It's OK to Break the Rules, Sometimes

A nurse leader advocates for "positive deviance" in nursing—bending or tweaking rules or guidelines in the interest of positively affecting patient care, even though there is no outcomes data to support the practice.

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!
Mary Parker (9/11/2013 at 9:46 AM)

If positive deviance is going to exemplify behaviors like this, then positive deviance is definitely not appropriate. Demerol should NEVER have been ordered for a geriatric patient becuase of its side effects and limited efficacy in managing pain, especially when there are safer options. This nurse should have requested a new medication order or questioned the order for Demerol in this patient. This is NOT an example of positive deviance[INVALID]-it's an example of operating beyond the scope of one's practice. - - - - - - - - - - - - - - - - - A nurse admitted a patient from the operating room to a general surgical unit following a surgical intervention for a hip fracture. The patient, a petite 89-year-old woman, weighed less than 110 lbs. Within an hour of being settled in the hospital room, the patient reported severe postoperative pain. The nurse consulted the routine postoperative order set from the orthopedic group. For pain management, the order set contained an as-needed order for two tablets of an oral analgesic, as well as meperidine (Demerol) 100 mg delivered either intramuscularly or intravenously. The patient, who had been groggy since admission, had just taken a few ice chips. The nurse decided against the oral analgesic because of the risk of aspiration and choking; and she was concerned about giving such a large dose of meperidine to a small, elderly woman. The nurse decided to administer 25 mg, evaluate its effectiveness after 30 minutes, and then administer another 25 mg if needed. Over the next eight hours, the entire dose of the originally ordered 100 mg of meperidine was administered to the patient, and the patient reported relief from her pain during this time. But because of the built-in controls of the electronic medication dispensing system, the nurse could only document a one-time dose of 100 mg of meperidine administered to the patient an hour after arrival from surgery. In this case, the behavior of the nurse exemplified the defining attributes of positive deviance. The decision to give the medication in delayed doses was intentional and honorable; it stemmed from the nurse's dedication to patient safety. The nurse departed from the established order set in an adaptive way to meet the patient's needs. By not giving the medication as ordered and not documenting what she actually did, the nurse put her career at some risk. These behaviors could be interpreted as prescribing a medication without a license, and essentially are in conflict with most nurse practice acts. However, the outcome was one that resulted in pain relief while minimizing the risks to the patient.


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