Normalization of Deviance—Part 2

Behaviors and actions that would normally be condemned have become normalized and excused. Behaviors that create a ripe environment for errors and patient harm are not addressed. This is normalization of deviance.

Posted under: Other, Quality of Care

Last week, I blogged about a topic that is very important to me, and quite frankly, is a key driver for NPIC membership—Normalization of Deviance.

It would seem that this topic is of great interest to many in the healthcare community. Within days, this blog has been viewed hundreds of times and generated a great deal of discussion, particularly surrounding bullying, “bad behavior,” and “behavior that is tolerated due to ‘expertise.’” I received multiple direct messages on LinkedIn, and thought I would share some overarching themes (changed a bit to protect individuals) and thoughts for the future:

“Turnover among the staff is so high. Preceptors are tired, the staff is tired, and no one seems to notice. There seems to be new staff all of the time, policies seem to get updated every other day, and teams can’t keep up.”

“Over time, [they] have reduced staffing numbers to a point that is no longer safe. Caring for two (2) patients in active labor has become the norm and not the exception.”

“Poor behavior is excused because someone is considered a clinical ‘expert’—their skills make up for their behavior.”

“’They have always acted that way’. People report the behavior but nothing is ever done. The culture of the unit is in peril, but nothing seems to change. We’ve simply gotten used to it over time.”

So, while most of the literature surrounding the Normalization of Deviance is focused on systems and processes, perhaps it is time to also devote as much energy towards actions (and inactions) over time that left unchecked create stressors and moral injury to those working within healthcare.

What many of these individuals describe are behaviors and actions that have been “normalized” and accepted behaviors that create negativity, isolation, and feelings of frustration, apathy, and complacency.

There is a multitude of studies, commentaries, and other media that relay the issues that exist within toxic work environments. Spend a day on social media, and it becomes increasingly concerning the sheer magnitude of this issue. And the turnover it creates, perpetuating the continued cycle of frustration, apathy, and complacency.

It is time that this issue is labeled for what it truly is…normalization of deviance. Behaviors and actions that would normally be condemned have become normalized and excused. Behaviors that create a ripe environment for errors and patient harm are not addressed. Accepting what was once unacceptable. Remember the discussion of the Shuttle Challenger disaster last week when introducing the concept of Normalization of Deviance? Rank and seniority became more important than expertise. Aerospace engineers found themselves having to prove harm rather than relying on their knowledge and expertise to avoid harm in the first place (When Doing Wrong Feels So Right: Normalization of Deviance - PubMed (

What if your teams treated the management of deviant behaviors a risk management issue? A risk mitigation issue? Would you handle deviant behavior differently if it was handled as a threat to patient safety? Would you handle staffing shortages differently? Accepting what was once unacceptable?

Call intimidation and bullying in perinatal care what they are…normalization of deviance. Accepting what was once unacceptable.

So, how do we break the cycle? How do we move beyond accepting poor behavior and moving towards a more civil and collegial work environment? How do we ensure that we are providing an environment that is both patient AND staff centered and focused?
  1. Culture comes from the top: Does your Board of Directors/Trustees know what Normalization of Deviance is? And the real risks it presents to patients? Teams? Organizations? Strategy?
  2. If your organization has not reviewed the Shuttle Challenger disaster proceedings and report, I strongly recommend its use in risk mitigation. There are excellent lessons about how people and processes allowed for the movement of the unacceptable to the acceptable. Some of these changes took time. Others were quick and unrecognized.
  3. Create an organization that does not stigmatize event reporting or near-miss reporting. Does your organization classify intimidation or bullying as a near-miss? If not, why not?
Let’s end this on a positive note. There are many hospitals and healthcare organizations that have prioritized eliminating the normalization of deviance and created risk reduction programs that connect all team members to a common goal and purpose: elevate patient care AND team cohesion. While the space shuttle program IS rocket science, creating positive, enriching work environments is not.

Make 2023 the year where normalization of deviance IS normalized in our conversations, and eventually eliminated as a threat to patient safety.

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