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Kassie AM, Eakin E, Abate BB, Endalamaw A, Zewdie A, Wolka E, Assefa Y. The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. BMC Health Serv Res 2024; 24:438. [PMID: 38589897 PMCID: PMC11003118 DOI: 10.1186/s12913-024-10850-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/11/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs. METHODS Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats. RESULTS A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections. CONCLUSION The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.
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Affiliation(s)
- Ayelign Mengesha Kassie
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia.
| | - Elizabeth Eakin
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Biruk Beletew Abate
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Aklilu Endalamaw
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Anteneh Zewdie
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Eskinder Wolka
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Foster BA, Seeley K, Davis M, Boone-Heinonen J. Positive deviance in health and medical research on individual level outcomes - a review of methodology. Ann Epidemiol 2022; 69:48-56. [PMID: 34915122 PMCID: PMC9081135 DOI: 10.1016/j.annepidem.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Positive deviance as a methodology is increasing in application yet there is high variability in how this approach is applied in health services research. METHODS We conducted a scoping review of the literature for positive deviance applied to health outcomes informed by PRISMA-ScR. We searched the literature from 1945 to 2020, including articles on positive deviance or positive outliers, and restricted to examining individual rather than organizational outcomes. We analyzed the methodology applied including the process of identifying deviants, the use of control groups, and the degree of community engagement. RESULTS Our initial search identified 1140 manuscripts; we included 104 papers describing 98 studies, 11 topical and one miscellaneous category. Most studies used objective measures of health or survey-based responses to identify deviants from a sub-set of the population at risk. The use of controls was less common in some topics (hospital infections), whereas controls were universally applied in other topics (malnutrition). The degree of community engagement varied widely. CONCLUSIONS Positive deviance would benefit from improvements in reporting and standardized approaches to defining deviance. Studies could be improved through clarified definitions of deviance/risk, explicit descriptions of community engagement, and more consistent use of controls.
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Affiliation(s)
- Byron A Foster
- Department of Pediatrics, Oregon Health & Science University, Portland, OR; School of Public Health, Portland State University and Oregon Health & Science University.
| | - Kylie Seeley
- Department of Pediatrics, Stanford University, Stanford School of Medicine, Palo Alto, CA
| | - Melinda Davis
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Janne Boone-Heinonen
- School of Public Health, Portland State University and Oregon Health & Science University
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Irshad M, Bartels J, Majeed M, Bashir S. When breaking the rule becomes necessary: The impact of leader-member exchange quality on nurses pro-social rule-breaking. Nurs Open 2021; 9:2289-2303. [PMID: 34255937 PMCID: PMC9374417 DOI: 10.1002/nop2.979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 12/22/2022] Open
Abstract
Aim Despite the literature on nursing leadership, the research on the quality of exchange relationship between nursing leaders and nurses is in its initial stages. Also, the underlying mechanism that exists between leader–member exchange and employee outcomes warrants further inquiry. This study aimed to fill these gaps by investigating the role of leader–member exchange relationships and organizational identification in nurses' intentional violation of hospital regulations to promote their patients' welfare, also called pro‐social rule‐breaking. In contrast to a vast number of previous studies, we argue that pro‐social rule‐breaking can be positive for organizations. Therefore, nurses should be given margin and autonomy to break hospital rules when needed by establishing a high‐quality exchange relationship with the supervisor. Design A quantitative study was conducted on nurses working in hospitals in Pakistan by utilizing a non‐probability convenience sampling technique. Method Data from nurses and their colleagues (n = 224) were collected at three‐time points between June 2019 and August 2019 through questionnaires. Results The results proved that nurses' possessing a high‐quality exchange relationship with their supervisor feels a higher level of identification with their organization. In turn, they are more likely to engage in pro‐social rule‐breaking as a form of constructive deviance.
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Affiliation(s)
- Muhammad Irshad
- Department of Management Sciences, National University of Modern Languages, Islamabad, Pakistan
| | - Jos Bartels
- Department of Communication Studies, School of Communication, Hong Kong Baptist University, Kowloon Tsai, Hong Kong, China
| | - Mehwish Majeed
- Faculty of Management Sciences, International Islamic University, Islamabad, Pakistan
| | - Sajid Bashir
- Department of Management Sciences, Namal Institute, Mianwali, Pakistan
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Olsson A, Thunborg C, Björkman A, Blom A, Sjöberg F, Salzmann-Erikson M. A scoping review of complexity science in nursing. J Adv Nurs 2020. [PMID: 32281684 DOI: 10.1111/jan.14382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/03/2020] [Accepted: 03/25/2020] [Indexed: 11/26/2022]
Abstract
AIM To describe how complexity science has been integrated into nursing. DESIGN A scoping review. DATA SOURCE/REVIEW METHOD Academic Search Elite, Scopus, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, PubMed and Web of Science were searched November 2016, updated in October 2017 and January 2020. The working process included: problem identification, literature search, data evaluation, synthesizing and presentation. RESULTS Four categories were found in the included 89 articles: (a) how complexity science is integrated into the nursing literature in relation to nursing education and teaching; (b) patients' symptoms, illness outcome and safety as characteristics of complexity science in nursing; (c) that leaders and managers should see organizations as complex and adaptive systems, rather than as linear machines; and (d) the need for a novel approach to studying complex phenomena such as healthcare organizations. Lastly, the literature explains how complexity science has been incorporated into the discourse in nursing and its development. CONCLUSION The review provided strong support for use in complexity science in the contemporary nursing literature. Complexity science is also highly applicable and relevant to clinical nursing practice and nursing management from an organizational perspective. The application of complexity science as a tool in the analysis of complex nursing systems could improve our understanding of effective interactions among patients, families, physicians and hospital and skilled nursing facility staff as well as of education. IMPACT Understanding complexity science in relation to the key role of nurses in the healthcare environment can improve nursing work and nursing theory development. The use of complexity science provides nurses with a language that liberates them from the reductionist view on nursing education, practice and management.
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Affiliation(s)
- Annakarin Olsson
- Faculty of Health and Occupational Studies, Department of Caring Science, University of Gävle, Gävle, Sweden
| | - Charlotta Thunborg
- Department of Neurobiology, Care Sciences and Society, Division of Clinical geriatrics, Karolinska Institutet, Stockholm, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Annica Björkman
- Faculty of Health and Occupational Studies, Department of Caring Science, University of Gävle, Gävle, Sweden.,Health Services Research, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Anneli Blom
- Centre for Clinical Research, Västmanland County Hospital, Västerås, Sweden
| | - Fredric Sjöberg
- Unit of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Martin Salzmann-Erikson
- Faculty of Health and Occupational Studies, Department of Caring Science, University of Gävle, Gävle, Sweden
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Hamer HP, Rowe M, Seymour CA. 'The right thing to do': Fostering social inclusion for mental health service users through acts of citizenship. Int J Ment Health Nurs 2019; 28:297-305. [PMID: 30152193 DOI: 10.1111/inm.12533] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2018] [Indexed: 11/28/2022]
Abstract
The theoretical framework of citizenship is increasingly being used in mental health settings to inform practice. This exploratory qualitative study describes in more detail the acts of citizenship embedded in the everyday practices of mental health workers that promote the social inclusion of people in their care. Acts make a claim for justice when one's rights and responsibilities of citizenship are denied. Semistructured interviews were conducted with 12 participants, seven mental health clinicians and five peer support workers, recruited from a mental health facility in Connecticut, USA. Two themes are presented, breaking the rules and the right thing to do, a rights-based practice that fosters inclusion for service users. Results suggest that staff undertake hidden acts of citizenship to promote inclusion and rights of service users by responsibly subverting the rules and norms of the organization. Changes to organizational practices to make visible such inclusionary acts are required. Implications for practice and considerations of organizational change through the development of a citizenship framework to underpin practice are recommended.
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Affiliation(s)
| | - Michael Rowe
- Department of Psychiatry, Yale University, New Haven, Connecticut, USA
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Abstract
Medication errors continue to be an issue for the critically ill and are costly to both patients and health care facilities. This article reviews published research about these errors and reports results of observational studies. The types of errors, incidence, and root causes have been considered along with adverse consequences. The implications for bedside practice as a result of this review are fairly straightforward. Medication errors are happening at an alarming rate in the critical care environment, and these errors are preventable. It is imperative that all personnel respect and follow established guidelines and procedural safeguards to ensure flawless drug delivery to patients.
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Redley B, Botti M, Wood B, Bucknall T. Interprofessional communication supporting clinical handover in emergency departments: An observation study. ACTA ACUST UNITED AC 2017; 20:122-130. [DOI: 10.1016/j.aenj.2017.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 05/19/2017] [Accepted: 05/19/2017] [Indexed: 01/22/2023]
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Oliveira FTD, Ferreira MMF, Araújo STCD, Bessa ATTD, Moraes ACB, Stipp MAC. Positive deviance as a strategy to prevent and control bloodstream infections in intensive care. Rev Esc Enferm USP 2017; 51:e03212. [PMID: 28380162 DOI: 10.1590/s1980-220x2016182303212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/30/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To describe the application of positive deviance as a strategy to prevent and control bloodstream infections. METHOD An intervention study with nursing and medical team members working in an intensive care unit in a university hospital, between June and December 2014. The four steps of the positive defiance methodology were applied: to define, to determine, to discover and to design. RESULTS In 90 days, 188 actions were observed, of these, 36.70% (n=69) were related to catheter dressing. In 81.15% (n=56) of these dressings, the professionals most adhered to the use of flexible sterile cotton-tipped swabs to perform antisepsis at catheter entry sites and fixation dressing. CONCLUSION Positive deviance contributed to the implementation of proposals to improve work processes and team development related to problems identified in central venous catheter care. OBJETIVO Descrever a aplicação do Positive Deviance como estratégia na prevenção e no controle da infecção de corrente sanguínea. MÉTODO Estudo de intervenção realizado na Unidade de Terapia Intensiva de um hospital universitário, com os membros das equipes de enfermagem e médica, de junho a dezembro de 2014. Foram aplicados os quatro passos da metodologia Positive Deviance: Definir, Determinar, Descobrir e Desenhar. RESULTADOS Em 90 dias 188 ações foram observadas, destas, 36,70% (n=69) estavam relacionadas aos curativos dos cateteres. Em 81,15% (n=56) desses curativos, o uso da haste flexível estéril para realização da antissepsia do local de inserção do cateter e de sua placa de fixação foi a ação de maior adesão. CONCLUSÃO O Positive Deviance auxiliou na implementação de propostas de melhorias de processo de trabalho e no desenvolvimento da equipe para os problemas identificados no cuidado com o cateter venoso central.
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Affiliation(s)
- Francimar Tinoco de Oliveira
- Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Departamento de Enfermagem Médico-Cirúrgica, Rio de Janeiro, RJ, Brazil
| | - Maria Manuela Frederico Ferreira
- Escola Superior de Enfermagem de Coimbra, Conselho para a Qualidade e Avaliação da Unidade Científico Pedagógica de Enfermagem Fundamental, Coimbra, Portugal
| | - Silvia Teresa Carvalho de Araújo
- Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Departamento de Enfermagem Médico-Cirúrgica, Rio de Janeiro, RJ, Brazil
| | | | - Advi Catarina Barbachan Moraes
- Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Departamento de Enfermagem Médico-Cirúrgica, Rio de Janeiro, RJ, Brazil
| | - Marluci Andrade Conceição Stipp
- Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Departamento de Metodologia da Enfermagem, Rio de Janeiro, RJ, Brazil
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Redley B, Raggatt M. Use of standard risk screening and assessment forms to prevent harm to older people in Australian hospitals: a mixed methods study. BMJ Qual Saf 2017; 26:704-713. [DOI: 10.1136/bmjqs-2016-005867] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 11/03/2022]
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