Within healthcare, evidence-based medicine is seen as a guide and not a mandatory set of instructions. Therefore a degree of flexibility is tolerated or even expected. A violation is defined as a deliberate deviation from a standard instruction, for example not performing handwashing before and after contact with a patient who is MRSA-positive. Violations can be necessary to optimise performance, or can be reckless and damaging.
Systemic migration of boundaries refers to the concept model of violations outside of the recognised safe field of practice, defined by our guidelines and protocols. This model is based on the work of Rene Amalberti (Amalberti et al, 2006). These violations occur frequently in all industries, even those with good safety records such as aviation. Violations outside of the safe space may bring benefits to both the individual and the system they work in, such as saving them time. Therefore the violations may be tolerated by the wider clinical team and occasionally actively encouraged if there is pressure – such as a high workload of patients.
Working in this ‘illegal-normal’ space becomes tolerated as ‘the real world of work’ where individuals feel safe as adverse outcomes in this area are rare. This area is also known as the borderline tolerated conditions of use. Violations within this area are so routine and tolerated that no one incident reports these migrations as incidents.
However over time our usual level of performance migrates to lying outside of the safe field of practice defined by our protocols. The result of this frequent migration into the illegal-normal space creates tension between following protocols against productivity, and causing anxiety that drives human error. Violations outside of safe practice can also push individuals to migrate further, and extreme violations can occur. These put both patients and the system at risk.
Safety is a choice. We need to acknowledge that migrations occur in order to create a just culture so that individuals can openly report their errors.
A just culture “considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution” (NHS, A Just Culture Guide). In a just culture, “investigators principally attempt to understand why failings occurred and how the system led to sub-optimal behaviours. However, a just culture also holds people appropriately to account where there is evidence of gross negligence or deliberate acts” (Department of Health and Social Care, 2018).
Opening discussions between staff and managers helps to establish a shared safety culture. Protocols may then be adjusted to reflect the real working world.
Watch the video below about the systemic migration of boundaries. The examples here have been referenced to maternity care, but can be generalised to all areas of obstetrics, gynaecology and healthcare.
Use the video to reflect on which boundaries you may migrate over, and how this could impact the patients in your care. What can you do to change this?