Normalizing Deviant Behavior in Healthcare
By Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA
This column originally appeared in the May 2022 issue of Healthcare Hygiene magazine.
When I first heard the term “normalization of deviance” my first thought was “What are they talking about?” As I continued to research the topic it became much clearer, and I found that it truly is something to which we in healthcare need to pay attention.
Diane Vaughan, a sociologist and a professor at Columbia University, used this phrase when describing the Challenger disaster. She found that the underlying cause of the space shuttle tragedy was related to the decision to continue to fly the space shuttle with a known design flaw of the O-rings.
Wikipedia describes the phrase of normalization of deviance as a term used by Vaughan to describe the process in which deviance from correct or proper behavior becomes normalized in a corporate culture. Vaughan defines this as a process where a clearly unsafe practice comes to be considered normal if it does not immediately cause a catastrophe: "a long incubation period [before a final disaster] with early warning signs that were either misinterpreted, ignored or missed completely."
When putting this into the healthcare perspective, how would this phenomenon happen? What would it look like?
The American Society for Healthcare Risk Management (ASHRM) states on a safety tip sheet that “Normalization of deviance is the gradual process of deviating from standard operating procedure (SOP) for various reasons and the deviation becomes the norm as no immediate adverse outcomes occur. Normalization of deviance in patient care has the potential for devastating outcomes. It plays a unique role in health care as the very safety practices and a larger culture of safety meant to prevent deviation from SOP are not as widespread as early patient safety movement proponents anticipated.”
So, again, I asked myself, what would this look like?
Not gowning when appropriate, improper application or failing to replace gloves, failing to confirm resident identify and using unapproved abbreviations are common deviations in healthcare. It can start small and can easily become the norm as more staff members do it and then mentor and train new staff. It doesn’t seem like a rule violation. Some might not even know there is a rule. It seems harmless to those involved.
Consider hand hygiene in a nursing home. For years we have had rules regarding when hand hygiene should be performed, how to perform it, and what soaps or alcohol-based handrubs (ABHRs) should be used. Many facilities have perfect policies and procedures written, which provide this information to the staff who are directed to follow them. However, in many facilities there was a lack of sinks or not enough ABHR stations or dispensers. Individual containers 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?
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).
Exploring Enhanced Barrier Precautions
By Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA
This column originally appeared in the October 2021 issue of Healthcare Hygiene magazine.
The title of this article raises some good questions. What are enhanced barrier precautions? Where do they fit when considering Standard Precautions and Transmission-based Precautions? How long have they been in effect?
In the past several weeks, it has become apparent that many facilities across the nation are unaware of these precautions. With the COVID-19 pandemic starting shortly after the effective date of this guidance, it is plausible that it got lost in the shuffle of many new requirements and rules and reporting mandates as well as the number of residents with the infection, shortage of staff and lack of personal protective equipment (PPE). However, these enhanced barrier precautions are an important ingredient to stopping the spread of multidrug-resistant organisms (MDROs), so it seems prudent to discuss it.
As of July 2019, novel or targeted MDROs included:
• Pan-resistant organisms
• Carbapenemase-producing Enterobacterales
• Carbapenemase-producing Pseudomonas spp.
• Carbapenemase-producing Acinetobacter baumannii
• Candida auris
In an interview of Kara Jacobs Slifka, MD, MPH, and Nimalie Stone, MD, MS, physicians with the long-term care team in the Prevention and Response Branch within CDC’s Division of Healthcare Quality Promotion, addressed why MDROs pose such a threat in nursing homes, even more than in other healthcare facilities, They stated, “MDROs, especially those for which we have limited antibiotic treatment options, pose a threat in healthcare because they colonize individuals for prolonged periods of time, silently spread, and cause invasive infections with high morbidity and mortality. As healthcare delivery keeps shifting away from hospitals, nursing homes are providing more care to medically complex and frail individuals who are more vulnerable to the harms from MDROs. The combination of the long lengths of stay, exposures to indwelling medical devices and antibiotics, and the increased dependence of nursing home residents contribute to the spread and acquisition in this setting.”1
Let’s examine the evolution of precautions to see how we got here.
Infection precautions of some sort have been used since the 14th century when ships were quarantined for 40 days out at sea to prevent the spread of the plague. By the early 1900s, some elementary practices were in place by using barrier gowns and the start of antisepsis such as handwashing and disinfection had begun. This was known as “barrier nursing.” It wasn’t until 1970 that published guidelines were introduced and used. Throughout the rest of the 20th century and the early years of the 21st century, the guidelines changed and in 2019 enhanced barrier precautions were introduced. The COVID -19 pandemic brought home the need for diligent use of precautions and PPE. For this journey through the changes, see Table 1.
Using contact precautions often is a balancing act between preventing MDRO transmission and residents’ quality of life. Use of PPE and room restrictions leads to residents being isolated from staff and family and causes depression and physical function decline as witnessed during the current pandemic.
CDC states, “Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time (e.g., months), and result in the silent spread of MDROs.”2
CDC indicates there is growing evidence that using Contract Precautions in the current manner isn’t adequate to prevent MDRO spread.
Implementation of enhanced barrier precautions is in the middle between Standard Precautions and Contact Precautions. PPE is used in certain circumstances but doesn’t require the resident to be restricted to their rooms, thus providing the goal of reducing MDRO spread while maintaining residents’ quality of life.
Perhaps to put enhanced precautions into some perspective we should discuss Standard and Contact Precautions.
Standard Precautions, as indicated earlier in Table 1, are infection prevention practices that are used when caring for all residents regardless of infection or colonization status. These practices are based on the premise that all body, blood fluids, secretions and excretions (except sweat) may contain infectious pathogens that are transmissible. Proper PPE, hand hygiene, safe infection practices, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and disinfection of point of care equipment.
Contact Precautions are one of the Transmission-based Precautions that are used to prevent the spread of infectious pathogens that are spread via direct and indirect contact from the resident or resident environment. It requires the resident to remain in their room and are restricted from group activities. It is usually a short-term intervention and should have a planned discontinuation such as when symptoms are not evident or other criteria has been met.
Enhanced barrier precautions became effective on July 26, 2019. The interim guidance was updated and posted on that date. This update does not replace the existing Contact Precautions nor is it intended for acute-care or long-term care hospitals. It expands the use of PPE beyond Standard Precautions and calls for the use of gloves and gowns during high-contact activities where MDROs might be transferred to staff hands and clothes. This includes residents that are infected or colonized when Contact Precautions don’t apply.
Only the following high-contact resident-care activities are included in these precautions and require the wearing of gloves and gowns:
• Providing hygiene
• Changing linens
• Changing briefs or assisting with toileting
• Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
• Wound care: any skin opening requiring a dressing3
Other resident care does not require these precautions unless indicated by Standard Precautions. Residents are free to come and go from their rooms. See Table 2 for a breakdown of the three precautions.
Table 2: Summary of PPE Use and Room Restriction When Caring for Residents Colonized or Infected with Novel or Targeted MDROs in Nursing Homes4
So, now you might be asking, how do I implement this guidance? There are six steps to using these precautions and they also apply to Contact Precautions. The most important factor is to ensure that staff are aware of the facility’s expectations regarding these precautions.
1. Signage: Be sure you have proper signs posted on the resident’s door or wall next to the door regarding the precaution. It should indicate the PPE required and for Enhanced Barrier Precaution it should Indicate which high contact activities require the PPE.
2. PPE: Critical to have appropriate and adequate PPE supplies outside the room.
3. Alcohol-based handrub (ABHR): Access to ABHR both inside and outside the room is preferable.
4. Trash can: Location of a trash can just inside the resident’s room door to allow for PPE removal.
5. Monitoring and assessment: To ensure that staff are following the policies and procedures for these precautions and to determine if additional education is needed. This can be random, under cover and planned/scheduled.
6. Education: Provide residents and family members with education and training opportunities on these precautions and why they are necessary.
Prevention of MDRO transmission in nursing homes requires more than just proper use of PPE and room restriction. Education, training, and monitoring is also needed to ensure the implementation of other recommended infection prevention practices (such as hand hygiene, environmental cleaning, proper handling of wounds, treatment of indwelling medical devices, and disinfecting of resident-care equipment) are occurring appropriately.
Cindy Fronning, RN-BC, CDONA, FACDONA, RAC-CT, IP-BC, AS-BC, is the director of education at NADONA. She was a national consultant for more than 20 years and developed and teaches the infection prevention and control certificate of mastery and antibiotic stewardship certificate of mastery courses.
The Long-Term Care Perspective
By Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA
Editor's note: This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.
Recently I had a facility ask what the Occupational Health and Safety Administration (OSHA) had to do with nursing homes. She had been asked for a bloodborne pathogen (BBP) plan and didn’t have one. She was of the opinion that she didn’t need one since her facility was a nursing home and not a hospital or industry-driven organization.
First, some history. OSHA was established under the Occupational Safety and Health Act of 1970. It was created to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education and assistance.
The Occupational Exposure to Blood Borne Pathogens Standard, § 1910.1030(d)(3) (56 FR 64175) published in 1991, protects workers who can reasonably be anticipated to contact blood or other potentially infectious material (OPIM) as a result of performing their job duties. This applies to any employer with this potential -- hospitals, post-acute facilities, freestanding labs, etc.
The Centers for Disease Control and Prevention (CDC) estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. All occupational exposure to blood or other potentially infectious materials (OPIM) places workers at risk for infection from bloodborne pathogens.
Other potentially infectious materials include other body fluids such as semen, vaginal secretions, cerebrospinal fluid and saliva to name a few.
In the years following the BBP standard’s publication, the CDC found that nearly 600,000 percutaneous injuries were sustained by healthcare workers annually involving contaminated sharps. Due to the concern over these exposures and the technological developments which can improve employee protection, the Needlestick Safety and Prevention Act was passed in 2000 which directed OSHA to revise the BBP Standard, requiring employers to identify and make use of effective and safer medical devices. This revision was effective April of 2001.
So, what does this mean for long-term care facilities? The BBP standard must be followed. The BBP plan must have these components:
A written exposure plan to eliminate or minimize exposures that identifies which job classifications are at risk, together with a list of task/procedures that might result in an exposure.
The plan must be updated annually to reflect the following:
• Changes in tasks /procedures
• Technological changes that might eliminate or reduce exposure
• Use of safer medical devices
• Document solicited input from frontline workers in identifying, evaluating and selecting effective engineering and work practice controls.
• Implementation of standard precautions.
Identify and use engineering controls such as sharps disposal containers, self-sheathing needles and sharps with engineered sharps injury protection and needleless systems.
Identify and ensure the use of work practice controls. These are practices that reduce the possibility of exposure by changing the way a task is performed.
Provide personal protective equipment (PPE), such as gloves, gowns, eye protection, and masks and the necessary fit testing if using N95 respirators.
Make available hepatitis B vaccinations to all workers with occupational exposure.
Make available post-exposure evaluation and follow-up to any occupationally exposed worker who experiences an exposure incident.
Use labels and signs to communicate hazards.
Provide information and training to workers
Maintain worker medical and training records including sharps injury log
Although the BBP standard is the main OSHA regulation that long term care facilities must follow, the premise of OSHA is one that we as employers must keep in mind at all times; to provide a safe and healthful working environment for our workers, and it carries a very high priority. Whether it is workplace violence, emergency preparedness or BBP we must be aware and always seeking ways to improve and provide the best working place we can for our employees.
COVID -19 placed a huge burden on the post-acute arena to not only keep our residents and clients safe and infection free but also our employees. Many of us lost employees to this pandemic infection. Those employees may have contracted the infection in the community or possibly at work. With that in mind we have reporting responsibilities not only to the Centers for Medicare & Medicaid Services (CMS), CDC, NSHN but also to OSHA.
OSHA was and is very much involved as evidenced by the three Interim Enforcement Response plan memorandums issued April 13, 2020, May 19, 2020 and March 3, 2021 involving annual fit testing of respiratory protection; six enforcement discretion memorandums dating from March 14, 2020 to Oct. 2, 2020 regarding respiratory protection; and three other memorandums addressing recording and reporting occupational injuries and illnesses and various standards that require annual or recurring audits, reviews, training or assessments.
OSHA has been surveying post-acute care facilities through the pandemic:
- 310 OSHA surveys have taken place in 23 states as of Jan. 14, 2021
- 912 tags have been issued resulting in more than $4 million in fines
- New York had 64 surveys with 172 tags and New Jersey had 101 surveys with 324 tags
The tags issued were similar among the 310 surveys (some facilities had multiple surveys done); they included PPE and reporting.
1910.134(e) Medical evaluation: specifies the minimum requirements for medical evaluation that employers must implement to determine the employee's ability to use a respirator
1910.134(e)(1) General: employer shall provide a medical evaluation to determine the employee's ability to use a respirator, before the employee is fit tested or required to use the respirator in the workplace.
1910.134(f)(1) Fit Testing: Fit testing is required prior to initial use, whenever a different respirator facepiece is used, and at least annually thereafter.
1910.134(g)(1)(i)(A) The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function;
1904.29(a) Basic requirement. OSHA 300, 300-A, and 301 forms, or equivalent forms, for recordable injuries and illnesses must be used. The OSHA 300 form is called the Log of Work-Related Injuries and Illnesses, the 300-A is the Summary of Work-Related Injuries and Illnesses, and the OSHA 301 form is called the Injury and Illness Incident Report. (https://www.osha.gov/recordkeeping/forms)
1904.39(a)(1) Within eight (8) hours after the death of any employee as a result of a work-related incident, you must report the fatality to the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor.
1904.39(a)(2) Within twenty-four (24) hours after the in-patient hospitalization of one or more employees or an employee's amputation or an employee's loss of an eye, as a result of a work-related incident, you must report the in-patient hospitalization, amputation, or loss of an eye to OSHA.
1904.39(a)(3) You must report the fatality, inpatient hospitalization, amputation, or loss of an eye
In reviewing complaints to OSHA regarding essential industries (healthcare, retail trade, grocery stores, construction, general warehousing, restaurants/eating establishments and auto repair) healthcare had 45 percent of the complaints issued.
The take-away from all this data are some questions that we need to ask ourselves regarding our facility and OSHA responsibilities:
- Do we have a complete BBP plan that is reviewed annually?
- Are we providing the training on the BBP plan and do we make it available to our employees?
- Are providing the appropriate PPE and providing fit testing when employees use N95 respirators?
- Are we gathering input from our employees and using that data to edit and improve our plan?
- Are we documenting and retaining that documentation for the time period indicated?
- Are we using the OSHA forms 300, 300A, and 301 and posting 300A from Feb. 1 to April 30 each year?
- How satisfied are our employees with the efforts we are expending to keep them safe?
Are we ready for a visit from OSHA? Can we afford to be unprepared for the sake of our residents/clients and staff? If you haven’t given OSHA much attention in the past, it might be time to sit down and do a thorough review of the facility BBP plan, supplies/equipment and reporting process.
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).