually is poor care- or what is unacceptable. This may be influenced by such factors as culture and attitudes .
Consider the following examples:
Patients with learning difficulties are lined up naked on a ward for a bath.
An old lady is fed her dinner whilst in a wet bed.
A gentleman is refused a clean incontinence pad during the night.
A lady dislikes the stew for dinner but is given nothing else.
Patients are restrained by belts .
All patients are got out of bed at 6am.

For some these may be totally unacceptable but not to others.

One lone voice amongst the staff may question poor practice. Yet others declare there is nothing wrong.
The reason for failing to question practice may well be team issues, such as adherence to the group. Another reason has been highlighted within my work. This is that poor care has become the norm.
Priellip et al (2010) explored this within anaesthetics and found that short cuts in practice were not questioned by other staff. Vaughan in Prielipp et al refers to this as “normalization of deviance”. “Normalization of deviance breaks the safety culture,substituting a slippery slope of tolerating more and more errors and accepting more and more risk, always in the interest of efficiency and on-time schedules” (Prielipp et al). Examples in anesthesia include removing vital monitors before the patient is awake and failing to wash hands. Whilst Prielipp refers to patient safety, this consideration may well extend further into aspects such as dignity and quality of life, which are vital considerations within care.
Vaughan proposed the term “normalizing deviance” following the Challenger space shuttle explosion in 1986, in which astronauts died. This was despite NASA knowing for many years of a defect. Vaughan proposes various reasons for this method of acceptance in healthcare including ; inefficient rules, imperfect knowledge, “for the good of the patient”, or workers afraid to speak up for fear of being reprimanded . This is evident within nursing, where staff may be wrongly accused, as in backstabbing or the treatment of whistleblowers (Dimon 2014) .
The norm may not be accepted by everyone even if adhered to, but enforced by the most dominant team members. Hence, certain staff members often prefer to work together .
Could it simply be acceptance of a lower standard and an excuse for poor care? Consider potting up medication as an example of poor practice. Potting up is when medication is put out in many pots at once and taken to patients – not on an individual basis, hence errors are more likely and undetected errors. A busy nurse may even delegate this task to the care assistant.
Nurses do have a responsibility to report this procedure according to nurse registration guidelines.
Banja (2010) further analyses normalizing deviance regarding healthcare, stating that deviance in healthcare “is virtually never carried out with criminal or malicious intent”. It appears that people convince themselves that the patient will come to no harm; a form of rationalization. This may also occur when caring for ones own children; some parents may allow Johnny to run around the streets alone at 6years of age , but not others. This is where risk taking is involved. Some individuals take more risks than others depending on their philosophy, upbringing or experiences.
In nursing should risk assessments be undertaken for any deviations from the required procedure, or would some managers and staff regard this as risky to themselves because they are then admitting what the situation is? If they feel unable to undertake such an assessment, then one may question why do it at all?
Is this why so many cases of medical errors or mistreatment of patients are never investigated by management or professionals? This may illustrate a difference in expectations and experiences of patients, relatives and staff. For example, a relative may consider the death of the patient to have been totally unavoidable and catastrophic, but staff may regard the death as a normal risk of treatment and care. The point of accepting lower standards extends further the points raised by Goffman (1961) who described the acceptable treatments of individuals within institutions, including excess routine, like bath times, bedtimes, and patient uniforms. As Goffman states “our status is backed by the solid buildings of the world, while our sense of personal identity often resides in the cracks “ (p28). People do need a sense of belonging which is threatened by opposing the “norm”. Banja also discusses institutionalization, socialization and rationalization further.
For a manager to correct deviations it may be troublesome and promote even worse results, such as staff leaving . This is akin to “turning a blind eye” to some issues. For example, the manager may well be aware that patients are lined up naked for a bath, or staff have an unofficial break in the bathroom.
Banja proposes recommendations including focus groups and staff education. In the UK, the government and campaigners call for transparency- this may well be one area in which it could apply. Staff and students need to be supported to address any disagreements or deviancy from the required standards . Involving relatives and patients on focus groups would help the situation as they do have different perspectives. Staff are not always aware of how their approach to care and actions they take may actually affect the patient or relative. Those who have had personal experiences are often more aware and may have a greater degree of empathy, as particularly may be the case within mental health nursing.
Could the concept of “normalizing deviance” pertain to care in general? This could explain the scenario of “we always do it this way”. It could well be the staff’s self protective mechanism, with them becoming immune to poor standards of care. So much easier to go to work and return home with a pay packet; no questions asked – “the ostrich syndrome”. In deviance individuals are considered as commodities, objects or numbers.
Consider your day at work. Is there anything in practice that you really would like to question?
It could well be that, this practice has always been the norm when exploring history or culture, in particular the care of the mentally ill, where, many years ago individuals were restrained, and still are in some countries . In Somalia, for example mentally ill patients may still be put in a cage with hyenas as a form of treatment (Hooper 2013).
Culture is adherence to the norms of a group (Durkheim 1993), defining how a nurse behaves and his or her attitude. In nursing, culture is a major determinator of patient outcomes, including cultural differences within countries.
Have some cases of poor care become the norm, or have they always been the norm?

Banja J (2010) The Normalization of Deviance in Healthcare Delivery 10.06 ncbi.nlm.gov/pmc/articles
Dimon C (2014) Nursing Backstabbers nursebloginternational.wordpress.com
Durkheim E (1993) Ethics and the Sociology of Morals Prometheus books
Goffman E (1961 ) Asylums Penguin
Prielipp, R. C. Magro, M. Morell, R. C. Brull, S. J. (2010). The Normalization of Deviance: Do We (Un)Knowingly Accept Doing The Wrong Thing? IAANA Journal. August v. 78 n. 4 pp.1499-1502
Hooper R (2013) Where Hyenas are Used to Treat Mental Illness 17 .10 bbcnews
Vauhan D (2011) The Normalisation of Deviance Chapter Twelve nttc.edu
Vaughan D Professionalism/ The Normalisation of deviance wikibooks

Carol Dimon 2014 c


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