Patients, Protocols, and Prosocial Behavior: Rule Breaking in Frontline Health Care

• Date: 01 January 2020
• Published date: 01 January 2020
• Author: Erin L. Borry,Alexander C. Henderson
• DOI: 10.1177/0275074019862680
• Subject Matter: Articles

https://doi.org/10.1177/0275074019862680

American Review of Public Administration

2020, Vol. 50(1) 45 –61

© The Author(s) 2019

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DOI: 10.1177/0275074019862680

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Article

Introduction

Emergency medical services (EMS) play a central role in

local public health services (Institute of Medicine, 2007).

The street-level bureaucrats who staff these agencies—emer-

gency medical technicians, paramedics, and other clini-

cians—are often tasked with implementing complex clinical

protocols and operational rules in time-bound and uncertain

situations, typically without direct supervision. This type of

essential public function requires attention to the appropri-

ateness of myriad rule sets in specific situations and in

response to varying patient characteristics. Although schol-

ars have focused intently on systems-level issues, such as

ambulance placement and staffing models, and on paramedic

education, and the efficacy of clinical interventions, less is

known about crosscutting issues that span all three, including

paramedic attitudes toward rules (Henderson, 2013a).

Considerations of how these individuals view, interpret, and

implement rules is crucial for understanding the intricacies

of public health services, especially those that are a central

common good (Van Milligan, Mitchell, Tucker, Arkedis, &

Caravalho, 2014). Rule-breaking behaviors in EMS—which

may include decisions to administer or withhold medica-

tions, perform a complex skill or diagnostic technique, or

make important logistical decisions, such as choice of desti-

nation hospital or method of transport—may mean the differ-

ence between positive outcomes or even chances of survival.

Thus, our understanding of rule breaking—in particular pro-

socially motivated rule breaking—provides important infor-

mation in assessing practice, reviewing and revising rule

sets, and improving patient outcomes.

Examinations of rules, decision making, and discretion

have increased in the last several years through conceptual

development of red tape (Bozeman, 1993; Bozeman &

Feeney, 2011) and green tape (DeHart-Davis, 2009, 2017),

and through empirical examinations of rules in action (Borry,

2017; Borry et al., 2018; Henderson, 2013a). The purpose of

this study is to add to this literature by testing the direct effects

of organizational ethical climate and paramedic empathy on

prosocial rule-breaking (PSRB) tendencies. Although terms

differ on a state-by-state basis, EMS providers trained at the

paramedic level are generally the most skilled clinical provid-

ers a patient might encounter before arriving at the hospital;

these providers have significant authority, skills, and deci-

sion-making responsibilities. This article contributes to the

body of knowledge that undergirds evidence-based decision

862680ARPXXX10.1177/0275074019862680The American Review of Public AdministrationBorry and Henderson

research-article2019

1The University of Alabama at Birmingham, USA

2Marist College, Poughkeepsie, NY, USA

Corresponding Author:

Erin L. Borry, Assistant Professor, Department of Political Science and

Public Administration, 409 Heritage Hall, 1401 University Boulevard,

Birmingham, AL 35294, USA.

Email: borry@uab.edu

Patients, Protocols, and

Prosocial Behavior: Rule Breaking

in Frontline Health Care

Erin L. Borry1 and Alexander C. Henderson2

Abstract

Rules are essential components of organizations, especially given their foundational role in inducing organizationally preferred

behavior and reducing behavioral variability among its members. Despite the existence and prevalence of these centrally

important tools, rule deviation occurs. This study proposes to understand the ways in which emergency medical service

(EMS) professionals break rules for prosocial purposes—to help patients. In particular, this research seeks to understand

how specific organizational and personal attributes influence rule-breaking tendencies. Results indicate that aspects of ethical

climate are significantly related to prosocial rule-breaking (PSRB) tendencies, whereas empathy is not. In addition, this study

finds that other characteristics, such as a conformist personality, risk taking, expertise, and experience on the job influence

PSRB. These findings contribute to the literature on rule deviation and EMS practices and shed light on the complexity of

decision making in frontline public services.

Keywords

prosocial behavior, rule breaking, street-level bureaucracy, emergency medical services

46 American Review of Public Administration 50(1)

making, and also allows for a better understanding of practice

in a way that shapes innovative changes to service provision.

This article begins with a discussion of literature on rules

and implementation, deviation from rules, and the unique

function of EMS. Next, we provide the results of a survey of

paramedics, and preliminary discussion of the factors that

affect PSRB tendencies. A discussion of implications for

theory and practice, future areas of research, and concluding

comments follow.

Literature Review

EMS personnel share a number of characteristics with other

frontline public and health care positions. These include sig-

nificant and potentially burdensome rule sets, task complex-

ity and situational characteristics that often preclude the

creation of truly comprehensive rule sets, a need to quick

assess and sort service recipients based on their characteris-

tics, the presence of other situational factors that may com-

plicate interactions, considerations of structure and

managerial direction or desires, and tremendous power in

concomitantly enacting the role of executive, legislative, and

judicial functions (Lipsky, 1980; Riccucci, 2005; Sandfort,

2000). Although health care systems are often described in a

broad manner, in most cases, the most consequential aspects

of the caring process are decisions at the front lines (Allen,

Griffiths, & Lyne, 2004).

As with many street-level functions, rules form the basis

for behavior among EMS providers and, as with other types

of bureaucratic functions, these rules are often designed to

ensure consistent and predictable behavior (Jackson &

Adams, 1979; Pugh, 1966; Weber, 1946). Where rules fall

short, other aspects of jobs such as occupational, profes-

sional, and organizational cultures provide guidance for

behavior, potentially in ways that conflict with formal rules

(Borry, 2017; Dworkin, 1977; Henderson, 2013a; Isett,

Morrissey, & Topping, 2006; Kelly, 1994; Maynard-Moody

& Musheno, 2003; Riccucci, 2005). These various types of

culture that concretely shape the behaviors of frontline work-

ers are complex, and can be tremendously difficult to alter

(Lurie & Riccucci, 2003). Practices, then, matter a great deal

to what frontline workers actually do in the course of their

duties. Fedoravicius, McMillen, Rowe, Kagotho, and Ware

(2008), in a study of frontline workers assessing children for

mental health care, noted the strength of practice in shaping

behavior: Children were routed to psychological evaluation

as a matter of practice, not individual need, and that social

service workers were responsive to desires to turn around

cases, rather than to providing individualized care.

Core activities of patient care require EMS providers to

engage in patient categorization or sorting (Allen et al., 2004;

Hasenfeld, 1972), a complex process of matching rules, situ-

ations, patient needs, and other factors (Henderson, 2013b).

Frontline workers, even in relatively straightforward cases,

may not properly categorize the individuals subject to assess-

ment (Bosma, Kunst, Dirkzwager, & Nieuwbeera, 2018). In

doing so, frontline workers may develop tendencies to

behave in ways that are more rule abiding—potentially at the

expense of the service recipient—or in ways that bring to the

fore the needs of the recipient despite the rules; Maynard-

Moody and Musheno (2003) labeled these “state-agents” and

“citizen-agents,” respectively (p. 9). Thus, EMS personnel

face situations in which rules and patient needs are ill

matched, which then require either rule-abiding or rule-devi-

ating behavior.

Rule Deviation: Bending and Breaking

Rules, even those that are clear, comprehensive, and well

intentioned, cannot address the intricacies of every complex

situation (Lipsky, 1980), and may invite breaking or bending

behaviors by those interacting with them. Although rules

provide consistency (Jackson & Adams, 1979), bureaucrats

must consider policy implementation in the context of inter-

actions with people, situations, and specific types of prob-

lems. In cases where rules and situations are at odds,

bureaucrats must make choices to rigidly adhere, bend, or

break rules. DeHart-Davis (2007) defines rule bending as a “

. . . willingness to depart from rules and procedures” (p. 893).

Variation, then, is found both in situations that may call for

rule-abiding or rule-bending behavior, and in individual ten-

dencies to follow rules (Oberfield, 2010). Both rule bending

and breaking are forms of rule deviation—the former an act

of partial rule violation and the latter an act of outright viola-

tion (Sekerka & Zolin, 2007). Thus, like Borry’s (2017)

study on ethical climate and rule bending, this research does

not differentiate between rule breaking and bending.

Empirical research on rule bending and rule breaking

indicates that a number of individual and organizational

attributes may contribute to or spur these types of decisions

in policy enactment. At the organizational level, both attri-

butes of the agency and the organizational climate have

been found to shape individual rule-bending tendencies

(Borry, 2017; Borry et al., 2018; Brockmann, 2017; DeHart-

Davis, 2007; Henderson, 2013a). DeHart-Davis (2007)

found that aspects of organizational structure such as cen-

tralization and formalization, as well as perceptions of rules

as onerous and unnecessary—as red tape—shape rule-

bending behavior; centralization increases rule bending,

whereas formalization reduces it.

The context of bureaucratic work can also affect rule-

bending tendencies. Henderson and Pandey (2013) found that

paramedic’s interactions with leaders in response to situa-

tional variables affected deviations from rule or directives. A

study of German state police found that “unbureaucratic

behavior”—used here in a manner to replicate work of

DeHart-Davis (2007)—was shaped by employee voice and

by readiness for change (Brockmann, 2017). Street-level

workers who were more readily able to express themselves to

managers in a manner that was consistent with their beliefs,

and who were more engaged and ready to implement mana-

gerial directives, were more likely to engage in rule-bending