OPINION

What makes you break the rules?

19 May, 2011 | By Nadine Woogara

Do current healthcare systems effectively encourage nurses to stick to protocol?

When you drive on the motorway, do you stick to the speed limit? I don’t. If the car I’m driving doesn’t shudder and break I drive at a comfortable 75 mph and 80 if I’m feeling annoyed or reckless, or if I’m pushed for time. They’re not great reasons, but they’re true.

So what pressures can encourage you as a nurse to break the rules? Are the reasons the same? Are you less likely to follow hand hygiene protocol if you’re pushed for time, you feel you’re not likely to get caught or if you have more of a natural propensity to take risks?

An interesting talk at this week’s Patient Safety Congress 2011 by John Pickles, associate medical director for patient safety, Luton and Dunstable Hospital NHS Foundation Trust, discussed human behaviour and risk taking in healthcare.

He said that driving on a motorway can be compared to working in healthcare. Factors that influence a nurse’s behaviour at work may be their pressure to hit targets, good or bad interaction with technology and increase in patient demand - just as you might start pushing 80 if you’re running late.

But the real question isn’t why do some nurses break the rules, as pointed out above – everyone does. But more important than that is the question – do the healthcare systems currently in place effectively encourage a culture of protocol compliance?

John emphasised that we need a culture of openness between staff at different levels that will encourage people to admit their mistakes and discuss what’s going well and what’s not – without the fear of being blamed and reprimanded.

Not that he encouraged a totally blame-free culture, but a culture where nurses and other staff communicate openly. “Is it working?” “No.” Well then let’s change things.

Will healthcare settings ever be able to be fully open – and will this really encourage professionals to stick to the speed limit?

Readers' comments (16)

Anonymous | 20-May-2011 12:22 pm
When I see patient safety incidents, it's almost always down to staff being rushed off their feet due to understaffing. I know it's not an excuse, but management are setting themselves up for this when they cut and cut. I've decided that I will walk out if it becomes a serious problem, and try to get others to come with me. I don't want to be in a Mid Staffs situation. We've got to keep shouting about it. I hate seeing patients who aren't getting the attention they need. I hate seeing staff who have stopped caring. It's all very depressing.
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Anonymous | 20-May-2011 12:30 pm
take me with you anonymous 12.22
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Anonymous | 20-May-2011 12:32 pm
things are pretty good on my ward! people always talk about whats going wrong & fix it
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Anonymous | 20-May-2011 4:15 pm
The knowledge that rules are for the guidance of the wise
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mike | 21-May-2011 2:52 pm
Nothing at all makes me break the rules guv!!! (The witchfinder generals at the NMC will probably be reading this as an easy way to target their next victims!)
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DH Agent - as if ! | 23-May-2011 2:37 pm
I'm not a nurse, but I am involved in a very complicated debate about EoLC: in my view, there is a lot of evidence, that nurses simply stick to protocols.

ALL PROFESSIONALS (especially those not at the top of hierarchies) tend to stick to protocols - because, they can then say (however ridiculous, their actions were) - 'but I followed our rules'.

This is pretty close to the the 'I was only following orders' defence of the German guards, at places like Auschwitz.
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Anonymous | 23-May-2011 3:25 pm
instead of adopting the culture of the moment which is constantly changing and totally unstable, why can't people in a profession as humanistic and caring as nursing just be allowed to be themselves without pretense and with the normal rights of free but appropriate expression to suit the situation of their profession with respect for those they are working with and for. perhaps then channels of communication would open up spontaneously and staff would feel better supported and able to do the job they have chosen and been trained to do? why are people so afraid to present an image of themselves and the valued person that they really are?
rules and regulations must be for everybody's protection but too many and those which are unreasonable stifle creativity, lateral thinking, initiative, taking responsibility and eventually kill all motivation. in turn this leads to stress, bullying, sickness, depression and the eventuality of professional burnout all of which has repercussions on team working and on the patients.
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Anonymous | 23-May-2011 3:47 pm
i agree with my dentist in Britain when she said that the trouble in this country is that people take rules and regulations far too seriously which is to their detriment. she was actually referring to EU regs. which have so seriously and numerously (excuse grammar) infiltrated the health services which often seem rather pointless and take up an inordinate amount of time in terms of extra paperwork which could be better spent on
seeing or caring for patients.

When I come to think of it, and look at our European counterparts, with whom I have worked for most of my long career, those of a Latin temperament from some parts of Europe still deliver very high standards of care but in a far more relaxed manner. In fact some of them, and I won't mention nationalities, spend their time trying to dodge the rules but this doesn't seem to make them any less able to care or perform their work to the highest and most exacting standards and they seem to get far more out of life and enjoy it than we do at present in Britain.

On the other side of the coin, there are those of a more Germanic temperament, but not all, and I am not referring specifically to those from Germany, who are even greater sticklers to rules, regulations discipline than in Britain and although they possibly also deliver excellent care they take all that they do extremely seriously which is sometimes devoid of humour.

It is how the French (now I have given it away but again above I refer to Francophones and not only the French) deal with traffic infractions which always amazes and amuses me! If I had one, I would be most upset, shamed and do my utmost to try and make sure it never happened again, whereas they prefer to pay the fines quite regularly in order to get to where they want in time or the parking space they want, even to the point of endorsement and eventual removal of their licences. Does nothing phase them?

rules, rules, rules and even more rules and exceptions to the rules!
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Anonymous | 23-May-2011 4:07 pm
I think today there are rules being brought in to pay lip service to being seen to be doing the "right" thing, where some of it doesn't make logical sense.
I have always been a mechanically minded person, an intuitive view that made me question things in my mind, but in the early days without confidence to challenge.

OK, I am not always right, BUT one simple example is the old practise of bending someone's arm after taking blood. It just never made sense but I followed the protocol because I assumed the "powers that be" had some rationale higher than mine. A few years later I was dutifully bending someones arm, when a passing anaesthatist said it was no longer recommended practise and we now had to keep the arm straight and apply pressure direct to the spot where the needle had been. I have to say, I felt quite smug ... quietly.

Anyway, the same applied when I saw nebilisers being dished out instead of spacers ... now it doesn't make sense to waste all this plastic covering notices on the wall "in case of aerosol infection". I mean, who is going to breathe in close proximity, my poster on weight ratios?? Surely, we are far greater at risk from the nooks and crannys on all our technology equipment?
When is someone going to design a gadget to sterilise the door handle when we leave the loo??
Why did we have less MRSA in the 70's?
I know.... it was because nurses had to wear clean stockings every day!!!
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Anonymous | 23-May-2011 4:18 pm
sometimes it is better to rely on intuition and plain commonsense even though big brother is watching

big brother may be on a higher rung up the ladder but may not possess the same knowledge, experience or insight
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Anonymous | 23-May-2011 4:19 pm
the only happy times i had at boarding school was when i was having fun breaking the rules and not getting caught.
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Anonymous | 24-May-2011 6:26 pm
Its a silly comparison- Breaking the speed limit is usually stupid and unnecessary. Its what causes death and I never do it
Most nurses dont want to break rules and regulations which are there for safeguarding care.
A lot of the rules though, are there to cover backs,so the NHS doesnt get sued- not for the good of the patient. Every one is accountable- noone in management seems supportive.
The culture is closed and secretive and mistakes are covered up,(made because of tiredness and busyness, not deliberate rule breaking) because of the punishment culture of management and the NMC- The Witch Finder General is a good term for it
Lets have an enlightened view - we are all in it together ,hopefully, to try and help people, not punish the help providers
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Anonymous | 25-May-2011 8:42 am
i alwways stick to the rules.....hey if i didn't i'd loose my registration and my job.
Often not easy to due to understaffing etc.

I also think that most of us do more then sticking to the rules, if not we'd cause the NHS to come to a standstill...... how many of us stayed on beyond the end of our shift to finish of work, worked through our lunch breaks etc......

Work to rule should just mean that but the majority of us are dedicated and do over and above this............
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DH Agent - as if ! | 25-May-2011 10:08 am
Anonymous | 24-May-2011 6:26 pm

A lot of the rules though, are there to cover backs,so the NHS doesnt get sued- not for the good of the patient.

QUITE !!!!
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Anonymous | 26-May-2011 8:14 am
Anonymous | 25-May-2011 8:42 am
''Work to rule should just mean that but the majority of us are dedicated and do over and above this...''

Doesn't that mean you are breaking the rules???????
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Anonymous | 2-Jun-2011 6:03 am
We as nurses have only ourselves to blame for the many predicaments we find ourselves in! Every now and then a task or a service once provided by others is because of one reason or another deemed to be reallocated to the remit of nurses. i find myself doing admin work, secretarial work,on site training , mentorship,and numerous other non nursing duties before I can practise basic nursing care which is what I want to do.I,m sorry to say this but its that very"dedication" which has been the main reason that nurses have and always will be seen to accept whatever management casts their way. As a conclusion we should either work the hours we,re paid for and do the duties of priority and nothing more or we should all shut up and get on with it!!!!
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