Sterile break seen as normal deviance

Authority figures in health care have the potential to influence whether deviation is normalized, notes John Banja, PhD, assistant director for health sciences and clinical ethics at Emory University in Atlanta.

Banja relates an example of the normalization of deviance he once heard from a doctor: When the doctor was a medical student, he was observing a surgical procedure and was surprised to see the surgeon inadvertently touch the tip of the instrument he was using to his plastic face mask. Everyone in the operating room paused and looked at the surgeon, waiting to see if he would ask for a new sterile instrument. The surgeon just continued on with the procedure and then accidentally touched his mask again a few minutes later. No one said or did anything, and the surgery was completed. When the medical student asked a nurse why no one had said anything, she told him, "Oh, it's no big deal. We'll just load the patient up with antibiotics."

The deviation had become normalized so that it was "no big deal."

"That's what we see a lot with the normalization process. When it's a person in authority, someone you look up to or maybe someone you are afraid to confront, what they do in that situation can become the way everyone does it," he says. "If the doctor in that situation had responded by following the right procedure and getting a new instrument, even if that was a lot of trouble, he would have sent a strong message to everyone in that room about doing it the right way. Instead, he sent a message that it was OK to deviate."