Working to rule?

Every day we have to decide upon the best approach to providing the best and safest care for patients.  This requires trawling our internal library and database full of facts and figures, mentally running through the  list of possible options for the signs and symptoms presented and the recommended treatments and solutions to these options.  Clinicians use knowledge gained through years of training and experience and at the same time have to have a constant awareness of new approaches, innovations and best practice.  With over two million research papers written each year this is a daunting task.  

In addition to clinical standards there are also organisational policies, procedures, interventions, and standard operating practices to consider.  It is no wonder that there is a gap between what we know should happen and what actually does happen.  Yet still I hear on a frequent basis; ‘why don’t they just do it’…. ‘why is it so hard for clinicians to simply do the right thing’… ‘why don’t they just do the right thing every time?’ and so on.

In safety language this is often described as violating best practice.  Even the words violating or violation have strong connotations of ‘disgraceful behaviour’; the tone is already set for those who are found to have not adhered to a set procedure.  

However, as Ken Catchpole (1) recently wrote in the BMJ Quality and Safety Journal, ‘violations and non-adherence are common, not always conscious, not always planned, are frequently well meaning, and in many cases allow the system to run smoothly’.  A theme I have often spoken about is the need to understand the just culture in the NHS.  Understanding why people ‘violate’ policies and procedures is a key component of this.

So what is exactly meant by a violation.  It is the failure to do something, or failure to complete one of the steps in a set process or the failure to provide the set treatment. They are typically classified as:

  • erroneous  – the clinician did not understand the policy or was not aware of the right steps

  • routine — when the policy or procedure is routinely bypassed or worked around

  • situational  – usually related to the environment or lack of resources which makes it difficult to take the right steps

  • exceptional – extreme circumstances which result in the clinician choosing to bypass the procedure
  • optimising —when in fact there is a better way or appears to be a better way of doing things

Interestingly, we probably don’t have a clear understanding of the scale and nature of the problem as incident reporting systems are poor at reflecting the nature and frequency of violations especially in relation to routine violations as they become normal, the ‘way we do things round here’.  If regarded as usual practice (not necessarily the written practice) then they will not be detected until perhaps something serious happens.  Experts suggest peer review or regular short periods of systematic observation of practice are better methods to detect and support understanding.

As Rene Amalberti (2) states, a resilient system requires flexibility to help it become safer, efficient and adaptive to changing circumstances.  It is therefore important to understand why this happens and not simply attempt to eliminate them and reprimand those concerned.


(1) Catchpole, K.  BMJ Qual Saf 2013;22:705-709 doi:10.1136/bmjqs-2012-001604

(2) Amalberti, R, Vincent C, Auroy, Y et al BMJ Qual Saf Health Care 2006;15:i66-i71 doi:10.1136/qshc.2005.015982