1. Kennedy, Maureen Shawn MA, RN


To serve the greater good, accurate documentation is essential.


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I generally don't dwell on my age, but there are times when I feel old-like when a neighbor's child, who was doing a school project, asked to interview me because I was alive during the time of the Vietnam War protests. I also feel old when I think of certain hospital policies and nursing practices that were in place when I became a nurse and started working in a hospital in 1971. Back then, in the dark ages, there was no such thing as open visiting hours; family members could visit only one or two at a time and only for short periods within specified hours. Most hospitals didn't allow husbands in the delivery room, nor were young children permitted to visit a new sibling. Life partners, significant others, and doulas were unheard of. And who would even think of telling a patient that a pet could visit? Fortunately, most of these policies have changed; some forward-thinking hospitals and institutions even have pet visitation programs.

Figure. Maureen Shaw... - Click to enlarge in new windowFigure. Maureen Shawn Kennedy

After reading Jodie C. Gary's article, "Exploring the Concept and Use of Positive Deviance in Nursing" (a CE feature this month), I thought about the countless innovations that have come about in nursing and health care, and realized that many were likely the result of positive deviance, which can be described as the "intentional act of breaking the rules in order to serve the greater good." Such acts are often a creative or adaptive response to a challenging situation. One important aspect of positive deviance is that there's often an element of risk for the rule breaker. Think about those nurses who first allowed children to visit newborn siblings, or smuggled a beloved dog or cat into a hospital to cheer up a depressed or dying patient. Actions like these might have caused those nurses to be written up by their supervisors, or worse.


Nursing history is replete with acts of positive deviance, which, as Gary notes, has also been referred to as "responsible subversion." Perhaps two of the most famous subversives were Florence Nightingale and Lillian Wald, who ignored social conventions and hierarchies so that they could create organizations and systems for delivering care to people who needed it. But we don't need to look that far back. Look around your workplace-I'll bet you'll find many people who have also bent or broken the rules on behalf of patients. I know I have.


As a staff nurse, I was once part of a team that deceived an overeager first-year surgical resident in order to protect a burn patient. The patient was scheduled for transfer that day to a hospital with a burn unit, and the transfer protocol was very specific in detailing how the wounds should be treated; debridement was definitely not to be done. But the first-year resident, wanting more experience, was insistent about performing debridement. With the charge nurse's tacit approval, we wheeled the patient out of our unit to an isolation room, telling the resident the patient was getting X-rays required by the burn unit. By the time the resident realized the patient wasn't in radiology, the transfer team had arrived.


I also remember several instances when, as a clinical director of nursing in a community hospital, I was asked to "counsel" ICU nurses who had repeatedly violated hospital policy by taking orders verbally over the telephone. In most cases, the orders were for pain medications. The nurses took the orders by phone because their patients were suffering, and they didn't want them to have to wait for the physicians to come and provide written orders. Because there was transparency-the nurses documented that patients were receiving inadequate pain relief, wrote "verbal order" and signed their names in the charts, and had the orders cosigned by the physicians when they did arrive-it was apparent that policies needed to change. The result was a new pain management protocol and standing orders for pain medications.


The need for positive deviance often signals that system processes aren't working. And as Gary points out, transparency is essential. All too often, the innovations and adaptive work-arounds that constitute acts of positive deviance aren't documented. Thus the illusion persists that the system is functioning well, when it isn't-and more dangerously, that patients are getting care exactly as it was prescribed, when they're not. Nightingale and Wald were careful recorders; their data provided the supporting evidence that made their innovations sustainable. We need to do the same if we want to change systems through positive deviance, making them safer for our patients and ourselves.