Abstract
BackgroundResearch in criminology and social-psychology supports the idea that visible signs of disorder, both physical and social, may perpetuate further disorder, leading to neighborhood incivilities, petty violations, and potentially criminal behavior. This theory of ‘broken windows’ has now also been applied to more enclosed environments, such as organizations.Main textThis paper debates whether the premise of broken windows theory, and the concept of ‘disorder’, might also have utility in the context of health services. There is already a body of work on system migration, which suggests a role for violations and workarounds in normalizing unwarranted deviations from safe practices in healthcare organizations. Studies of visible disorder may be needed in healthcare, where the risks of norm violations and disorderly environments, and potential for harm to patients, are considerable. Everyday adjustments and flexibility is mostly beneficial, but in this paper, we ask: how might deviations from the norm escalate from necessary workarounds to risky violations in care settings? Does physical or social disorder in healthcare contexts perpetuate further disorder, leading to downstream effects, including increased risk of harm to patients?ConclusionsWe advance a model of broken windows in healthcare, and a proposal to study this phenomenon.
Highlights
This paper debates whether the premise of broken windows theory, and the concept of ‘disorder’, might have utility in the context of health services
We advance a model of broken windows in healthcare, and a proposal to study this phenomenon
We introduce a novel approach to conceptualizing these normalization processes within healthcare, one which may shed new
Summary
Broken windows: A theory of spreading disorder in neighborhoods Almost 40 years ago, Wilson and Kelling famously used broken windows as a metaphor for disorder within neighborhoods, arguing that ‘if a window in a building is broken and is left unrepaired, all of the rest of the windows will soon be broken’ [5]. The limited evidence available suggests that such violations are remarkably common, often tolerated among healthcare workers, and tend to be performed because they provide some other benefit (e.g., efficiency, increased patient-centeredness, personal enhancement) despite being a deviation from the norm [4, 17, 18] This begs the questions, is a brokenwindows type effect something we might observe in a hospital environment? It would point toward some very clear strategies for quality improvement, as well as ways to enhance patient and staff satisfaction, in ‘taking care of the little things’, for example, by keeping the physical environment clean and tidy This is not to suggest a ‘zero-tolerance’ approach to violations in healthcare as has been applied for neighborhood disorder, because often the very nature of the work—complex, time-pressured and dynamic—requires staff to make various forms of trade-offs, or engage in necessary workarounds [17, 35]. Following Sampson and Raudenbush’s [8] contention that social stigma affects what is perceived as disorder, this could allow us to unpack more complex relationships among inequality, hospital disorder and patient and staff outcomes
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