were not readily available or even supplied at all . Nurses started taking short cuts , justifying it by thinking : “ I wash my hands after I take my gloves off but not always before I put them on .” “ I wash my hands when I go into a room but not always before I leave .” “ I use ABHR but I don ’ t always wash my hands with soap and water when I have taken care of someone with C . difficile .”
The shortcuts take on a life of their own and if not recognized as poor practice and identified as a deviant practice ; without some kind of outcome or penalty , the practice continues . It is a slow incubation period and until a tragedy occurs or a significant outcome is experienced , it continues to happen .
Let ’ s move now into the post-COVID era of our lives . How many of those nurses in those first several days and weeks were practicing hand hygiene in the manner that they had for the past months and years ? What if some of those residents that contracted COVID-19 or some of the staff that became infected did so because of that negligent practice ? How many infections could have been avoided by auditing and providing remedies for the poor performance prior to this pandemic ?
Another example of this is described by John Banja in a paper , “ The Normalization of Deviance in Healthcare Delivery .” The story was relayed to him by another physician : “ When I was a third-year medical student , I was observing what turned into a very difficult surgery . About two hours into it and after experiencing a series of frustrations , the surgeon inadvertently touched the tip of the instrument he was using to his plastic face mask . Instead of him requesting or being offered a sterile replacement , he just froze for a few seconds while everyone else in the operating room stared at him . The surgeon then continued operating . Five minutes later he did it again and still no one did anything . I was very puzzled , but when I asked one of the nurses about it after the operation , she said , ‘ Oh , no big deal . We ’ ll just load the patient with antibiotics , and he ’ ll do fine .’ And , in fact , that is what happened ; the patient recovered nicely .”
What about the next time ? What about the patient having to receive antibiotics that might not have been needed if the physician had practiced appropriate infection prevention procedures ? What if someone had spoken up ? What if the patient developed C . difficile from the antibiotics ?
When questioned about these deviant practices some common responses have been :
• “ The rules are stupid and inefficient ”
• “ Knowledge is imperfect and uneven ”
• “ Knowing rules , guidelines , why does the guideline exist ?”
• “ How many rules or checklists are you expected to know in your daily practice ?”
• “ I ’ m breaking the rule for the good of my patient ”
• “ Workers are afraid to speak up ”
• “ The rules don ’ t apply to me / you can trust me ”
• “ Leadership is withholding or diluting findings on system problems ”
We , as an industry , have an obligation to our residents and our staff to speak up and recognize these practices for what they are : noncompliance and a disaster in the making .
We need to make some changes to stop this from occurring and bring us back to the place of following the rules that provide both residents and staff with the best safety possible . How do we do that ?
We , as an industry , have an obligation to our residents and our staff to speak up and recognize these practices for what they are : noncompliance and a disaster in the making .
We need to make some changes to stop this from occurring and bring us back to the place of following the rules that provide both residents and staff with the best safety possible .”
Again , it must be a priority , something for which we are on the alert . Currently , you would stop a staff person from stepping into a transmission precaution room with a resident with COVID , from entering without PPE . We need to be on the alert with not only the big items but the small things as well . Here are some ways to accomplish this :
• Conducting audits for various practices – This could be shared between the director of nursing ( DON ), infection preventionist , nurse , nurse educator , environmental services , dietary , etc .
• Creating a no-blame culture where the staff member isn ’ t blamed , but the system goes under review ( such as not having ABHR available ). Developing a culture where staff feel comfortable speaking up and sharing as well as intervening when seeing those process deviations .
• Talk to staff and get their feedback about procedures that are found not to be in compliance . Do a deep dive to find out why they are taking shortcuts .
• Take the time to review a practice and see if it needs updating . Test it out and get suggestions on how to prevent those short cuts from occurring .
Paying attention to details like incident reports , audits and feedback will help us . Together they can direct us on how to proceed . This is an excellent project for QAPI . It calls for identifying the issue , doing a root cause analysis , creating some interventions , and then trying them out .
We can ’ t be overly optimistic that we can fix it quickly but with determination and resolve we can whittle away and in time prevent the next “ catastrophe ” from happening .
Cindy Fronning , RN , GERO-BC , IP-BC , AS-BC , RAC-CT , CDONA , FACDONA , is a master trainer and director of education for the National Association of Directors of Nursing Administration in Long-Term Care ( NADONA ).
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