“The best time to mediate in correcting a deviant practice is early rather than later”: The case of Mona.
The recent incident of Konjengbam Mona Devi from Moirang Konjengbam Leikai, a young girl who struggled all alone to save her mother but all to no avail because of the lack of support, was a despicable reality that exposes the loss of ethical and humane values among medical professionals. There was apathy, insincerity and irresponsibility among health professionals that became apparent from her wretched experiences. Medical professionals need empathetic people to deliver their service effectively. Being friendly, empathetic and kind should and must be the watchword and guiding principle of health professionals. Trust is the central theme that guides the relationship between professional and patient as the latter put their lives in their hands. What is vital is patience on the part of the professional to clearly and flawlessly explain the course of action to the patient and party, avoiding jargons of their professions, for it is more than likely a patient might not have specific knowledge to question the extent of authority of the professional.
If this is not the case, a trust deficit between health worker and patient may often lead to undesirable conflict. Medical professionals earn their respect and trust from compassionate relationships and the service they render and not from the technological device, drug and medical procedures they provide. It is only after knowing the emotional status of the patient he/she can develop and endure an effective relationship.
As Talcott Parsons once said, ‘affective neutrality’ should be the basis for professionalism where personal interests and views should not come against professional work. A professional is marked by human and humane emotions, and if commercialization and commodification of medical health care becomes a normal part of the social process, then doctors will begin to be reduced to no more than vendors in the eye of the patient consumers. Particularly in the government hospitals, the treatments subsidized by tax money and are given at lower rates or either free of cost, thus it appears that negligence and insincerity of the health worker seems to arise out of the clash of interest between commercial value and professional ethics. The case of Mona reveals the bitter aspect of the medical world and there is also a high probability that there might already have been many more unreported similar cases.
Her case reveals some of the defective practices held by medical workers but often gets unacknowledged and evaded which in the course of time get normalized within the system. One study conducted by American Association of Critical Care Nurses revealed that common deviation practice in American hospital include not sanitizing or washing hand properly, skipping infection control procedures, not changing gloves when required, not performing safety check, not getting required approval before acting, to rely on patient to transmit clinical reports to others, ineffective supervision of clinical and non-clinical staffs, using abbreviation, violating policies on storing and dispensing medication and so on. Deviation herein, can be interpreted as a forthright violation of operational rule or variation in practice that so departs from the required standard ideal that unreasonably increase the risk of patients. In Diane Vaughan words, “What begins as deviations from standard operating rules become, with enough repetitions, ‘normalized’ practice patterns”.
‘Normalization of deviance’ was first coined by American sociologist Diane Vaughan to describe the unlawful or deviant organizational action. She defines normalization of deviance as a social process “where people within the organization become so accustomed to a deviant behavior that they don’t consider it as deviant, despite the fact that they far exceed their own rules for their elementary safety”. She explain how a seemingly benign/harmless routine judgment within the individuals professional were made despite the fact that they far exceed their own rules for safety which consequently came to be defined as normal and acceptable which resulted in a cultural belief within the larger organizational structure that it was safe to practice the same mode of behavior until the disaster is ensued. However the actions done by health workers are not committed with a malicious intent which is the case in white collar crime. Nevertheless institutionalization, socialization and rationalization reinforce each other in developing deviant behavior among health workers which work similarly for white collar organization.
The new generation of health professionals are exposed to the deviant behavior frequently done by authority figures and they come to define those behavior as organizationally normative which led to the institutionalization process. The socialization process acts as a medium to determine the newcomer to either choose the group by complying to the deviant behavior with a system of reward and punishment. And in course of time their action became rationalized by convincing themselves that their actions are acceptable and perhaps even necessary. These processes work as a tool to dissolve anxiety by rationalizing their act but not as an immoral response to their work challenges. Therefore it is recommendable that the deviant unsafe practice must be identified and halted before they become normalized and pose genuine risk to patient safety and care. (The normalization of deviance in healthcare delivery, Banja, John)
Here are some cases of deviation which I observed in Mona’s case and the sub-heading point are taken from John Banja, a medical ethicist article on the normalization of deviance in healthcare delivery which I find corresponding to the issue under consideration. This report is based on the secondary data which I have collected from Imphal Review articles, Tom TV media reports supported by sociological theory.
- Ineffective supervision of clinical and non-clinical staff: Clinical care and effective supervision are given for ensuring beneficial intervention at the right time to the right patients. It aims to control the risk of patient harm and the patient should be the focus of health care intervention to ensure their needs are sufficiently fulfilled but in this case there is serious behavioral flaw and utter negligence.
In Mona’s words: “One night, my mother’s oxygen supply got exhausted and I called the staff to attend my need but they said I should go by myself to the 2nd floor to get the oxygen cylinder but I am not strong enough to carry it. And I don’t have any idea how to fix/change the cylinder. So I was begging the staff to help bring the cylinder and I hung on for more than two hours but my mother’s oxygen was running out. When her breathing got slower, I informed the staff to send a doctor to give CPR but nobody came for two hour and I have given CPR by myself”.
- Inability to confront or afraid to speak up: The violation of standard rule gradually increases if the person who witnesses the situation refuses to intervene out of fear of retaliation, lack of ability to confront or the idea that ‘It is not my job’. Such inaction leads to the unsafe and deviant practice normalized within the system in course of time.
In this case, the victim’s daughter reported to the staff: “The health of my mother is deteriorating! And the health worker expressed, they need to intubate her as she is confronting to put ventilation. Two doctors came and they tried inserting the Ryle tube but it seems to me that the Ryle tube has been inserted beyond the necessary limit because the water cannot pass through, usually it should be put till around 15cm. When I saw my mother becoming weak, I fixed the tube myself and finally water could go inside. But I fear to speak up and intervene because I was just a student”. Therefore if any individual agency gets intimidated to call the attention of the responsible worker to their deviant act then it is likely that the unsafe practice will continue to persist until the disaster is ensued.
- 3. Concealing and diluting information: It is one of the aberrant behaviors practiced by concerned authorities that causes the deviant behavior to be swept under the carpet and thus destined to remain unrecognized. The authority might have enough awareness of the rule violation but he/she may try to conceal out of fear from superior or either to save face of a disreputable remark. Marc Gerstein termed this “politics triumphing over safety” through concealment, to save face from one’s superiors. In this instance, the JNIMS spokesperson clarified in a media briefing stating that the deceased patient was given full attention and medication was given perfectly as per their report. But the victim’s daughter complained against it testifying that the case lacked proper investigation and medication was not supplied adequately and there were inconsistencies while giving medication and also lack of efficiencies as if there was no proper rule.
- Violating policies on storing or dispensing medication: It includes medication administrative error in the form of wrong time, wrong rate or wrong dose, unavailability of drugs and medicine at right time.
In the case under consideration, the daughter alleges that no timely and proper medication was given since day one. She said: At one instance I enquired the health professional; If they could give antiviral drugs like Remdesivir and Hydroxychloroquine. But the doctor replied, Hydroxychloroquine was in stock before but presently it is not available but they will give the Remdesivir antiviral. Then I waited for the medication to arrive which was reported on the night of 3 December but even after two days the medication was not given. And later on 5 December at around 10 ‘O’clock at night I enquired the doctor and the doctor said he/she would advise the nurse to give the medicine. But due to the delay, after one hour I informed the nurses again, but to my surprise they replied that the doctor didn’t inform them. And I asked the doctor over again about the medicine but to my shock responded that Remdesivir was not at stock.
- Uneven Knowledge: Confusion over standards or rules can become acute if the professional feels uncomfortable in asking help or in admitting their ignorance. The supervisor is required to share their experience and knowledge to the less experienced or uninitiated. Here Mona said there was inconsistencies while giving the medication doses, sometimes they give Favipiravir once a day and sometimes twice and onetime ignored and they don’t even know.
- Skipping Hygienic rule and infection-control procedures : Hospital should be the place where cleanliness and hygiene should be given utmost importance but it seems the authority does not pay heed to such deplorable conditions. Mona alleges that the state of hygiene is in awful state and she finds many rats running over and above her. She further added that her cell- phone was used by the nurses as their means of communication without acknowledging the risk of transmission from the glove they wear and the hand glove was not disposed of when required but used for every treatment.
(The point which I have delineated here can be found in John, Banja articles on normalization of deviance in healthcare delivery and the remedial measure can be check from the same www.ncbi.nlm.nih.gov)