Nurses Who Break the Rules to Innovate: Study Reveals What Drives Creative Deviance

In the highly structured world of hospital care, where protocols are designed to protect patients and hierarchies define who may act, a surprising behaviour is quietly taking place: nurses pursuing unauthorized innovations in the hope of helping their organizations. Researchers call this phenomenon creative deviance, sometimes known as bootlegging, and a new cross-sectional study of 650 clinical nurses in China offers one of the first systematic portraits of how often it happens and what conditions make it more likely. The findings, published in Nursing Open, suggest that the inner sense of purpose nurses draw from their work and the psychological safety of their teams are far more influential than salary, shift patterns, or workload.

Creative deviance occupies an unusual position in organizational psychology. Unlike misconduct, it is a pro-organizational behaviour: employees bend or break reference norms without the organization’s knowledge, but with the sincere intention of benefiting it. It typically emerges when formal channels fail to accommodate promising ideas, a situation that is common in healthcare, where standardized procedural management systems and chronic resource shortages can stifle experimentation. Previous research in other industries has shown that effectively harnessing such deviant innovation can improve individual and team performance and enhance organizational innovation over time, which is why the concept has attracted growing scholarly attention.

To frame their investigation, the researchers drew on Social Cognitive Theory, which holds that behaviour arises from dynamic interactions between personal factors and environmental events. Within this framework, workplace spirituality was treated as an individual-level psychological resource: a transcendent experience nurtured through meaningful work and a sense of connection with others. Team psychological safety climate, by contrast, was conceptualized as a team-level environmental factor representing shared perceptions of interpersonal risk, meaning the collective belief that members will not be penalized for speaking up, asking for help, sharing ideas, making mistakes, or expressing concerns. Conservation of Resources Theory adds a complementary lens, proposing that individuals strive to obtain, retain, and protect valued resources, and that a rich inner sense of purpose strengthens intrinsic motivation and stimulates initiative.

The study was conducted between May and June 2024 across three tertiary general hospitals in Quzhou City, each representing a different healthcare service model: a municipal comprehensive teaching hospital with strict hierarchical management, a hospital integrating traditional and Western medicine, and a psychiatric specialty hospital operating in a high-risk environment. Using convenience sampling, the team recruited registered nurses with at least one year of clinical experience. A power analysis indicated a minimum sample of 143 participants, but the final dataset of 650 valid responses, drawn from 712 distributed questionnaires for a 91.3 percent effective response rate, provided substantially greater statistical power. Respondents were predominantly female at 96.5 percent, with a mean age of 32.13 years and average work experience of 10.73 years, and 82.0 percent held a bachelor’s degree or higher.

Participants completed a general information questionnaire along with three validated instruments. The five-item Creative Deviance Scale, originally developed by Criscuolo and colleagues and adapted for Chinese use with a content validity index of 0.91, showed strong internal consistency in this sample with a Cronbach’s alpha of 0.897. The 27-item Workplace Spirituality Scale, covering meaningful work, sense of community, and alignment between organizational and individual values, achieved an alpha of 0.983, while the 16-item Team Psychological Safety Climate Scale, spanning direct expression of opinions, mutual respect, interpersonal risk-taking, and mutual trust, reached 0.911. Rigorous quality controls were applied: questionnaires with contradictory responses, more than 50 percent identical answers, or completion times under three minutes were excluded, and Harman’s single-factor test indicated no serious common method bias, with the first unrotated factor explaining 48.476 percent of variance.

The headline result was that creative deviance among clinical nurses sits at a moderate level, with a mean scale score of 17.78 out of a possible 25 and a per-item mean of 3.55, above the theoretical midpoint of 3.00. Notably, this figure is lower than the per-item mean of 4.10 reported among employees in education, finance, and public utilities, a gap the authors attribute to nursing-specific barriers. The hierarchical structure of nursing, with clear chains of command and direct supervision, may discourage bottom-up innovation, while systemic obstacles such as unfamiliar innovation ecosystems, lengthy development processes, fear of idea theft, difficulties with commercialization, and insufficient organizational support for nurse-led innovation further dampen unauthorized creativity.

Univariate analyses revealed significant differences in creative deviance scores across six variables: illness, monthly night-shift frequency, weekly working hours, annual salary, workplace violence, and work pressure. Nurses without illness scored higher than those with illness, those working up to eight night shifts per month scored higher than those working none or nine or more, and scores declined as weekly hours increased beyond 40. Higher income and higher self-rated work pressure were also associated with higher scores in bivariate comparisons. However, when all of these variables were entered into a multivariable linear regression model, most of these effects disappeared, leaving only three independent predictors.

The regression results were strikingly clear. Workplace spirituality showed the strongest positive association with creative deviance, with a standardized coefficient of 0.364, followed by team psychological safety climate at 0.271, both significant at p less than 0.001. Illness was the sole negative predictor, with a coefficient of minus 0.070. The overall model explained 36.8 percent of the variance in creative deviance. Bivariate correlations reinforced the pattern: creative deviance correlated positively with workplace spirituality at r equal to 0.556 and with team psychological safety climate at r equal to 0.524, both highly significant. Within the psychological safety measure, interpersonal risk-taking recorded the lowest per-item score at 3.02, suggesting that the willingness to take visible social risks remains the weakest link in these teams.

The theoretical interpretation is that nurses with high workplace spirituality accumulate spiritual resources such as job satisfaction, organizational identity, and attachment, which motivate them to engage in uncertain innovative activities despite the absence of formal authorization. Meanwhile, a psychologically safe team climate reduces the fear of unfavourable consequences when experiments fail, enabling individuals to concentrate fully and strengthen their commitment to organizational goals. The authors emphasize, however, that the cross-sectional design precludes causal inference and that the findings should be read as hypothesis-generating. Limitations also include the single provincial healthcare system, convenience sampling, a single-item measure of work pressure, and the absence of normative data for the Creative Deviance Scale in Chinese nursing populations.

Crucially, the researchers do not advocate individual rule-breaking in a field where operating outside established norms could compromise patient safety. Instead, they recommend that nursing managers foster psychologically safe climates in which nurses feel able to voice concerns and propose innovative solutions through official channels, cultivate workplace spirituality through values alignment and purpose-driven practice, and support health-promoting behaviours and scientifically assigned workloads. The positive deviance approach, which has been shown to reduce healthcare-associated infections, supports the same principle of building supportive climates rather than encouraging solitary violations. By aligning innovation with patient safety, the core mission of nursing, these evidence-informed strategies may prove transferable across diverse clinical contexts internationally, offering nurse managers, educators, and policymakers a constructive path for turning quiet, unauthorized ingenuity into sanctioned, sustainable improvement.

Subject of Research: Creative deviance among clinical nurses and its associations with workplace spirituality and team psychological safety climate

Article Title: The Level and Associated Factors of Creative Deviance of Clinical Nurses

Article References: The Level and Associated Factors of Creative Deviance of Clinical Nurses. (n.d.). https://doi.org/10.1002/nop2.70830

Image Credits: AI Generated

DOI: 10.1002/nop2.70830

Keywords: creative deviance, clinical nurses, workplace spirituality, psychological safety, nursing innovation, bootlegging, cross-sectional study, nursing management, organizational behaviour, patient safety, China, Nursing Open