Production Pressure and Normalization of Deviance: An Examination of Their Prevalence Among Certified Registered Nurse Anesthetists in Their Primary Clinical Practice Setting

Normalization of deviance (NoD) occurs when an individual intentionally and repeatedly circumvents established standards of care, professional regulations, or institutional policies designed to maintain safety. Over time, these violations become incorporated into the individual’s routine until they are no longer viewed as safety threats but as acceptable means to achieving organizational goals. Production pressure (PP) occurs when an individual perceives pressure to maximize productivity—either from another individual or administrators within an organization. Production pressure is frequently cited as a leading cause of NoD within all industries. The purpose of this study was to examine the prevalence of PP and NoD among CRNAs in their primary clinical practice setting. The following research questions and hypotheses guided this study: Q1 What is the prevalence of normalization of deviance in various clinical practice settings (e.g., hospitals, ambulatory surgery centers, specialty clinics)? Q2 What is the prevalence of normalization of deviance among various anesthesia practice models (e.g., anesthesia care team [ACT], independent practice, or CRNA-only practice)? Q3 What is the relationship between normalization of deviance and years of practice as a certified registered nurse anesthetist? H0: There will be no relationship between normalization of deviance based on years of practice as a certified registered nurse anesthetist. Ha Years of practice as a certified registered nurse anesthetist will have an effect of the prevalence of normalization of deviance. Three elements of NoD were identified for this study: (a) PP, (b) safety violations, and (c) repetition of violations over time. Within health care, production pressure and NoD post substantial risks to patient safety could lead to adverse patient outcomes including increased morbidity (e.g., temporary or permanent disability), prolonged hospital stays, increased medical costs, and even death. A descriptive quantitative design was utilized to ascertain the presence and prevalence of NoD based on clinical practice setting, anesthesia practice model, and years of clinical experience. Statistical analysis was performed on all completed surveys (n = 260) including 19 individual safety violations and six violation domains. The study results indicated that approximately 94% of CRNAs experienced PP more often than monthly in their primary clinical practice setting. Six safety violations met the a priori study criterion (mean score > 2) to establish NoD. Significant differences existed between clinical practice settings for PP (F = 4.409, p = .013), medication batching violations (F = 4.356, p = .018), multidose medication vial use violations (F = 9.438, p < .001), mediation safety violations (F = 6.695, p = .002), and overall (F = 3.161, p = .044). Statistically significant differences between anesthesia practice models included preanesthetic evaluation violations (F = 5.514, p = .005), laboratory and diagnostic study violations (F = 3.807, p = .023), ultrasound prove cover use violations (F = 7.180, p = .001), provider vigilance violations (F = 10.265, p = < .001.), patient preparation (F = 5.092, p = .007) and infection control violations (F = 3.952, p = .020). Statistically significant correlations were identified between clinical experience and four safety violations: neuromuscular blockade monitoring (r = -.135, p = .030), medication batching (r = .128, p = .039), single-dose medication vial use (r = -.126, p = .042), and multidose medication vial use (r =.129, p = .038). The results indicated that PP and NoD were prevalent among all clinical practice settings and anesthesia practice models. The study results should be a call to action to reevaluate all aspects of patient care and to refocus the lens on patient-centered care as opposed to profit-centered care.