Illustration by Janet Hamlin.
By Sylvia Foley, AJN senior editor
The word deviant tends to have a negative connotation, suggesting something aberrant or harmful. But deviance simply means a departure from the expected or usual way of doing things—and there are times when being able and willing to do so is crucial. Indeed, some have called this trailblazing.
In “Exploring the Concept and Use of Positive Deviance in Nursing,” an August CE, author Jodie Gary points out that “the clinical setting contains an infinite assortment of situations” in which applicable professional standards might be unavailable or unrealistic; at such times, “nurses might have to react creatively” in order to provide optimal patient care. This article provides an in-depth, evidence-based look at positive deviance in nursing.
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, offering nurses a basis for decision making when the normal, expected actions collide with the nurse’s view of the right thing to do.
Gary further argues for the importance of accurate documentation. “Nurses who are positive deviants may be generating new knowledge on the fly,” she writes. “We need to be able to access that knowledge. It’s essential, then, that nurses have a way to safely report the deviations they make for the sake of patients. The true cause-and-effect relationships between care and outcomes cannot be known otherwise.”
To learn more, read the article, which is free online, and listen to our podcast with the author. If you’ve used positive deviance in your practice or know nurses who have, we’d love to hear your stories and thoughts in the comments.
Positive deviance is a term that is unfamiliar to me but the action is a process that I practice on a regular basis. I work nights and the doctors are not as accessible as if it were days. There were many times I had to assist my patients in the wee hours in the morning. My decisions were always in the better interest of my patients. After reading this article it is reassuring to me knowing that as risky as my actions could be, it is termed “responsible subversion.” I know nurses will take that extra step at all times for the betterment of their patients. I’m very excited to know that these actions are considered ‘creative,’ ‘innovative,’ and ‘honorable to name a few. Positive deviance is my new motto.
To deviate from an existing procedure as long as positive outcomes result may be acceptable but standards are important as they provide consistency of caregiving. Cost savings are important but can be found through process improvements that benefit all.
I understand the importance of positive deviance. It is necessary at times to provide the best patient care. Even so, we must be careful that we do not harm our patients in the process. Nurses are innovators and it is my opinion that without some form of positive deviance, then we would not have new protocols and procedures to put in place. Nurses performing direct patient care often have an insight that policy makers may not have. The nurses on the front line know what works and what does not work for patients. It would be advantageous to work together with those who develop policies in order to provide excellent patient care without endangering your license in the process.
As a nurse working for industry and focused on patient safety I think we need to find a balance in our nursing culture related to positive deviance. Our culture has promoted the idea of “get the job done” at all costs which basically can end up condoning cutting corners and going outside of technology or other tools/practices as it may be seen as cumbersome.
There are always process improvements that will provide positive benefits for providers of care that will result in cost savings. Hopefully these will also be balanced with what is the benefit to the patient. I could not work in an environment that short cuts care that results in not making the patient the priority & produces positive outcomes.
The PPACA program Partnership for Patients is all about innovation from the bedside to make care safer, better and cut costs. Although all hospitals who receive Medicare are signed up for the program, which reaches its goal at the end of 2013, I find that in many facilities most nurses are unaware of the program. I am interested to hear of experiences in “positive deviation” to meet the program goals.