ORIGINAL ARTICLE

A naturalistic decision-making perspective on anaesthetists’rule-related behaviour

Denham L. Phipps • Dianne Parker

Received: 7 August 2013 / Accepted: 10 May 2014

� Springer-Verlag London 2014

Abstract As a widely recognised feature of work activity,

procedural violations have been of considerable interest to

human factors specialists, and several models have been

proposed to aid in understanding their occurrence. A common

feature of these models is that they depict violations as being,

to a greater or lesser extent, intentional; therefore, rule-related

behaviour could be reconceptualised as an exercise in deci-

sion-making. In this paper, we examine anaesthetists’ use of

rules from the perspective of naturalistic decision-making.

Doing so suggests that their rule-related behaviour is a product

of the extent to which following a rule is consistent with other

principles that guide their decision-making. Observational

and interview data from 23 consultant anaesthetists indicated

the presence of three such principles: ‘‘doing the right thing’’;

‘‘doing what works in the circumstances’’; and ‘‘using one’s

skills and expertise’’. Hence, rule-related behaviour in this

setting is better understood as a form of situated action than as

the following or breaking of rules per se. We discuss the

implications of this view for understanding why violations

occur, and how to address them.

Keywords Healthcare � Rule-related behaviour �Procedural violations � Naturalistic decision-making �Cues � Situated action

1 Introduction

Procedural violations—actions that breach established

working protocols or rules—have been studied in a range

of occupations (Alper and Karsh 2009). These include

aviation (English and Branaghan 2012; Wiggins et al.

2012), rail transport (Lawton 1998), driving (Reason et al.

1990), pharmaceutical manufacture (Nyssen and Cote

2010), and medicines administration (Alper et al. 2012).

Few violations are intended specifically to cause harm, or

are a direct cause of accidents; however, they can serve to

reduce the operational safety margin (Reason et al. 1998).

They have, therefore, been a subject of interest to those

managing human risks to safety–critical systems.

Several theoretical accounts have been proposed to

explain violations. Battmann and Klumb (1993) use the

notion of behavioural economics, which sees them as a

result of people desiring to optimise their expenditure of

physical and psychological resource. So, for example, if

complying with a rule incurs extra effort for no obvious

benefit compared to deviating from a rule, then the latter

course of action will be preferred by actors. An alternative

view of violations comes from Hale and Swuste (1998),

who argue that while rules are a useful way of maintaining

system safety, they can be counterproductive to the extent

that they restrict workers’ capacity to respond and adapt to

situations that are not covered by the rules. In other words,

violations can occur in order to ensure the achievement of

task goals when existing rules do not apply to the situation.

Amalberti et al. (2006), meanwhile, describe violations as a

‘‘migration’’ of work practice beyond a pre-defined and

nominally safe range of behaviour into a range that is

closer to the actual boundaries of safe practice. Rules

therefore define either the safe range or the maximum

boundaries of safe practice. If they represent the former,

then violations are not necessarily detrimental to safety, but

do increase the potential for dangerous situations to arise.

Hale and Swuste’s and Amalberti et al.’s depictions of

violations lead to a consideration of the role played by rules

D. L. Phipps (&) � D. Parker

NIHR Greater Manchester Patient Safety Translational Research

Centre, University of Manchester, Manchester, United Kingdom

e-mail: Denham.Phipps@manchester.ac.uk

123

Cogn Tech Work

DOI 10.1007/s10111-014-0282-2

themselves. Woods and Shattuck (2000) consider rules to

form a basic specification of task behaviour, but one that

should be adapted to the circumstances in which actors find

themselves. In other words, rules provide a resource for

guiding actors’ interactions with each other and with the

environment during a task (Suchman 1987). Problems arise

when rules are slavishly adhered to without taking into

account variations in the situation, or when they are not

used to guide attempts at adaptation (Woods and Shattuck

2000; Dekker 2003). Furthermore, rules can serve to

directly inhibit adaptation, as illustrated in Dierks et al.

(2004) case study of a protocol for operating theatre nurses.

Here, attempts to follow the protocol added to the work-

load on nurses, due to the cognitive demand imposed.

During high-workload phases of the main task, when the

nurses had to adapt to presence of concurrent activities,

interruptions, and changes in staffing, the protocol caused

overall task performance to degrade. In a situation such as

this, a violation of the rule would arguably be a rational

response.

These alternative perspectives on rule-related behaviour

account for the different types of violations described by

authors such as Lawton (1998) and English and Branaghan

(2012). They also, though, have a common theme: they

appear to ascribe to violations a degree of intentionality. To

elaborate this point, we refer to Cook and Woods’ (2005)

description of ‘‘operating at the sharp end’’, in which

actors’ intentions are determined by their knowledge base,

attentional control, and strategy for trading off the goals

that govern the task activity. In effect, the actor is engaging

in some form of decision-making. This has traditionally

been described using the so-called classical paradigm, in

which the actor chooses between options on the basis of

their comparative probability and/or expected utility

values. However, recent work has recognised that in

dynamic work settings, decision-making can be better

characterised by the flexible application of one’s domain-

relevant knowledge according to the manner in which

problems present themselves (e.g., Patel et al. 2002; Falzer

2004; Crosskerry 2009).

Therefore, the formation of rule-related behavioural

intentions could be usefully captured within the naturalistic

decision-making (NDM) paradigm proposed by Klein et al.

(1993). In NDM, decision-making is not a deliberate and

systematic analysis of all factors and options for respond-

ing (as it would be classical decision-making models), but

the application of one’s knowledge and experience ‘‘on the

fly’’ to assess the situation, determine what is happening

and identify the most plausible responses. According to

Orasanu and Connolly (1993), the circumstances under

which NDM applies include the following: multiple actors;

action-feedback loops; time stress; high stakes; shifting

goals; ill-structured problems; organizational norms and

goals to be balanced against the decision-maker’s interests;

and uncertainty. These are likely to be characteristics of the

high-hazard tasks in which violations are of most concern.

Naturalistic decision-making has been portrayed by a

number of models; to set the scene for the current study,

two of the models are presented here. The first is the rec-

ognition-primed decision model (RPD; Klein 1993), which

describes how people form general behavioural intentions

during dynamic work activity. According to RPD, the

actor’s assessment of a situation is characterised by the use

of heuristics (‘‘recognition’’). Recognition is based on the

actor’s experience and has four aspects: plausible goals;

critical cues; expectancies; and course(s) of action. Table 1

illustrates how these might apply to a task which is gov-

erned by a particular rule. If it is clear that the course of

Table 1 Recognition-primed

decision-making in the context

of a hypothetical rule

Recognition aspect Example

Plausible goals

What can be reasonably accomplished in this

situation?

I can carry out the task without following the rule

Salient cues

What cues are important? Do I have time to follow/deviate from the rule?

Do I have the resources?

What risk factors are present?

Expectancies

What can I expect to happen if I have understood

the situation correctly?

I can/cannot deal with any risks that arise from

following/deviating from the rule

Action(s)

What action(s) could I take? Follow the rule

Deviate from the rule

Modify the task

Abandon the task

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action can be implemented (e.g. it is not possible to deviate

from the rule, and there is sufficient time and resources to

follow it), then it is implemented. Where the choice is less

clear-cut, the actor, using mental simulation, evaluates the

course of action to determine whether it will be successful.

If it is unlikely to succeed, then the actor may then evaluate

alternative courses of action, such as abandoning the task,

modifying the task (for example, by rescheduling it until

such a time that it can be conducted whilst following the

rule), or deviating from the rule.

The second approach of interest is image theory

(Beach 1990), which depicts decision-making as being

guided by three mental schemata, or ‘‘images’’. These

include a ‘‘value’’ image (the beliefs, values, and prin-

ciples held by the decision-maker), a ‘‘trajectory’’ image

(the goal(s) that he or she wants to accomplish), and a

‘‘strategic’’ image (the plans for achieving the goal(s),

and the implementation of these plans). Table 2 shows

how image theory might apply to a task that is governed

by a rule. Here, the value image includes sentiments

about the value of rules themselves or about other fac-

tors that could impinge on rule-following (for example, a

desire to save time or a belief in one’s self-efficacy in

the face of the situation). The trajectory image includes

possible goals that may or may not be consistent with

rule-following. Similarly, the strategic image includes

plans that, in themselves, may or not be consistent with

rule-following.

The study described in this paper examines violations in

anaesthetic practice. Gaba (1994, p. 199) characterised

anaesthetic work in terms of ‘‘extreme dynamism, intense

time pressure, high complexity, frequent uncertainty, and

palpable risk’’. Phipps et al. (2008) found that anaesthe-

tists’ behaviour with regard to rules is determined by the

characteristics of the rules themselves (e.g. their status and

clarity), of the anaesthetist (e.g. self-efficacy and group

norms), and the situation to which the rule has to be applied

(e.g. time pressure and resource availability). This suggests

that anaesthesia can be seen as a NDM task; indeed,

Fletcher et al. (2004) used a NDM-based approach to

capture behavioural markers of anaesthetists’ non-technical

skills. Hence, as suggested in the foregoing paragraphs,

anaesthetists’ rule-related behaviour can be explained with

reference to decision-making, which is in turn (as illus-

trated by the two models described earlier) guided by a set

of general principles. The aim of this study was to examine

how anaesthetists’ rule-related behaviours can be charac-

terised as instances of NDM.

2 Methods

2.1 Design

The study used a qualitative design, which focused on

describing the nature and context of anaesthetists’ rule-

related behaviours. To provide sufficiently rich data, we

combined first-hand observations with insider accounts

from a small sample of anaesthetists. Our interest was in a

detailed examination of these participants’ experiences,

including the processes by which they arrive at a decision

to follow or deviate from a rule.

2.2 Participants

Following institutional and NHS Research Ethics Com-

mittee approval, 23 consultant anaesthetists were recruited

from two sites (a specialist hospital and a general teaching

hospital) in the north-west of England. The anaesthetists

were recruited on a purposive basis to provide represen-

tation of a range of roles and operating lists at each site.

Each gave written informed consent to take part in the

study.

2.3 Procedure

Each participant was involved in both an observation ses-

sion and a semi-structured interview. The purpose of the

observations was to gain insight into the factors present in

anaesthetists’ work environments that influence their rule-

related behaviour. The first author accompanied the par-

ticipant as he or she carried out anaesthetic tasks, either

during two half-day operating lists or one full-day list.

Much of the observation took place in the operating the-

atre, anaesthetic room and recovery room, but some

observations were also made of preoperative assessments

on wards. The researcher did not play a hands-on role in

any of the tasks observed, but was occasionally able to

discuss ongoing tasks with the participant. During breaks in

each list and immediately following the end of it, the

researcher made handwritten notes about the progress of

Table 2 Image-driven decision-making in the context of a hypo-

thetical rule

Image Examples

Value Following the rules matters

We need to save as much time as we can

I am in control of the situation

Trajectory Complete the task as expediently as possible

Minimise the risk incurred during the task

Push the equipment to its performance limits

Strategic Disable a safety device

Request more time to complete the task

Adapt the work method

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the list and the events and interactions that involved the

anaesthetist. These notes were transcribed into electronic

form within 24 h of their being taken. Concerns about

intrusiveness and the unavailability of suitable equipment

precluded audio or video recording. A total of 170 h of

observation were carried out at both sites. Further details

about the anaesthetic work observed are reported in Phipps

et al. (2008).

Each participant was interviewed by the first author

after he or she had been observed. Interviews were con-

ducted on a one-to-one basis in a private location and

were audio-recorded for subsequent transcription, with the

consent of the participants. Each interview lasted for

approximately 1 h, during which the interviewer and

participant discussed the use of rules in anaesthetic work,

and how the participant decides whether or not to follow

the rules encountered in practice. Participants were free to

discuss hypothetical or real examples of rule-related

behaviour. In addition, as each interview was conducted

after the participant had been observed, the participant

was invited to corroborate the researcher’s observational

notes and reflect on the events that had occurred during

the observed list(s).

2.4 Analysis

We analysed the data by using an inductive thematic analysis

(Braun and Clarke 2006). The first author (DLP) initially

read through the observational notes and interview tran-

scripts, coding those parts of the data that identified ways in

which anaesthetists decide to follow or deviate from a par-

ticular rule. The data extracts thus coded were organised into

themes according to their similarity. The themes were then

compared with the data set to ensure that they provided

adequate coverage of the rule-related behaviour described

within it. Finally, the themes were reviewed by author DP (a

social and organizational psychologist) and two other subject

matter experts (a biomedical engineer and a consultant

anaesthetist) for their relevance to anaesthetic practice.

3 Results

3.1 Rules encountered by the anaesthetists

During the observations and interviews, several situations

emerged in which anaesthetists encountered some form of

rule governing their practice (Phipps et al. 2008). These

situations, which form the background to our findings,

include the following:

• Preoperative visits. Anaesthetists were expected to visit

each patient on the hospital ward before he or she was

brought into the operating theatre, in order to assess the

patient’s fitness for surgery and to formulate the

anaesthetic plan;

• Equipment checks. Anaesthetists were also expected to

check that their equipment (e.g. the anaesthetic

machine) is fit for use at the start of each operating list;

• Infection control. There were various rules concerning

infection control. These included the need to wash and

sterilise hands when moving between patients, the

requirement for gowns and masks when conducting

invasive procedures, and the prohibition of sharing a

drug ampoule between different patients;

• Fasting. Patients were required to fast for a minimum

period of time before being anaesthetised;

• Medicating. Medication is licensed for use under

certain circumstances and may also have contraindica-

tions (circumstances under which it should not be

used).

3.2 ‘‘Following the rules’’ versus ‘‘doing the right

thing’’

In many of the situations discussed, participants referred to

their ethical beliefs; certain courses of action were con-

sidered to be the ‘‘right’’ thing to do, whether or not they

were consistent with the rules. For example, participants 3

and 12 explained why, during the observations, they

insisted on carrying out preoperative visits and machine

checks, respectively, even in the face of time pressure.

Generally I don’t like doing patients that I’ve not

seen myself. Quite often [when I’m asked to take on

another anaesthetist’s case] it’s an emergency that

they’re just trying to slot in and they say ‘‘oh, the

registrar’s seen it, it’s fine’’. But I think patients

deserve to be seen by the person that’s going to look

after them. […] I like to make sure I’ve got time to

see the patient, even if they’ve already been seen and

had all the boxes ticked already [3].

Do you fancy being in a situation where something

goes wrong and you say ‘‘you know what? I didn’t

bother checking my machine, and now they’re hyp-

oxic and brain damaged.’’ […] It’s quite easy to think

a lot of these things through because you think ‘‘am I

responsible for this? Is it my responsibility – yes it is.

Could they come to harm if I don’t do it – yes they

could.’’ And I suppose those are the two things you

probably ought to ask yourself [12].

While rule-following was considered to be the ethical

course of action in these situations, there were others in

which a deviation from the rules was believed to be in the

best interests of the patient. For example, participant 14

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described a situation that occurred during the observations,

in which he proceeded with an anaesthetic despite the

guidelines suggesting that he should not.

The patient this morning had a cup of tea at six

o’clock and we administered an anaesthetic at ten

o’clock. […] Our fasting guidelines say […] a patient

can have clear fluids up until two hours before a

procedure, but mustn’t have solids within six hours of

a procedure if it’s an elective procedure. […] Tea on

its own is a clear fluid, but she’d had a small amount

of milk in it, which could be construed as a solid

food. [But] on balance, a cup of tea with a small

amount of milk in, I was happy that after three hours

she would have emptied that from her stomach and

wouldn’t be at risk of aspiration, and wouldn’t have

been at risk of an anaesthetic. If I’d been following

the guidelines to the letter, I wouldn’t have done her

this morning and she would still be sitting on the

ward now with a very sore abscess and probably

wouldn’t get done until this evening and might even

be postponed until tomorrow [14].

Participant 15, meanwhile, describes a situation in

which a patient was given a spinal anaesthetic despite this

being contraindicated given the patient’s history.

I performed a spinal anaesthetic on someone who had

been given a large dose of an anticoagulant within the

last twenty-four hours, and also who had evidence of

sepsis. Both of those are contraindications to per-

forming a spinal anaesthetic. However, weighing up

the risks and the benefits a general anaesthetic for this

poor patient, the risks of giving [the patient] a general

anaesthetic were far greater [15].

In these excerpts, the ‘‘right’’ thing to do is that which is

believed to be in the best interests of the patient. However,

for some participants, there were other ethical concerns—

notably, a desire to make efficient use of resources. Again,

this desire could bring them into conflict with rules. Here,

participants 13 and 2 reflect on situations that occurred

during the observations: participant 13 having divided the

contents of a drug ampoule between syringes; participant 2

having delayed the start of anaesthetic in order to conduct a

preoperative visit of a patient who had arrived late.

[Some] drugs are expensive and large amounts [of

them] are drawn out and could suffice for a whole

operating list, but if you were to discard each

[ampoule after only one] usage then it would be

terribly wasteful. […] You know, it would cost con-

siderably more for the morning’s activity just by

adhering to a rule that doesn’t confer any direct

patient benefit [13].

Interviewer: Do you ever find that because the patient

has turned up [late] you then have to go ahead

without having had time for a [preoperative visit]?

Participant: No. We’re trained never to do that. We

would always stop the list and go and see them –

which means we waste time. We waste theatre time,

which is a valuable resource. Nobody’s got any idea

how valuable it is, but I suspect it’s in the order of

[…] £10,000 an hour to run an operating theatre [2].

It would appear that the use of rules is influenced by a

consideration both of the need to maintain a minimum stan-

dard of care, and of the need to maintain efficient and pro-

ductive list activity. The comments made here about

preoperative assessment, fasting, and machine checking

suggest that participants will, in practice, aim to strike a bal-

ance between the two—but, in any case, these considerations

appear to matter more than following rules for their own sake.

If somebody has put guidelines up that clearly are

unworkable, clearly are inappropriate, […] you’re

failing in your duty to say ‘‘well, I was just fol-

lowing the guidelines, even though they’re patently

wrong’’. What you’ve got to do is apply your

clinical judgement and clinical acumen as a medic

and do what you consider to be the right thing [2].

3.3 ‘‘Following the rules’’ versus ‘‘doing what works

in the circumstances’’

Another consideration that arose in participants’ accounts

was the feasibility of rule-following given the circum-

stances within which anaesthetists found themselves. For

example, participants 22 and 23 discuss the difficulties in

carrying out preoperative visits in conditions of time or

resource limitations.

The ideal situation, which arises in most circum-

stances, is that patients [have a] preoperative assess-

ment in the cold light of day for elective surgery. […]

Where difficulties arise […] are patients coming for

[a session] that I do on a Wednesday morning, where

[often] there is no bed available. […] I have to do my

preoperative assessment of the patient either in the

day room, surrounded by lots of other patients, where

privacy and confidentiality is obviously a major issue,

or I have to make do and see the patient at the nurse’s

station or wherever there’s an appropriate space. And

that is […] very unsettling for the patient, it’s very

unsatisfactory for the anaesthetist, and it doesn’t lead

to a good and efficient use of theatre time [23].

Interviewer: Do you find that anaesthetists always get

time to do the preoperative visit?

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Participant: They should do. Where there’s a problem

is where, for example, somebody […] got a morning

list that’s a full list, and the patients for the afternoon

list come in during the morning. They’re then pres-

sured to see the patients to start the afternoon list on

time. That’s a problem, you know, and particularly

when you’ve got complicated patients coming in. An

example of that might be [the] urology list where the

patients have got a lot of coexisting disease [22].

It is interesting that participant 22 should refer to the

urology list (or, indeed, lists that attract ‘‘complicated’’

patients in general) as causing difficulties for preoperative

visits. According to Painter and Ludbrook (2013), such lists

are the very ones where the preoperative assessment is

most important, due to increased perioperative risk.

Therefore, the scenario described by participant 22 actually

provides conflicting cues to decision-making: on the one

hand, to avoid wasting time; on the other hand, to ensure

that the risks are minimised. One option for dealing with

such conflicts is to effect a workaround, such as those

described by participants 5 and 12.

Probably the commonest reason [for not carrying out

a preoperative visit] is that you know it’s an elective

patient, you’ve spoken to someone about them, like

the surgeon, and you’ve already started the list

because they’ve turned up late. […] The [anaesthetic

assistant] [has] a checklist of questions. Half of that is

what you do on your preoperative visit. So […] you

can get the answers to eighty percent of your ques-

tions just by listening [to the assistant], and then

while you’re doing that you can also flick through the

notes and see what the medical history is, and […]

with the skill and experience, you can ask two or

three pertinent questions if you need to, there and

then, before you start. […] So, although it may not be

done on the ward it can be done preoperatively in the

anaesthetic room [5].

People don’t check their anaesthetic machine because

they say ‘‘somebody’s checked it already, and they’re

very reliable, and it was checked this morning. It’ll be

okay’’. You’re in a rush, […] you’ve got to get […]

started. You forget to check your anaesthetic machine

[…] [but] you think ‘‘oh, well, I’ll be alright because

I’ve got an ambi-bag I can ventilate somebody with,

I’ve got a back-up cylinder.’’ That’s the […] nature of

cock-ups isn’t it? [12]

However, some anaesthetists consider certain rules

important enough that they will adhere to them even in

unfavourable circumstances. For example, participants 19

and 21 explain why they consider it necessary to carry out

machine checks every time.

If you’re doing an elective list then you’ve got time to

check the [equipment]. The anaesthetist should carry

out checks, and also the [assistant], because if I find a

problem with the machine, it’s going to take a while

to fix it. If the [assistant] found it half an hour earlier

then it’s fixed. […] But [as] you’ll be operating the

machine yourself, you’re going to have to be happy

that you’ve got your bail-out options and that you can

manage a major failure of the system, so…I’d want to

check my own things anyway. [And] you’ve got to be

checking it all the time [19].

You know, people for example check their anaes-

thetic machine before the start of the list because they

quite clearly recognise that there’s a benefit – forget

the legal thing, but if you find malfunctioning

equipment during the procedure and you hadn’t

checked it, you would regret the fact that you hadn’t.

If on the other hand it was purely [a case of] ‘‘if you

don’t do this, we’re going to kick you out of your

job’’, people would probably do it grudgingly, but I

suspect the uptake would be much less than it cur-

rently is [21].

These comments highlight the need for anaesthetists to

consider the trade-off between risk and benefit that is

associated with a given course of action, or the relative risk

to the patient of adopting alternative courses of action. In

this respect, the value of a rule is its ability to arbitrate

between effectiveness and safety.

3.4 ‘‘Following the rules’’ versus ‘‘using one’s skills

and expertise’’

Consultant anaesthetists possess a great deal of expertise in

their field. They also, in conjunction with the surgeon, are

ultimately responsible for the well-being of patients under

surgery. Because of this, anaesthetists assume considerable

autonomy over what they do in the course of their work.

[If] I can justify my actions [to myself] then I should

be able to justify [them] to anybody else. If [my

practice is] not good enough then it should be

improved independent of external scrutiny. Either

you believe in it or you don’t [13].

This means that anaesthetists will bring ‘‘professional

judgement’’ to bear in many aspects of their work,

including those to which rules nominally apply. For

example, participant 5 referred to a difference in opinion

between anaesthetists with regard to the application of

infection control guidelines.

We had [central venous pressure] line insertion

guidelines. Fine, [we have to] gown up, [which we

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do] anyway, and yet the [intravenous team] was

putting in what they called mid-line catheters […].

They didn’t gown up, they just put gloves on and did

them, and they said ‘‘we don’t need to, they’re not

central lines’’. I said ‘‘they are [central lines]’’ [but

they replied] ‘‘no they’re not, they’re mid-line cath-

eters’’. […] The implications and the issues are

exactly the same – it’s one of access of bugs into the

central veins. The fact that they stop here [along the

arm] on the x-ray rather than here [under the clavicle]

is irrelevant [5].

Participant 3 discussed another infection control

issue—hand washing. At face value, this issue, as she

described it, seemed less contentious than that of the mid-

line catheters.

Basic hygiene is something that we really have to

work on in hospitals at the moment, with the infection

risk, and it’s very easy for us to pick up and transfer

bacteria from one patient to the next, so good hand-

washing or alcohol rub between each patient is very

important [3].

The interviewer remarked that this seemed to be a

common sense view that was supported by empirical evi-

dence, and hence one that presumably would be accepted

by many anaesthetists. However, the conversation contin-

ued as follows:

Participant: Common sense suggests it’s a good idea

but I don’t think anybody’s managed to produce

robust evidence to persuade us. […] And that’s very

common. Unless somebody shows that you’re the one

with the MRSA up your nose, you pick your nose in

theatre and then touch all the patients, until they can

show that, people won’t stop going from patient to

patient without practicing decontamination.

Interviewer: Even though you said it’s common

sense?

Participant: Well it is common sense but some people

just don’t make that link do they? [3]

This discussion highlights a complication of appeals to

evidence as a basis for rule-following. The evidence, if it

exists at all, is more readily accepted by some anaesthetists

than others. As the following excerpts suggest, the influ-

ence of an ‘‘evidence-based rule’’ on anaesthetists’ practice

possibly depends on the extent to which it is compatible

with two alternative values—the anaesthetist as an evi-

dence-based practitioner and the anaesthetist as someone

who uses professional judgement.

Some of the rules we have that we follow are based

on […] physiological principles and guesswork of

saying ‘‘what do you think would happen if we did

this to a patient with the following condition?’’

There’s an element of things being plausible or

believable, whether or not there’s actually any evi-

dence [12].

You’ll join 5-6 of my colleagues and [they] will all

do one operation, from an anaesthetic point of view,

very differently […] based on their past experiences,

how they were taught, what they have read in the

literature, what they consider to be the newest and

latest best thing, things like that. […] I think variety

is healthy, because there is no [single] right way to do

something [8].

Situations involving ‘‘off-label’’ medication adminis-

tration (that is, outside of the conditions specified in the

medication’s licence) raise interesting questions with

regard to rule-following. As participants 8 and 11 describe,

the problem here can be that the anaesthetic situation lies

outside the scope of the extant rule, and so there is a greater

need for anaesthetists to rely on their expertise instead.

Participant: Ethically it is very difficult to get chil-

dren volunteers for drug studies. […] So you tend to

find that all the data that is collected on safety drug

dosing etcetera is on adults. […] They just assume

that with time, if it is demonstrated to be safe in

adults, then people will use it in paediatrics. Nobody

has any data to say that giving IV paracetamol to

children under ten is dangerous. Nobody has any

information to say that it is not dangerous. […] So

[the limit described in the licence] is an arbitrary cut-

off point really […] to stop people who are not used

to prescribing or using it just giving it at the drop of a

hat.

Interviewer: In theory, could you be held to account

for prescribing a drug that is not officially licensed?

Participant: Yes, you could. You could be seriously

reprimanded. Some people say you could be disci-

plined and sacked. And that is one of the constant

battles that we are faced with. We have to do things

that are against current recognised practice. But […]

with a lot of things, there are no hard and fast rules

[8].

Participant: We often use nonsteriodal anti-inflam-

matory drugs for pain relief. There’s not many that

come as IV preparations, and one of the ones that

does is called ketorolac. But if you read the pack-

aging, it’s contraindicated for perioperative use,

which is obviously when we would like to give it. So

[…] it does get given occasionally perioperatively,

going against the recommendations though. But, you

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know, other drugs such as voltorol [and] diclofenac

work in a very similar way to ketorolac, but [are not

contraindicated].

Interviewer: So why would you use the contraindi-

cated drug?

Participant: Well I don’t think it’s contraindicated, it

just says not advised to be given perioperatively, and

I presume it’s down to its effects on platelets, making

bleeding more likely. […] In neurosurgery for

instance, when any bleeding is a catastrophe intra-

cranially you obviously wouldn’t use them in that

situation. But if someone’s having a hernia repaired,

that might be a different thing [11].

There seems to be two demands on the anaesthetist: one

is to bring the full range of one’s expertise to bear in

dynamic and varied clinical situations; the other is to

maintain a margin of safety in one’s practice. The chal-

lenge is to find an appropriate balance between the two. As

participant 9 explains, one way in which rules can be useful

is in helping to achieve this balance.

The guidelines are there to help people who know

less about that subject than the person who wrote the

guidelines. Obviously not everybody can be an expert

on morphine infusions [for example]. […] [Those

who wrote the guideline will] have seen that there’s

three different ways of doing morphine infusions and

all three are pretty safe. But […] most of them

appreciate that to [stick to one] in one place keeps it

safe for everybody else [9].

4 Discussion

The current study started out with the premise that anaes-

thetists’ rule-related behaviour could be examined from the

perspective of NDM. From this perspective, procedural

violations are seen less as an aberration, rather as an

informed choice in response to the work situation in which

the actors found themselves. The choice is informed both by

an appraisal of the situation and by the beliefs and prefer-

ences that the actors bring to it. To support this character-

isation, we have identified from anaesthetists, accounts of

their work a set of values that guide their decision-making,

and which, in a given situation, may be aligned or misa-

ligned with rule-following. In a sense, the anaesthetists in

this study are similar to the process and aviation controllers

in Hayes’ (2013) study of operational decision-making; their

work can be seen primarily as an exercise of professional

identity and experience as well as (or rather than) a matter of

following or deviating from rules.

In effect, the role of rules in this study appeared similar

to that described earlier in the paper; that is, they were

often treated as a resource to be strictly adhered to or

adapted as the anaesthetist saw fit. We can think of this in

terms of Amalberti et al.’s notion of practice migration. For

example, assessing a patient preoperatively in the anaes-

thetic room instead of on the ward could be seen as

transgressing a nominal boundary of practice. Not carrying

out any form of assessment, though, is a transgression of

the absolute boundary of practice—permissible, maybe,

only under exceptional circumstances. In the language of

medical practice, this distinction is implied by the labelling

of a rule as being either a ‘‘guideline’’ or a ‘‘protocol’’

(which usually provide the nominal and the absolute

boundary, respectively).

An alternative distinction between types of rules was

made by Grote et al. (2009), between rules for standardi-

sation (those that prescribe how a task must be performed,

and so are to be strictly adhered to) and rules for flexibility

(those that suggest how a task might effectively be per-

formed, and so provide a resource for situated action).

Zala-Mezo et al. (2009) found that during an anaesthetic

task, standardisation appeared to facilitate team coordina-

tion by reducing the need for explicit coordinating behav-

iours. However, some degree of flexibility is also necessary

in order to deal with contingencies during task execution

(Grote et al. 2009).

Essentially, as Woods et al. (1994, 2007) argue, rule-

related behaviour is often a result of practitioners’ attempts

to adapt to the complexity that they encounter in their work

tasks. This complexity can be an intrinsic feature of the

task, or it can be due to flaws in the work system estab-

lished to conduct the task. An example of the latter in the

current study is the inefficiencies that occurred during the

process of admitting patients to a ward and transferring

them from there to the operating theatre. This caused

delays in the presentation of patients for preoperative

assessment or for the operation itself. Nemeth et al. (2004)

describe healthcare work as a matter of dealing with the

‘‘messy details’’—the constraints, resources, demands, and

affordances—in order to achieve one’s goal(s). From this

perspective, and as demonstrated in the current study, the

idea of committing a ‘‘violation’’ is less straightforward

than it might seem from the basic definition provided

earlier. The findings of the current study can also be

compared to those of Kahol et al.’s (2011) structured

observation of trauma clinicians’ procedural deviations.

Kahol et al. interpreted a number of these deviations as

either attempts to adapt the treatment protocol to a par-

ticular case, or as actions demanded by the work envi-

ronment. Similarly, the anaesthetists in our study often

referred to adapting rules to the clinical or organizational

situations in which they found themselves.

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How can rules best be used, whether in anaesthesia or in

other work settings? From a NDM perspective, one con-

sideration is the extent to which the knowledge and

assumptions driving one’s decision-making are shared

across the workforce. The more that is commonly under-

stood, the stronger the basis for using rules in either style.

Put in different terms, the appropriate use of rules within an

organization would be facilitated by shared mental models,

and possibly transactive memory (Zajac et al. 2013;

Michinov et al. 2008). It is also likely to be a matter of

consensus between those who create rules and those who

follow them; recall participant 21’s remark about machine

checking, in which he observed that those anaesthetists

who adhere to the rule do so not simply because it is a rule,

but because they recognise its benefit. However, it was

apparent in our study that in some cases, the anaesthetists

had rules imposed on them without their involvement in the

rule’s creation or implementation (see also Phipps et al.

2008).

That decision-making can be influenced by ‘‘cues’’,

according to RPD, suggests a further approach to under-

standing rule-related behaviour. In their examination of

various habitual behaviours, Ouellette and Wood (1998)

and Verplanken (2006) consider them to be triggered by

situational cues—and, therefore, habitual to the extent that

these cues are consistently available. It follows that a

habitual behaviour can be broken by disrupting the

appearance of the cues that trigger this behaviour. Could

such an approach be used to address violations? Gollwitzer

and Sheeran (2006) proposed the concept of ‘‘implemen-

tation intentions’’, by which the intention to behave in a

particular way (e.g. adhering to a rule that one should

adhere to) is implemented as a behavioural response to be

enacted in the situation of concern (e.g. the presence of an

incentive to deviate from the rule). In other words, the

person decides in advance that ‘‘if situation X arises, then I

will respond with behaviour Y’’. Elliott and Armitage

(2006) found that the formation of implementation inten-

tions during a driver education programme increased self-

reported post-intervention compliance with speed limits,

compared to a control group who did not form imple-

mentation intentions. These findings, amongst others,

suggest that implementation intentions have potential as

the basis of a behavioural change intervention to modify

rule-related behaviour (Eccles et al. 2007; Armitage 2008).

As a caveat, though, some of the cues to violating in the

current study would be better addressed by their elimina-

tion at source rather than relying on administrative or social

controls. To take an example from the current study, if

anaesthetists find themselves under time pressure because

of inefficiencies at other points in the patient pathway (such

as the patient’s admission to the ward or addition to an

operating list), then re-engineering this pathway would

remove the cue completely. This reflects Xiao et al.’s

(2004) argument that work adaptations, including those

that are labelled as violations, can be indicative of socio-

technical issues in that need to be accounted for or

addressed in improvement interventions.

A final, more radical, view to be considered is that of

Dekker et al. (2013). In their examination of a different

medical specialty—obstetrics—they argue that it is not

simply a complicated endeavour (i.e. one that can be

described completely and exhaustively, and therefore con-

trolled by a standard method), but a complex one (i.e. not

fully knowable due to dynamic interactions between the

components, and therefore not amenable to control by a

standard method). The corollary of this argument, according

to Dekker et al., is that notions of ‘‘compliance’’ and ‘‘vio-

lation’’ are misleading or even completely meaningless in

obstetrics. If anaesthesia can be described in similar terms,

as Dekker et al. imply, then the logical conclusion of their

argument is that rule-related behaviour is not a matter of

compliance and violation—or perhaps even of rules at all—

but of some kind of situated rationality amongst workers.

This, in fact, is the same position at which one would arrive

by extending the arguments of other authors cited here, such

as Dierks et al. Hence, decision-making is seen as a sub-

stitute for rule-related behaviour rather than simply a way of

explaining it. Whether this is a tenable argument and what

implications it has for the philosophy of management-by-

rules are issues that are outside the scope of the current

paper to settle. Hayes (2013) suggests that at the very least,

it would require organizations to give greater recognition to

the value of professional expertise in maintaining safe and

reliable operations, rather than assuming that this is achieved

only by strict adherence to rules.

While this study benefits from being grounded in field

data from the activity in question, it also has some limi-

tations. Firstly, the range of sites included was small and

concentrated in one geographical area. Secondly, it is not

possible on the basis of our data to establish a causal link

between the antecedents of decision-making, the decisions

made in practice, and the actual behaviour of the respon-

dents. Therefore, it is necessary to confirm the findings

using a method that can capture all parts of this causal

chain, e.g. a simulation study.

5 Conclusion

Rule-related behaviour remains both a theoretical and a

practical challenge for the management of human risks in

the workplace. This study demonstrated that NDM is a

useful framework for understanding how workers respond

to situations that are governed by rules. A NDM perspec-

tive highlights the role of mental models and behavioural

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cues in rule-related behaviour, in addition to attitudinal

variables such as have been identified in previous studies

(e.g. Phipps et al. 2010; Paris and Van Den Broucke 2008).

This has practical implications for improving the use of

rules, as well as theoretical implications for the conceptu-

alisation of rule compliance and violations.

Acknowledgments This study was funded by the Engineering and

Physical Sciences Research Council (EP/C513339/1). The authors

would like to thank Paul Beatty, George Meakin, Chidozie Nsoedo,

and Elisah Pals for their assistance with the work.

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