The NHS is littered with inquiries in the wake of patient safety failures, all reporting depressingly similar findings.
The 2001 inquiry into Bristol Royal Infirmary led to the introduction of clinical governance and the 2013 inquiry into Mid Staffordshire NHS Foundation Trust brought a focus on values and culture, and yet reports of avoidable deaths, poor safeguarding, and failure to listen to patients and families persist.
“Normalisation of deviance is not a culture or a values failure; it is a predictable result of a system under strain”
Elaine Maxwell
In recent weeks, the Muckamore Abbey Hospital Public Inquiry and the Independent Maternity Review of Nottingham University Hospitals NHS Trust have both attributed failures in part of the ‘normalisation of deviance’.
This has been largely overlooked or misunderstood in media discussions. Where it has been considered, the implication is that individuals chose to deviate from established practice and are a human resource issue.
But evidence suggests the opposite; the system in which frontline staff work frequently leaves them no option but to deviate. The issue is whether the deviation becomes normalised rather than the system being corrected.
Originally identified in NASA’s investigations into the 1986 Apollo Challenger disaster, normalisation of deviance describes how individuals or teams drift away from established practice standards.
This starts as an adaptation to meet changing conditions and may appear to be an efficient alternative. In the absence of any feedback, it becomes routine and accepted as ‘how we do things here’.
However, deviations can interact in unpredictable ways. A minor documentation shortcut, plus a communication breakdown, together with understaffing, can combine into catastrophic harm.
Normalisation of deviance has always been a feature of nursing practice, described by educators as the theory-practice gap and by safety scientists as the difference between work as imagined and work as done.
While there may be a tiny fraction of the workforce who are just lazy or do not care, can we really tar the whole profession with the same brush?
The Muckamore Abbey Hospital Public Inquiry found that there were multiple system factors that created an impossible work environment.
Chronic staff shortages were exacerbated from 2010 as the push to resettle long stay patients and close wards led to vacancy freezes. The push to close wards changed the case mix.
Stable long-stay patients moved to wards with patients being admitted with acute mental health problems and a steep increase in the number of autistic people. This produced a sharp rise in challenging behaviours – better described as distressed behaviours.
Positive behaviour support plans prescribed enhanced supervision (sometimes two or even three staff to one patient) but ward establishments (devised using tools developed for adult nursing in acute hospitals) did not allow enough staff to provide this even before the high vacancy rates.
Wards became increasingly violent and, in the absence of sufficient expertise, the response to patients’ distressed behaviours became dehumanised. Use of restrictive practices and seclusion rose with increasing deviations from best practice.
The result was a police investigation with a number of nursing staff already charged with offences of ill treatment of a patient under the Mental Health Order, wilful neglect, false imprisonment and making a false entry in a record.
Contrary to the pervading narrative, staff did report concerns. From 2012, the service manager (and lead nurse) frequently reported that staffing was unsafe to both the trust and to the Regulation and Quality Improvement Authority – the Northern Ireland equivalent of the Care Quality Commission.
In 2013, one ward manager told the local university that there were insufficient staff to accept student placements.
A retrospective review of Datix reports showed aggressive and inappropriate behaviour incidents by patients towards staff quadrupled between 2010 and 2017. High numbers of safeguarding referrals were dismissed as normal for learning disability services.
There was data that deviations from best practice was causing harm to patients, but Belfast Health and Social Care Trust failed to conduct an adequate analysis and was unaware of the rise in Datix reports of aggressive behaviours until preparing submissions to the inquiry.
Staff received no feedback and the trust failed to consider that working conditions were producing deviations or to take action that would facilitate best practice. It was only the viewing of CCTV in 2017 that revealed how far practice with some patients had deviated.
While these findings come from a learning disability hospital, the concept of normalisation of deviance was also described in midwifery at Nottingham and likely exists in all services providing care in sub-optimal conditions.
Poor working conditions together with awareness of missed care can lead to staff stress and burnout with associated reduced cognitive bandwidth, meaning that staff do not perceive their practice as deviation from professional standards and cannot see that their behaviour has become task orientated rather than compassionate.
While individual nurses must be held to account, the conditions in which they practise must also be considered.
It is, therefore, incumbent on nurse leaders (at all levels) to be vigilant, to acknowledge when conditions are sub-optimal and to identify high risk practices and regularly assess for workarounds.
There is a need to move from monitoring compliance with polices and action plans to a sophisticated analysis of multiple data sources – including patient and family feedback – to build a real-time picture of how a service is deviating, and whether the desired outcomes of safe, effective and dignified care are being consistently met.
Normalisation of deviance is not a culture or a values failure; it is a predictable result of a system under strain.
The deviations themselves are not the problem. Ultimately, the failure of senior leadership to identify and assess deviations before they become normalised is the real problem.
Dr Elaine Maxwell is an independent consultant and panel member for the Muckamore Abbey Hospital Public Inquiry. A nurse by background, she was previously a clinical advisor at the National Institute for Health Research and associate professor at London South Bank University.
Timeline on Muckamore Abbey Hospital
