Exploring the Concept and Use of Positive Deviance in Nursing

Home , Deviance (sociology), Positive deviance

2.5 HOURS CE Continuing Education

‘Responsible subversion’ and why accurate documentation matters.

OVERVIEW Positive deviance involves an intentional act of breaking the rules in order to serve the greater good. For nurses, the rightness or wrongness of such actions will be judged by other people who are in charge of rules enforcement; but the decision to engage in positive deviance lies solely with the nurse. There is no uniform or consistent definition of positive deviance. This article uses the Walker and Avant method of concept analysis to explore and identify the essence of the term positive deviance in the nursing practice environment, provide a better understanding of the concept, and clarify its meaning for the nursing profession. In turn this led to an operational definition: positive deviance is intentional and honorable behavior that departs or differs from an established norm; contains elements of innovation, creativity, adaptability, or a combination thereof; and involves risk for the nurse. The concept of positive deviance is useful, offer- ing nurses a basis for decision making when the normal, expected actions collide with the nurse’s view of the right thing to do.

Keywords: clinical decision making, concept analysis, nursing practice, positive deviance, standard practice guidelines

rofessional nursing standards guide patient that is aberrant or will elicit disapproval. Yet the con- care services and lay the foundation for best cept of positive deviance is a useful one, and the term Ppractices. But standards often aren’t enough; is widely used in such fields as business, management, for nurses, decision making involves multiple condi- sociology, criminology, and even health care. There is tions of certainty, uncertainty, and risk.1 The clinical no uniform or consistent definition of positive devi- setting contains an infinite assortment of situations ance as it applies to nursing. This article will explore that require nurses to use their technical skills and and identify the essence of the term in the nursing situation-specific knowledge and follow a profes- practice environment, using the Walker and Avant sional code of conduct.2 Moreover, applicable pro- procedure for concept analysis.3 In doing this concept fessional standards may not be available or may not analysis, my intent was to increase our understand- be realistic in certain situations. Nurses might have ing of what positive deviance is and is not, within the to react creatively in order to meet the needs of their context of professional nursing practice, and to pro- patients. In such situations, some nurses may use vide an operational definition. a concept called positive deviance to guide their actions. SELECTION OF THE CONCEPT The word deviance can be emotionally charged, As Walker and Avant have explained, concepts evoking a range of images and connoting behavior are useful “mental constructions” that represent

26 AJN ▼ August 2013 ▼ Vol. 113, No. 8 ajnonline.com By Jodie C. Gary, PhD, RN Illustration by Janet Hamlin. Illustration by

categories of information.3 A concept’s attributes or Some articles led to other articles through their bib- characteristics are what distinguish it from other liographies; others were sent to me by classmates. concepts. Thus, concept analysis is a process that I found little discussion in the nursing literature to involves examining the attributes or characteristics clarify the concept of positive deviance as a distinct of a concept and results in “a precise operational behavior, and only modest exploration of how nurses definition” of that concept. Identifying a concept’s provide patient-centered care within the realm of stan- defining attributes also facilitates decisions about dard practice guidelines. Yet there is evidence that pos- which phenomena are good examples of the concept itive deviance is a behavior used by some nurses under and which are not. The Walker and Avant method some circumstances to provide care to their patients. of concept analysis provides a systematic way to un- Following are several uses of the concept in various dertake analysis of a nebulous term that might have fields that were revealed by the literature search. The multiple meanings. defining attributes of the concept of positive devi- This concept analysis of positive deviance began ance, and its antecedents and consequences, are also with a literature search conducted between Decem- described. ber 2009 and August 2011. I searched WorldCat and other databases, including PubMed, the Cumu USES OF THE CONCEPT OF POSITIVE DEVIANCE lative Index to Nursing and Allied Health Literature As an oxymoron—and a viable behavior. Experts (CINAHL), and EBSCO, using multiple terms and in many fields have found various ways to distin- no date restrictions. The literature search ranged guish the concepts of deviance, negative deviance, across several fields, including not only nursing and and positive deviance. In an article published in health care but also sociology, business, manage- Safety Science, Polet and colleagues described devi ment, organizational studies, and even criminology. ations as a normal part of any workplace process, [email protected] AJN ▼ August 2013 ▼ Vol. 113, No. 8 27 regardless of the kind of work.4 Yet as Dehler and and explaining “positive, norm-departing behav- Welsh have noted, to label someone as deviant im- iors.”11 They described a normative approach that plies that their behavior is harmful in some way.5 defines positive deviance as “intentional behaviors Indeed, in a book on positive deviance as a process, that depart from the norms of a referent group in Pascale and colleagues described it as “an awkward, honorable ways.”11 (An example of this might be the oxymoronic term.”6 employee who, against company policy, disobeys an Although it’s not certain when the term positive order to dump toxic waste into a river.8) This ap- deviance came into use, I found the term first used proach, which is similar to Warren’s, uses evalua- in broadening the discipline of organizational behav- tive criteria—such as norms—to identify conduct ior.7 Dodge initially defined deviance as neutral: “any that ought or ought not to occur. act, role/career, attribute, or appearance that departs In the nursing and health care literature, Clancy significantly from social situational expectations.”7 has described his realization that “positive deviance He then defined positive deviance as departures that acknowledges that expertise is widely distributed and “surpassed” those expectations. In contrast, Robinson that those on the front line”—nurses at the bedside— and Bennett considered most deviance negative, de- “many times have a better sense for what is working” fining it as “voluntary behavior that violates signifi- for patients than their managers do.12 Lloyd stated cant organizational norms and in so doing threatens that positive deviance occurs when individuals use the well-being of the organization, its members, or “uncommon practices/behaviors [that] enable them both,” and developing a typology of deviant work- to find better solutions to problems than their neigh- place behaviors.8 Vardi and Wiener defined organi- bors who have access to the same resources.”13 zational misbehavior as any intentional action by an In the fields of sociology, business, and organiza- organizational member that “defies and violates (a) tional studies, as well as nursing management and shared organizational norms and expectations, and/ health care administration, then, positive deviance or (b) core societal values, morals and standards of is viewed as nonprescribed practices or strategies proper conduct.”9 that are intended to produce or do produce better outcomes than traditional standard practices. As a noun. Several terms, with various connota- Positive deviants are atypical nurses tions, have been used to describe someone who is a positive deviant. Bloch used the term trailblazers, explaining that positive deviants aren’t afraid to leave who practice differently and more the beaten path and strike out in a new direction in order to find a better way to get things done.14 Bloch effectively than their peers. described positive deviants as “focused, persistent and optimistic” in pursuing their goals; they are people who make things happen in organizations, and Warren criticized these definitions of deviance for who are crucial to the success of change efforts. Field- not considering the societal dangers of blind com- ing and colleagues described positive deviants as ex- pliance with given norms and for not clearly stating ceptional high achievers who exceed the normal or which societal values will be used to determine misbe- average levels of performance in a given group.15 havior.10 She conceptualized deviance from a behav- In studying nurses who acted as positive deviants, ioral approach, one which stressed “the importance Clancy found that certain nurses were considered es- of reference groups and normative standards as the sential to a successful work environment.12 Their col- basis for ‘labeling’ deviant behavior.” She categorized leagues described them with phrases such as “always deviance as either constructive or destructive; her cri- finds a way to get the job done,” “is the glue that teria for constructive deviance included behaviors that holds us all together,” and “is extremely resourceful, break or depart from reference group norms and are knowledgeable, and adaptable.” Positive deviants, socially or organizationally beneficial—for example, then, are atypical nurses who practice differently and whistleblowing that brings to light an organization’s more effectively than their peers. illegal or immoral practices. Warren further noted As a process. Positive deviance is often viewed as that while organizational and societal interests may a process or approach to organizational change, or overlap, some variations usually exist. This idea is as a framework for understanding organizational also relevant to nursing practice. For example, nurs- behaviors13, 16-18; as an alternative method of identifying standards are instilled to provide models of best ing best practices19, 20; as a valuable tool for identi practices; nevertheless, in specific patient care situa- fying innovative health care practices16, 21; and as a tions, some variation from those standards may be problem-solving technique.13 necessary. The development of positive deviance as a process Spreitzer and Sonenshein sought to provide a con- is attributed to Jerry and Monique Sternin of the Posi- ceptual framework for understanding, identifying, tive Deviance Initiative in the 1990s.18, 22 The process

28 AJN ▼ August 2013 ▼ Vol. 113, No. 8 ajnonline.com has been used to address such difficult problems as the defining attributes of the concept.3 Based on the childhood malnutrition, sex trafficking of girls, and characteristics found to be most frequently associated hospital-acquired infections.18 Lindberg and Clancy with positive deviance as a behavior in the literature, pointed out that this process is based on the belief positive deviance that there are people in every organization whose • is intentional and honorable. different work practices produce better outcomes, • departs or differs from an established norm. even though others in the organization have access • contains elements of innovation, creativity, to the same resources.17 adaptability, or a combination of these. In nursing, the process of positive deviance • involves risk for the person deviating. can take the form of a method of inquiry, in which Or, restated as an operational definition: positive researchers “focus on individuals who behave differ- deviance is intentional and honorable behavior that ently from the rest of the community and, in so do- departs or differs from an established norm; contains ing, succeed where others fail.”23 Kim and colleagues elements of innovation, creativity, adaptability, or a used this method to study Indonesian nurses and pa- combination thereof; and involves risk for the person tients who communicated especially effectively dur- deviating. ing family planning consultations.23 They were able to identify several factors that made some participants more effective communicators than others. For ex- Positive deviance involves behaviors ample, those nurses who were positive deviants described professional knowledge and skills as the most important element in communication, and had im- characterized by honorable intentions, proved their knowledge and skills through independent study; they also created communication aids to independent of outcomes. use with patients. As a management strategy. Positive deviance has been suggested as a way to improve clinical perfor- Intentional and honorable. According to Bloch, mance outcomes in health care systems. Lloyd noted positive deviants have a strong achievement focus that despite the top-down hierarchies predominant but are “unfettered by the need to conform,” which in modern business and society, there seem to be sub- allows them to look for innovative solutions to prob- groups of people who figure out solutions to problems.14 Bloch also noted that, unlike negative devi- lems and solve them on their own, using persuasion ants, positive deviants are driven by dedication to or citing guidelines and even laws to legitimatize their their organization’s values and goals. Spreitzer and actions.13 Tarantino suggested that instead of relying Sonenshein specifically stated that positive deviance on outside parties to solve problems, an institution involves behaviors characterized by honorable inten- should identify and rely on its existing experts who tions, independent of outcomes.11 may have knowledge of preexisting, applicable so- In a study of hospital-based nurses, Hutchinson lutions.20 identified the construct and process of responsible Clancy described a situation in which, despite subversion as describing the behavior of nurses who months of planning, the implementation of an elec- bent the rules for the sake of their patients.24 The tronic medical record (EMR) system at one health nurses’ behavior was deemed responsible because care system went awry.12 It was “perceived as cumber- they used their best nursing judgment in deciding some” by nurses, who delayed using it until the end which rules to bend and when and how to do so. Yet of their shifts, driving up overtime. But a few nurses these behaviors were also subversive, because they were observed completing their EMRs on time, and violated hospital policies or physicians’ orders, even it was discovered that they had adapted and altered in some cases the state’s nurse practice act. Much like the hospital’s EMR practices after becoming frus- Spreitzer and Sonenshein, Hutchinson acknowledged trated with the prescribed method. Clancy notes that that responsible subversion is independent of positive although their flaunting of the hospital’s usual pro- or negative outcomes. Similarly, Vardi and Wiener’s cess wasn’t well received by the unit manager, “these review of the literature on organizational misbehav- rogues had solved a problem in a matter of weeks” ior found that “misconduct in organizations has not that preimplementation teams had worked on for only been viewed as pervasive, but, for the most part, months.”12 He challenged managers of complex health as intentional work-related behavior.”9 They classi- care environments “to find the positive deviants in fied such misconduct by whether the underlying in- your organization and tap into their creative minds.” tention was to benefit or harm the organization, and acknowledged that intention was separate from out- THE DEFINING ATTRIBUTES OF POSITIVE DEVIANCE comes. When characteristics of a given concept appear re- Different. Dehler and Welsh stated that it is criti- peatedly in literature, these are determined to be cal to recognize that deviance involves “thought or [email protected] AJN ▼ August 2013 ▼ Vol. 113, No. 8 29 action that differs from something.”5 Hutchinson adaptive behavior may or may not be considered noted that the anthropological and sociological litera- deviant.5) ture has examined how work gets done “in spite of or Koerner used the term active intelligence to de- in opposition to the formal system” or the commonly scribe how some nurses use imagination and creativity accepted norms.24 Hutchinson further affirmed that in examining a given practice and considering ways nurses who bend the rules for the sake of patients are in which it might be accomplished or improved.27 “fully socialized . . . and recognize that their values of And Clancy pointed out that although nursing work- patient advocacy are different from those of the orga- arounds are often seen in a negative light, they can nization.” be both creative and valuable—“diamonds in the rough.”12 Risky for the person deviating. Positive deviance Although nursing workarounds are makes people uncomfortable and involves risk.26 Stewart and colleagues described how covert rules and expectations are often at play as nurses decide often seen in a negative light, they can whether or not to stretch the limits of their scope of practice.28 Most nurses practice warily, in the interest be both creative and valuable. of preserving their licenses. They realize that when they step outside the boundaries of hospital rules and protocols, they put their careers at risk. But nurses Positive deviants are able to stand back and look who are positive deviants also know that their ability for new ways to approach and solve problems. Bloch to make autonomous decisions is crucial to patient explicitly stated that positive deviants are not anar- safety, and they accept the risk in order to do what’s chists; rather, they strongly identify with the values of best for their patients.29 Indeed, Rycroft-Malone and their organization, and are motivated by wanting it colleagues pointed out that although most nurses to succeed.14 When they behave in unusual ways, it’s view the expansion of traditional nursing roles favor- in the service of the organization. Warren pointed out ably, such expansion also concerns nurses because that the management literature often assumes that it means they’re more open to liability.30 a behavior that challenges social norms to achieve something positive is distinctly different from a be- ANTECEDENTS AND CONSEQUENCES OF POSITIVE DEVIANCE havior that does so to achieve something negative.10 IN NURSING Yet both behaviors are fundamentally similar in that As Walker and Avant explain, antecedents are “those both require the employee to “resist social pressure events or incidents that must occur prior to occurrence to conform.” of the concept.”3 Consequences are “those events or Innovative, creative, adaptable. Dehler and Welsh incidents that occur as a result of the occurrence of argued that deviance is an important “source of adap- the concept”—that is, the concept’s outcomes. Identi- tive capacity in organizational transformation.”5 They fying a concept’s antecedents and consequences help credit Hanke and Saxberg with originating the con- to further pinpoint its defining attributes. cept of constructive deviance in 1985, an idea based Antecedents. Standard practice guidelines or on the combined social theories of creative individu- hospital policies that limit a nurse’s ability to pro- alism, productive nonconformism, and opinion devi- vide patient-centered care may trigger conflict in the ance. nurse—and that sense of conflict is an antecedent to McCall described U.S. Army nurses as historically positive deviance. Australian researchers Berner and able to adapt quickly to unique wartime situations in colleagues acknowledged this potential dilemma, order to provide the best possible care to soldiers.25 noting that nursing standards also contain elements Their creativity and innovations “not only solved that require the nurse to break with guidelines if the problem of the moment but were instrumental following them will compromise patient safety.31 in the advancement of the professional practice of Similarly, a conflict exists when standard practice nursing.”25 guidelines do not allow a nurse to provide care that Appelbaum and colleagues considered innova- meets the specific needs of the patient and clinical tion, a type of “pro-social behavior,” to be positive situation.24, 29, 32 deviance only if the behavior diverged from organi- Another antecedent is a certain level of clinical zational norms, was voluntary, and had honorable expertise, which is also necessary to the nurse’s rec- intent.26 They described innovative thinking as “in- ognition of situational differences in the delivery of volving the creation and development of new ideas patient care. Experts have spoken to the complex- that are not held by the majority.” (However, Dehler ity of nursing care, which requires continuous devel- and Welsh pointed out that some experts do not de- opment of clinical knowledge through experiential fine every departure from norms or expectations learning.33, 34 Noting that a nurse cannot “practice as deviance; depending on the definition used, an beyond her [or his] experience,” Benner stated that

30 AJN ▼ August 2013 ▼ Vol. 113, No. 8 ajnonline.com experiential learning is a precursor to clinical discern- dispensing system, the nurse could only document ment and individualization of patient care.33 Benner a one-time dose of 100 mg of meperidine adminis- and colleagues further observed that nursing experi- tered to the patient an hour after arrival from sur- ence must be combined with attunement to the pa- gery. tient and a sense of the timing and logistics of care In this case, the behavior of the nurse exempli- in ever-changing clinical situations.34 fied the defining attributes of positive deviance. The Consequences. The most practical consequence decision to give the medication in delayed doses was of positive deviance in nursing appears to be the devi- intentional and honorable; it stemmed from the nurse’s ance itself. Rules are broken, standard practice guide- dedication to patient safety. The nurse departed from lines are not followed, and the nursing roles or scope the established order set in an adaptive way to meet of responsibility are expanded. Other consequences the patient’s needs. By not giving the medication as might include care that is undocumented, so that any ordered and not documenting what she actually did, outcomes of the deviation remain unreported. If this the nurse put her career at some risk. These behav- happens, it can lead to a delay in the advancement of iors could be interpreted as prescribing a medication nursing practice, as well as place the nurse in a tenu- without a license, and essentially are in conflict with ous legal and ethical situation. most nurse practice acts. However, the outcome was There are times when nurses make decisions to one that resulted in pain relief while minimizing the go beyond standard practice guidelines or find work- risks to the patient. arounds.28, 31, 35 In such cases, when nurses don’t report A contrary case. The same nurse described in the the exact care provided, the outcomes of positive de- previous case admitted a second patient from the op- viance are lost. Ironically, this also lends false support erating room following surgical intervention for a to those ineffective or insufficient protocols and poli- knee fracture. This second patient was a large, ath- cies that were the basis for the nurse’s positive devi- letic 32-year-old man weighing 200 lbs. As in the first ance in the first place. Accurate documentation with case, shortly after being settled in the hospital room, regard to acts of positive deviance is essential to the this patient reported severe postoperative pain. The advancement of nursing practice. nurse again consulted the routine postoperative order set from the orthopedic group and found the same CASE EXEMPLARS pain management order set containing an as-needed A model case provides a clear example of the use order for two tablets of an oral analgesic, as well as of positive deviance in nursing by utilizing all of the meperidine 100 mg delivered intramuscularly or in- defining attributes. A contrary case represents the travenously. This patient was a bit drowsy from anes- exact opposite of the model case and may be help- thesia and was just starting to take a few ice chips. ful in explaining what positive deviance in nursing The nurse administered the 100-mg dose of the me- is not. peridine as ordered. Within 30 minutes, the nurse A model case. A nurse admitted a patient from evaluated its effectiveness and found the patient’s the operating room to a general surgical unit fol- pain adequately controlled. lowing a surgical intervention for a hip fracture. The patient, a petite 89-year-old woman, weighed less than 110 lbs. Within an hour of being settled in the Nursing standards require the nurse hospital room, the patient reported severe postoperative pain. The nurse consulted the routine postoperative order set from the orthopedic group. For pain to break with guidelines if following management, the order set contained an as-needed order for two tablets of an oral analgesic, as well as them will compromise patient safety. meperidine (Demerol) 100 mg delivered either intramuscularly or intravenously. The patient, who had been groggy since admission, had just taken a few As Dehler and Welsh point out, conformity is the ice chips. The nurse decided against the oral analge- “polar opposite” of positive deviance.5 For a nurse sic because of the risk of aspiration and choking; and (or anyone) who responds to conflicting role expec- she was concerned about giving such a large dose of tations by following orders rather than challenging meperidine to a small, elderly woman. The nurse de- them, conformity probably reduces stress. However, cided to administer 25 mg, evaluate its effectiveness in this case, there was no need to consider such a chal- after 30 minutes, and then administer another 25 mg lenge. In following standard practice guidelines and if needed. Over the next eight hours, the entire dose the routine order set, the nurse safely and effectively of the originally ordered 100 mg of meperidine was met the needs of this patient. There was no need to administered to the patient, and the patient reported intentionally depart from usual care; no elements of relief from her pain during this time. But because innovation, creativity, or adaptability were needed; of the built-in controls of the electronic medication and the nurse incurred no risks. [email protected] AJN ▼ August 2013 ▼ Vol. 113, No. 8 31 DISCUSSION Kramer and Schmalenberg discuss several ways that Empirical referents offer a way to measure a concept, nurses commonly “renegotiate” that scope, including or at least determine its existence, in the real world.3 “do and inform later” and “persist until the patient As defined by Walker and Avant, empirical referents gets what he or she needs.”29 A small study of nurses are “classes or categories of actual phenomena that identified as using exceptional caring practices found by their existence or presence demonstrate the oc- that all “crossed the boundaries of standard nurse– currence of the concept.”3 But determining empiri- client care in one form or another.”39 Another study cal referents for the concept of positive deviance in exploring how nurses interpreted autonomy in every- nursing practice is challenging, because the behav- day clinical practice found that when nurses encoun- iors tend to be hidden and undocumented. As yet, tered barriers—such as “not being heard” and having no empirical referents for positive deviance in nurs- their experience overlooked—they “found other cre- ing can be given. ative ways” to persist toward their goals and advo- Practice dilemmas arise when standard practice cate their patients’ best interests.28 guidelines do not fit the needs of a specific patient Such creative ways can include adaptations, mod care situation. With clinicians increasingly functioning ifications, work-arounds, and innovations that dif- “as knowledge workers rather than [as] task-driven fer from standard practice guidelines. For example, care providers,”36 the incidence of practice dilemmas Clancy describes how after becoming frustrated with and of positive deviance will likely increase also. In their hospital’s newly implemented EMR system, order to measure positive deviance in nursing prac- some nurses spoke with friends who had used sim tice, the concept needs to be explored through quali- ilar systems in other facilities, then adapted what tative research investigating the actual nursing care they learned for their own system.12 In another study, provided in such instances. aware of deficits in their formal training, Indone- sian nurses reported improving their nurse–patient communication skills through independent study, Positive deviants are able role-playing, and the use of communication aids.23 And in her historical review of U.S. Army nurses, McCall stated that under wartime conditions, nurses to stand back and look for “either adapted quickly or gave up . . . a lot of im- provisation was required.”25 She detailed numerous new ways to approach and ingenious examples, large and small, from using tent frames in applying traction to changing how patients solve problems. were assigned. Complexity science. It can be useful to consider positive deviance through the lens of complexity The literature does hint at the widespread presence science—an interdisciplinary field that studies “the of positive deviance in nursing, and its inherent con- manner in which complex adaptive systems evolve, flicts. Nurses who use creative approaches have been interact, and maintain order.”40 Complexity science described as going “under the radar” or “working the looks at organizations less as machines and more as system.”35, 37 In so doing, they may find themselves “living” entities, made up of subsystems and indi- bending or breaking rules such as policies, orders, viduals and characterized by interconnectedness and even laws governing nursing practice.24, 31, 38 Berner unpredictability.41 The current health care system and colleagues found that 92% of surveyed critical may be viewed in this way.38, 41, 42 care nurses were aware of legal limits when they made Complexity science suggests that complex sys- decisions related to patient care, and 70% reported tems require a flexible approach.40 Attempts at rigid having made decisions that went beyond those lim- control can backfire, because such control isn’t flexi- its.31 (Interestingly, 73% of respondents “believed that ble enough to allow for individual or circumstan- this should not be occurring.”) Hutchinson noted tial differences.43 When individuals try to circumvent that nurses tend to be less autonomous and more rigid controls, their attempts can lead to unforeseen rule-bound in their practice than either administrators problems and consequences. Yet positive deviations or physicians, because most nursing actions occur can also solve problems and improve outcomes. As within a set of rules or guidelines imposed by others.24 Matlow and colleagues stated, system change has She described how nurses who bent the rules felt traditionally been approached by focusing on struc- strongly about their role as patient advocate; yet in tures and processes, often leading to the creation of most situations the nurses kept their rule-bending more rules; but it may be more useful to focus on the behaviors secret. relationships among agents within a system.43 By bet- There are some scenarios in the literature describing ter understanding how nurses, patients, physicians, nurses who intentionally provided care that pushed and others interact in the delivery of health care, the the boundaries of their scope of practice. For example, process could be better individualized.40, 43

32 AJN ▼ August 2013 ▼ Vol. 113, No. 8 ajnonline.com The need for accurate documentation. Although protocols become, “clinical puzzles that arise every- nurses may at times act as positive deviants, they gen- day cannot be solved without engaged thinking and erally choose not to report (or are unable to report, clinical reasoning in and through the specific context owing to system constraints) the exact care they pro- of each individual situation.”34 vided. Thus, there is no outcome data for the care that was really provided—and this lack also lends RECOMMENDATIONS false support to ineffective or insufficient protocols Nurses’ clinical decisions are clearly crucial to patient and policies. Accurate reporting and documentation outcomes; so transparency about those decisions is vi- of the actual nursing care delivered are essential to tal. Koerner described nurses as “walk[ing] between having accurate outcomes data, to ensuring patient two worlds: the concrete world of a scientist and the safety, and indeed to furthering the profession. abstract world of an artist.”27 A more comprehensive Furlong has stated that in making decisions about understanding of creative acts of positive deviance in patient care, nurses must balance “what evidence- nursing will help to foster the development and im- based practice dictates, what the law mandates, and plementation of strategies that support nurses in their what the ethical dilemma calls for.”44 She added that clinical decision making and practice; and it will im- in certain situations, fearing the penalty of law, a nurse prove our knowledge of how positive deviance affects might violate the professional code of ethics and fail patient outcomes. to be a patient advocate. For example, if a terminally It’s essential, then, that nurses have a way to safely ill patient refuses hydration but has no advance di- report the deviations they make for the sake of pa- rective, the nurse might feel compelled to administer tients. The true cause-and-effect relationships between hydration anyway. Positive deviance, on the other care and outcomes cannot be known otherwise. Ac- hand, might focus more on the patient’s wishes. In- curate data about practice and outcomes are vital. If deed, when the usual or expected nursing actions outcomes are improved, then the quality of patient collide with the nurse’s view of the right thing to do care is improved. Nurses who are positive deviants for the patient, the concept of positive deviance can may be generating new knowledge on the fly; we need provide a basis for decision making. to be able to access that knowledge. Proper documen- Marsh and colleagues suggested that insights tation of deviations will in turn facilitate the develop- into how and why positive deviants behave differ- ment or improvement of guidelines for specific patient ently from their peers can help us to develop strate- care situations. gies that promote desirable behaviors in health care.21 Increased nursing input on policy issues that af- Dowding and Thompson pointed out that because fect the delivery of patient care is also needed. Ga- nurses’ decisions have a tremendous impact on pa- wande spoke to the need to push decision-making tient outcomes and experiences, “how we measure power from the center out to the periphery when the accuracy or ‘goodness’ of nurses’ judgements confronted with complex and unusual problems: and decisions is . . . of prime importance.”45 A core “You give people the room to adapt, based on their challenge in studying positive deviance, then, is link- experience and expertise. All you ask is that they ing quantitative measures of variables that might talk to one another and take responsibility. That is influence “top performance” with qualitative find- what works.”46 ings.19 In his book The Checklist Manifesto, Gawande acknowledged the enormous complexity of health When nurses don’t report the exact care, and noted that “there are often times when a clinician has to just do what needs to be done. For- get the paperwork. Take care of the patient.”46 In his care provided, the outcomes of view, the question of when to follow protocol and when to follow personal judgment is a crucial one: positive deviance are lost. “You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected The ultimate goal of this exploration was to pro- difficulties.” Similarly, Benner noted that a nurse’s vide an operational definition for the concept of pos everyday ethical and clinical conduct are guided “not itive deviance within the practice of nursing. Such a so much by quandary and extreme cases that fall out- definition can offer nurses a basis for decision mak- side the boundaries of good practice” but by the abil- ing when the normal or expected actions in a given ity to make qualitative distinctions between “worthy situation collide with the nurse’s view of the right competing goods.”32 This decisional aspect of positive thing to do. deviance is what makes it essential that the dialogue As nurses become more autonomous providers be brought out into the open. No matter how well de- of primary health care services, I believe the use of veloped “best practice” standards and evidence-based positive deviance must become a goal. Although [email protected] AJN ▼ August 2013 ▼ Vol. 113, No. 8 33 better documentation and further research are needed, 21. Marsh DR, et al. The power of positive deviance. BMJ it seems likely that patient care and outcomes will 2004;329(7475):1177-9. 22. Positive Deviance Initiative. History. 2010. http://www. improve when nurses have the courage to make in- positivedeviance.org/about_pdi/history.html. tentional, honorable decisions to provide innovative, 23. Kim YM, et al. Factors that enable nurse-patient communi creative, and adaptive care in situations that de- cation in a family planning context: a positive deviance study. mand it. ▼ Int J Nurs Stud 2008;45(10):1411-21. 24. Hutchinson SA. Responsible subversion: a study of rule- bending among nurses. Sch Inq Nurs Pract 1990;4(1):3-17; For 66 additional continuing nursing education discussion 9-22. 25. McCall SC. Lessons learned by army nurses in combat: a articles on research topics, go to nursingcenter. historical review. Carlisle, PA: U.S. Army War College; 1993 com/ce. Apr 15. http://www.dtic.mil/dtic/tr/fulltext/u2/a264441.pdf. 26. Appelbaum SH, et al. Positive and negative deviant workplace behaviors: causes, impacts, and solutions. Corporate Governance: the International Journal of Effective Board Jodie C. Gary is an assistant professor in the College of Nursing, Performance 2007;7(5):586-98. Texas A&M Health Science Center, Bryan, TX. Contact author: [email protected]. The author and planners have disclosed no 27. Koerner J. Insight: the application of complexity science to decision making. Creat Nurs 2009;15(4):165-71. potential conflicts of interest, financial or otherwise. 28. Stewart J, et al. Clinical nurses’ understanding of autonomy: accomplishing patient goals through interdependent practice. REFERENCES J Nurs Adm 2004;34(10):443-50. 1. Huber D, editor. Leadership and nursing care management. 29. Kramer M, Schmalenberg C. The practice of clinical auton- 4th ed. Maryland Heights, MO: Saunders/Elsevier; 2010. omy in hospitals: 20 000 nurses tell their story. Crit Care 2. Tuckett AG. An ethic of the fitting: a conceptual framework Nurse 2008;28(6):58-71. for nursing practice. Nurs Inq 1998;5(4):220-7. 30. Rycroft-Malone J, et al. Protocol-based care: impact on roles 3. Walker LO, Avant KC. Strategies for theory construction in and service delivery. J Eval Clin Pract 2008;14(5):867-73. nursing. 4th ed. Boston: Prentice Hall; 2005. 31. Berner KH, et al. Critical care nurses’ perceptions about their 4. Polet P, et al. Modelling the border-line tolerated conditions involvement in significant decisions regarding patient care. of use (BTCU) and associated risks. Saf Sci 2003;41(2-3): Aust Crit Care 2004;17(3):123-31. 111-36. 32. Benner P. Honoring the good behind rights and justice in 5. Dehler GE, Welsh MA. Problematizing deviance in contem healthcare when more than justice is needed. Am J Crit Care porary organizations: a critical perspective. In: Griffin RW, 2005;14(2):152-6. et al., editors. Dysfunctional behavior in organizations: vio- 33. Benner P. The wisdom of our practice. Am J Nurs 2000;100 lent and deviant behavior. Stamford, CT: JAI Press; 1998. (10):99-101. p. 241-69. 34. Benner P, et al. Clinical wisdom and interventions in acute 6. Pascale RT, et al. The power of positive deviance: how un- and critical care: a thinking-in-action approach. 2nd ed. New likely innovators solve the world’s toughest problems. Bos- York: Springer Publishing; 2011. ton: Harvard Business Review Press; 2010. 35. Gordon S. Nursing against the odds: how health care cost 7. Dodge DL. The over-negativized conceptualization of devi- cutting, media stereotypes, and medical hubris undermine ance: a programmatic exploration. Deviant Behav 1985;6(1): nurses and patient care. Ithaca, NY: Cornell University Press; 17-37. 2005. Culture and politics of health care work. 8. Robinson S, Bennett R. A typology of deviant workplace be- 36. Melnyk BM, Davidson S. Creating a culture of innovation haviors: a multidimensional scaling study. Acad Manage J in nursing education through shared vision, leadership, inter- 1995;38(2):555-72. disciplinary partnerships, and positive deviance. Nurs Adm 9. Vardi Y, Wiener Y. Misbehavior in organizations: a motiva- Q 2009;33(4):288-95. tional framework. Organization Science 1996;7(2):151-65. 37. Spenceley SM, et al. The road less traveled: nursing advocacy 10. Warren DE. Constructive and destructive deviance in orga- at the policy level. Policy Polit Nurs Pract 2006;7(3):180-94. nizations. Acad Manage Rev 2003;28(4):622-32. 38. Milton CL. Breaking the rules of the game: ethical implica- 11. Spreitzer GM, Sonenshein S. Toward the construct definition tions for nursing practice and education. Nurs Sci Q 2006; of positive deviance. Am Behav Sci 2004;47(6):828-47. 19(3):207-10. 12. Clancy TR. Diamonds in the rough: positive deviance and 39. Yonge O, Molzahn A. Exceptional nontraditional caring complexity. J Nurs Adm 2010;40(2):53-6. practices of nurses. Scand J Caring Sci 2002;16(4):399-405. 13. Lloyd JC. For clues to HAI prevention, seek out positive de- 40. Ebright PR. The complex work of RNs: implications for viance. Healthcare Purchasing News 2011;35(1):46-7. healthy work environments. Online J Issues Nurs 2010; 14. Bloch S. Positive deviants and their power on transforma- 15(1):11. tional leadership. Journal of Change Management 2001;1(3): 41. Wilson M. Complexity theory. Whitireia Nursing Journal 273-9. 2009;16:18-24. 15. Fielding KS, et al. Reactions to positive deviance: social iden- 42. Fairchild RM. Practical ethical theory for nurses responding tity and attribution dimensions. Group Process Intergroup to complexity in care. Nurs Ethics 2010;17(3):353-62. Relat 2006;9(2):199-219. 43. Matlow AG, et al. How can the principles of complexity sci- 16. Abrahamson K, et al. Proposing a positive deviance model ence be applied to improve the coordination of care for com- to improve management of cancer-related psychosocial dis- plex pediatric patients? Qual Saf Health Care 2006;15(2):85-8. tress. J Theory Constr Test 2010;14(1):6-9. 44. Furlong E. Right or wrong: legal and ethical issues and deci- 17. Lindberg C, Clancy TR. Positive deviance: an elegant solu- sion making. In: Lewenson S, Truglio-Londrigan M, editors. tion to a complex problem. J Nurs Adm 2010;40(4):150-3. Decision-making in nursing: thoughtful approaches for prac- 18. Marra AR, et al. Positive deviance: a new strategy for improv- tice. Sudbury, MA: Jones and Bartlett Publishers; 2008. p. ing hand hygiene compliance. Infect Control Hosp Epidemiol 29-46. 2010;31(1):12-20. 45. Dowding D, Thompson C. Measuring the quality of judge- 19. Bradley EH, et al. Research in action: using positive deviance ment and decision-making in nursing. J Adv Nurs 2003;44 to improve quality of health care. Implement Sci 2009;4:25. (1):49-57. 20. Tarantino DP. Positive deviance as a tool for organizational 46. Gawande A. The checklist manifesto: how to get things change. Physician Exec 2005;31(5):62-3. right. New York: Henry Holt and Company; 2009.

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