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



  1. Gary, Jodie C. PhD, RN


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.


Article Content

Professional nursing standards guide patient care services and lay the foundation for best practices. But standards often aren't enough; for nurses, decision making involves multiple conditions of certainty, uncertainty, and risk.1 The clinical setting contains an infinite assortment of situations that require nurses to use their technical skills and situation-specific knowledge and follow a professional code of conduct.2 Moreover, applicable professional standards may not be available or may not be realistic in certain situations. Nurses might have to react creatively in order to meet the needs of their patients. In such situations, some nurses may use a concept called positive deviance to guide their actions.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Janet Hamlin.

The word deviance can be emotionally charged, evoking a range of images and connoting behavior that is aberrant or will elicit disapproval. Yet the concept of positive deviance is a useful one, and the term is widely used in such fields as business, management, sociology, criminology, and even health care. There is no uniform or consistent definition of positive deviance as it applies to nursing. This article will explore and identify the essence of the term in the nursing practice environment, using the Walker and Avant procedure for concept analysis.3 In doing this concept analysis, my intent was to increase our understanding of what positive deviance is and is not, within the context of professional nursing practice, and to provide an operational definition.



As Walker and Avant have explained, concepts are useful "mental constructions" that represent categories of information.3 A concept's attributes or characteristics are what distinguish it from other concepts. Thus, concept analysis is a process that involves examining the attributes or characteristics of a concept and results in "a precise operational definition" of that concept. Identifying a concept's defining attributes also facilitates decisions about which phenomena are good examples of the concept and which are not. The Walker and Avant method of concept analysis provides a systematic way to undertake analysis of a nebulous term that might have multiple meanings.


This concept analysis of positive deviance began with a literature search conducted between December 2009 and August 2011. I searched WorldCat and other databases, including PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EBSCO, using multiple terms and no date restrictions. The literature search ranged across several fields, including not only nursing and health care but also sociology, business, management, organizational studies, and even criminology. Some articles led to other articles through their bibliographies; others were sent to me by classmates.


I found little discussion in the nursing literature to clarify the concept of positive deviance as a distinct behavior, and only modest exploration of how nurses provide patient-centered care within the realm of standard practice guidelines. Yet there is evidence that positive deviance is a behavior used by some nurses under some circumstances to provide care to their patients. Following are several uses of the concept in various fields that were revealed by the literature search. The defining attributes of the concept of positive deviance, and its antecedents and consequences, are also described.



As an oxymoron-and a viable behavior. Experts in many fields have found various ways to distinguish the concepts of deviance, negative deviance, and positive deviance. In an article published in Safety Science, Polet and colleagues described deviations as a normal part of any workplace process, regardless of the kind of work.4 Yet as Dehler and Welsh have noted, to label someone as deviant implies that their behavior is harmful in some way.5 Indeed, in a book on positive deviance as a process, Pascale and colleagues described it as "an awkward, oxymoronic term."6


Although it's not certain when the term positive deviance came into use, I found the term first used in broadening the discipline of organizational behavior.7 Dodge initially defined deviance as neutral: "any act, role/career, attribute, or appearance that departs significantly from social situational expectations."7 He then defined positive deviance as departures that "surpassed" those expectations. In contrast, Robinson and Bennett considered most deviance negative, defining it as "voluntary behavior that violates significant organizational norms and in so doing threatens the well-being of the organization, its members, or both," and developing a typology of deviant workplace behaviors.8 Vardi and Wiener defined organizational misbehavior as any intentional action by an organizational member that "defies and violates (a) shared organizational norms and expectations, and/or (b) core societal values, morals and standards of proper conduct."9


Warren criticized these definitions of deviance for not considering the societal dangers of blind compliance with given norms and for not clearly stating which societal values will be used to determine misbehavior.10 She conceptualized deviance from a behavioral approach, one which stressed "the importance of reference groups and normative standards as the basis for 'labeling' deviant behavior." She categorized deviance as either constructive or destructive; her criteria for constructive deviance included behaviors that break or depart from reference group norms and are socially or organizationally beneficial-for example, whistleblowing that brings to light an organization's illegal or immoral practices. Warren further noted that while organizational and societal interests may overlap, some variations usually exist. This idea is also relevant to nursing practice. For example, nursing standards are instilled to provide models of best practices; nevertheless, in specific patient care situations, some variation from those standards may be necessary.


Spreitzer and Sonenshein sought to provide a conceptual framework for understanding, identifying, and explaining "positive, norm-departing behaviors."11 They described a normative approach that defines positive deviance as "intentional behaviors that depart from the norms of a referent group in honorable ways."11 (An example of this might be the employee who, against company policy, disobeys an order to dump toxic waste into a river.8) This approach, which is similar to Warren's, uses evaluative criteria-such as norms-to identify conduct that ought or ought not to occur.


In the nursing and health care literature, Clancy has described his realization that "positive deviance acknowledges that expertise is widely distributed and that those on the front line"-nurses at the bedside-"many times have a better sense for what is working" for patients than their managers do.12 Lloyd stated that positive deviance occurs when individuals use "uncommon practices/behaviors [that] enable them to find better solutions to problems than their neighbors who have access to the same resources."13


In the fields of sociology, business, and organizational studies, as well as nursing management and health care administration, then, positive deviance is viewed as nonprescribed practices or strategies that are intended to produce or do produce better outcomes than traditional standard practices.


As a noun. Several terms, with various connotations, 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 the beaten path and strike out in a new direction in order to find a better way to get things done.14 Bloch described positive deviants as "focused, persistent and optimistic" in pursuing their goals; they are people who make things happen in organizations, and who are crucial to the success of change efforts. Fielding and colleagues described positive deviants as exceptional high achievers who exceed the normal or average levels of performance in a given group.15


In studying nurses who acted as positive deviants, Clancy found that certain nurses were considered essential to a successful work environment.12 Their colleagues described them with phrases such as "always finds a way to get the job done," "is the glue that holds us all together," and "is extremely resourceful, knowledgeable, and adaptable." Positive deviants, then, are atypical nurses who practice differently and more effectively than their peers.


As a process. Positive deviance is often viewed as a process or approach to organizational change, or as a framework for understanding organizational behaviors13, 16-18; as an alternative method of identifying best practices19, 20; as a valuable tool for identifying innovative health care practices16, 21; and as a problem-solving technique.13


The development of positive deviance as a process is attributed to Jerry and Monique Sternin of the Positive Deviance Initiative in the 1990s.18, 22 The process has been used to address such difficult problems as childhood malnutrition, sex trafficking of girls, and hospital-acquired infections.18 Lindberg and Clancy pointed out that this process is based on the belief that there are people in every organization whose different work practices produce better outcomes, even though others in the organization have access to the same resources.17


In nursing, the process of positive deviance can take the form of a method of inquiry, in which researchers "focus on individuals who behave differently from the rest of the community and, in so doing, succeed where others fail."23 Kim and colleagues used this method to study Indonesian nurses and patients who communicated especially effectively during family planning consultations.23 They were able to identify several factors that made some participants more effective communicators than others. For example, those nurses who were positive deviants described professional knowledge and skills as the most important element in communication, and had improved their knowledge and skills through independent study; they also created communication aids to use with patients.


As a management strategy. Positive deviance has been suggested as a way to improve clinical performance outcomes in health care systems. Lloyd noted that despite the top-down hierarchies predominant in modern business and society, there seem to be subgroups of people who figure out solutions to problems and solve them on their own, using persuasion or citing guidelines and even laws to legitimatize their actions.13 Tarantino suggested that instead of relying on outside parties to solve problems, an institution should identify and rely on its existing experts who may have knowledge of preexisting, applicable solutions.20


Clancy described a situation in which, despite months of planning, the implementation of an electronic medical record (EMR) system at one health care system went awry.12 It was "perceived as cumbersome" by nurses, who delayed using it until the end of their shifts, driving up overtime. But a few nurses were observed completing their EMRs on time, and it was discovered that they had adapted and altered the hospital's EMR practices after becoming frustrated with the prescribed method. Clancy notes that although their flaunting of the hospital's usual process wasn't well received by the unit manager, "these rogues had solved a problem in a matter of weeks" that preimplementation teams had worked on for months."12 He challenged managers of complex health care environments "to find the positive deviants in your organization and tap into their creative minds."



When characteristics of a given concept appear repeatedly in literature, these are determined to be the defining attributes of the concept.3 Based on the characteristics found to be most frequently associated with positive deviance as a behavior in the literature, positive deviance


* is intentional and honorable.


* departs or differs from an established norm.


* contains elements of innovation, creativity, adaptability, or a combination of these.


* involves risk for the person deviating.



Or, restated as 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 person deviating.


Intentional and honorable. According to Bloch, positive deviants have a strong achievement focus but are "unfettered by the need to conform," which allows them to look for innovative solutions to problems.14 Bloch also noted that, unlike negative deviants, positive deviants are driven by dedication to their organization's values and goals. Spreitzer and Sonenshein specifically stated that positive deviance involves behaviors characterized by honorable intentions, independent of outcomes.11


In a study of hospital-based nurses, Hutchinson identified the construct and process of responsible subversion as describing the behavior of nurses who bent the rules for the sake of their patients.24 The nurses' behavior was deemed responsible because they used their best nursing judgment in deciding which rules to bend and when and how to do so. Yet these behaviors were also subversive, because they violated hospital policies or physicians' orders, even in some cases the state's nurse practice act. Much like Spreitzer and Sonenshein, Hutchinson acknowledged that responsible subversion is independent of positive or negative outcomes. Similarly, Vardi and Wiener's review of the literature on organizational misbehavior found that "misconduct in organizations has not only been viewed as pervasive, but, for the most part, as intentional work-related behavior."9 They classified such misconduct by whether the underlying intention was to benefit or harm the organization, and acknowledged that intention was separate from outcomes.


Different. Dehler and Welsh stated that it is critical to recognize that deviance involves "thought or action that differs from something."5 Hutchinson noted that the anthropological and sociological literature has examined how work gets done "in spite of or in opposition to the formal system" or the commonly accepted norms.24 Hutchinson further affirmed that nurses who bend the rules for the sake of patients are "fully socialized... and recognize that their values of patient advocacy are different from those of the organization."


Positive deviants are able to stand back and look for new ways to approach and solve problems. Bloch explicitly stated that positive deviants are not anarchists; rather, they strongly identify with the values of their organization, and are motivated by wanting it to succeed.14 When they behave in unusual ways, it's in the service of the organization. Warren pointed out that the management literature often assumes that a behavior that challenges social norms to achieve something positive is distinctly different from a behavior that does so to achieve something negative.10 Yet both behaviors are fundamentally similar in that both require the employee to "resist social pressure to conform."


Innovative, creative, adaptable. Dehler and Welsh argued that deviance is an important "source of adaptive capacity in organizational transformation."5 They credit Hanke and Saxberg with originating the concept of constructive deviance in 1985, an idea based on the combined social theories of creative individualism, productive nonconformism, and opinion deviance.


McCall described U.S. Army nurses as historically able to adapt quickly to unique wartime situations in order to provide the best possible care to soldiers.25 Their creativity and innovations "not only solved the problem of the moment but were instrumental in the advancement of the professional practice of nursing."25


Appelbaum and colleagues considered innovation, a type of "pro-social behavior," to be positive deviance only if the behavior diverged from organizational norms, was voluntary, and had honorable intent.26 They described innovative thinking as "involving the creation and development of new ideas that are not held by the majority." (However, Dehler and Welsh pointed out that some experts do not define every departure from norms or expectations as deviance; depending on the definition used, an adaptive behavior may or may not be considered deviant.5)


Koerner used the term active intelligence to describe how some nurses use imagination and creativity in examining a given practice and considering ways in which it might be accomplished or improved.27 And Clancy pointed out that although nursing work-arounds are often seen in a negative light, they can be both creative and valuable-"diamonds in the rough."12


Risky for the person deviating. Positive deviance makes people uncomfortable and involves risk.26 Stewart and colleagues described how covert rules and expectations are often at play as nurses decide whether or not to stretch the limits of their scope of practice.28 Most nurses practice warily, in the interest 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 who are positive deviants also know that their ability to make autonomous decisions is crucial to patient safety, and they accept the risk in order to do what's best for their patients.29 Indeed, Rycroft-Malone and colleagues pointed out that although most nurses view the expansion of traditional nursing roles favorably, such expansion also concerns nurses because it means they're more open to liability.30



As Walker and Avant explain, antecedents are "those events or incidents that must occur prior to occurrence of the concept."3 Consequences are "those events or incidents that occur as a result of the occurrence of the concept"-that is, the concept's outcomes. Identifying a concept's antecedents and consequences help to further pinpoint its defining attributes.


Antecedents. Standard practice guidelines or hospital policies that limit a nurse's ability to provide patient-centered care may trigger conflict in the nurse-and that sense of conflict is an antecedent to positive deviance. Australian researchers Berner and colleagues acknowledged this potential dilemma, noting that nursing standards also contain elements that require the nurse to break with guidelines if following them will compromise patient safety.31 Similarly, a conflict exists when standard practice guidelines do not allow a nurse to provide care that meets the specific needs of the patient and clinical situation.24, 29, 32


Another antecedent is a certain level of clinical expertise, which is also necessary to the nurse's recognition of situational differences in the delivery of patient care. Experts have spoken to the complexity of nursing care, which requires continuous development of clinical knowledge through experiential learning.33, 34 Noting that a nurse cannot "practice beyond her [or his] experience," Benner stated that experiential learning is a precursor to clinical discernment and individualization of patient care.33 Benner and colleagues further observed that nursing experience must be combined with attunement to the patient and a sense of the timing and logistics of care in ever-changing clinical situations.34


Consequences. The most practical consequence of positive deviance in nursing appears to be the deviance itself. Rules are broken, standard practice guidelines are not followed, and the nursing roles or scope of responsibility are expanded. Other consequences might include care that is undocumented, so that any outcomes of the deviation remain unreported. If this happens, it can lead to a delay in the advancement of nursing practice, as well as place the nurse in a tenuous legal and ethical situation.


There are times when nurses make decisions to go beyond standard practice guidelines or find work-arounds.28, 31, 35 In such cases, when nurses don't report the exact care provided, the outcomes of positive deviance are lost. Ironically, this also lends false support to those ineffective or insufficient protocols and policies that were the basis for the nurse's positive deviance in the first place. Accurate documentation with regard to acts of positive deviance is essential to the advancement of nursing practice.



A model case provides a clear example of the use of positive deviance in nursing by utilizing all of the defining attributes. A contrary case represents the exact opposite of the model case and may be helpful in explaining what positive deviance in nursing is not.


A model case. A nurse admitted a patient from the operating room to a general surgical unit following 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 hospital room, the patient reported severe postoperative pain. The nurse consulted the routine postoperative order set from the orthopedic group. For pain management, the order set contained an as-needed order for two tablets of an oral analgesic, as well as meperidine (Demerol) 100 mg delivered either intramuscularly or intravenously. The patient, who had been groggy since admission, had just taken a few ice chips. The nurse decided against the oral analgesic because of the risk of aspiration and choking; and she was concerned about giving such a large dose of meperidine to a small, elderly woman. The nurse decided to administer 25 mg, evaluate its effectiveness after 30 minutes, and then administer another 25 mg if needed. Over the next eight hours, the entire dose of the originally ordered 100 mg of meperidine was administered to the patient, and the patient reported relief from her pain during this time. But because of the built-in controls of the electronic medication dispensing system, the nurse could only document a one-time dose of 100 mg of meperidine administered to the patient an hour after arrival from surgery.


In this case, the behavior of the nurse exemplified the defining attributes of positive deviance. The decision to give the medication in delayed doses was intentional and honorable; it stemmed from the nurse's dedication to patient safety. The nurse departed from the established order set in an adaptive way to meet the patient's needs. By not giving the medication as ordered and not documenting what she actually did, the nurse put her career at some risk. These behaviors could be interpreted as prescribing a medication without a license, and essentially are in conflict with most nurse practice acts. However, the outcome was one that resulted in pain relief while minimizing the risks to the patient.


A contrary case. The same nurse described in the previous case admitted a second patient from the operating room following surgical intervention for a knee fracture. This second patient was a large, athletic 32-year-old man weighing 200 lbs. As in the first case, shortly after being settled in the hospital room, this patient reported severe postoperative pain. The nurse again consulted the routine postoperative order set from the orthopedic group and found the same pain management order set containing an as-needed order for two tablets of an oral analgesic, as well as meperidine 100 mg delivered intramuscularly or intravenously. This patient was a bit drowsy from anesthesia and was just starting to take a few ice chips. The nurse administered the 100-mg dose of the meperidine as ordered. Within 30 minutes, the nurse evaluated its effectiveness and found the patient's pain adequately controlled.


As Dehler and Welsh point out, conformity is the "polar opposite" of positive deviance.5 For a nurse (or anyone) who responds to conflicting role expectations by following orders rather than challenging them, conformity probably reduces stress. However, in this case, there was no need to consider such a challenge. In following standard practice guidelines and the routine order set, the nurse safely and effectively met the needs of this patient. There was no need to intentionally depart from usual care; no elements of innovation, creativity, or adaptability were needed; and the nurse incurred no risks.



Empirical referents offer a way to measure a concept, or at least determine its existence, in the real world.3 As defined by Walker and Avant, empirical referents are "classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept."3 But determining empirical referents for the concept of positive deviance in nursing practice is challenging, because the behaviors tend to be hidden and undocumented. As yet, no empirical referents for positive deviance in nursing can be given.


Practice dilemmas arise when standard practice guidelines do not fit the needs of a specific patient care situation. With clinicians increasingly functioning "as knowledge workers rather than [as] task-driven care providers,"36 the incidence of practice dilemmas and of positive deviance will likely increase also. In order to measure positive deviance in nursing practice, the concept needs to be explored through qualitative research investigating the actual nursing care provided in such instances.


The literature does hint at the widespread presence of positive deviance in nursing, and its inherent conflicts. Nurses who use creative approaches have been described as going "under the radar" or "working the system."35, 37 In so doing, they may find themselves bending or breaking rules such as policies, orders, even laws governing nursing practice.24, 31, 38 Berner and colleagues found that 92% of surveyed critical care nurses were aware of legal limits when they made decisions related to patient care, and 70% reported having made decisions that went beyond those limits.31 (Interestingly, 73% of respondents "believed that this should not be occurring.") Hutchinson noted that nurses tend to be less autonomous and more rule-bound in their practice than either administrators or physicians, because most nursing actions occur within a set of rules or guidelines imposed by others.24 She described how nurses who bent the rules felt strongly about their role as patient advocate; yet in most situations the nurses kept their rule-bending behaviors secret.


There are some scenarios in the literature describing nurses who intentionally provided care that pushed the boundaries of their scope of practice. For example, Kramer and Schmalenberg discuss several ways that nurses commonly "renegotiate" that scope, including "do and inform later" and "persist until the patient gets what he or she needs."29 A small study of nurses identified as using exceptional caring practices found that all "crossed the boundaries of standard nurse-client care in one form or another."39 Another study exploring how nurses interpreted autonomy in everyday clinical practice found that when nurses encountered barriers-such as "not being heard" and having their experience overlooked-they "found other creative ways" to persist toward their goals and advocate their patients' best interests.28


Such creative ways can include adaptations, modifications, work-arounds, and innovations that differ from standard practice guidelines. For example, Clancy describes how after becoming frustrated with their hospital's newly implemented EMR system, some nurses spoke with friends who had used similar systems in other facilities, then adapted what they learned for their own system.12 In another study, aware of deficits in their formal training, Indonesian nurses reported improving their nurse-patient communication skills through independent study, 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 "either adapted quickly or gave up... a lot of improvisation was required."25 She detailed numerous ingenious examples, large and small, from using tent frames in applying traction to changing how patients were assigned.


Complexity science. It can be useful to consider positive deviance through the lens of complexity science-an interdisciplinary field that studies "the manner in which complex adaptive systems evolve, interact, and maintain order."40 Complexity science looks at organizations less as machines and more as "living" entities, made up of subsystems and individuals and characterized by interconnectedness and unpredictability.41 The current health care system may be viewed in this way.38, 41, 42


Complexity science suggests that complex systems require a flexible approach.40 Attempts at rigid control can backfire, because such control isn't flexible enough to allow for individual or circumstantial differences.43 When individuals try to circumvent rigid controls, their attempts can lead to unforeseen problems and consequences. Yet positive deviations can also solve problems and improve outcomes. As Matlow and colleagues stated, system change has traditionally been approached by focusing on structures and processes, often leading to the creation of more rules; but it may be more useful to focus on the relationships among agents within a system.43 By better understanding how nurses, patients, physicians, and others interact in the delivery of health care, the process could be better individualized.40, 43


The need for accurate documentation. Although nurses may at times act as positive deviants, they generally choose not to report (or are unable to report, owing to system constraints) the exact care they provided. Thus, there is no outcome data for the care that was really provided-and this lack also lends false support to ineffective or insufficient protocols and policies. Accurate reporting and documentation of the actual nursing care delivered are essential to having accurate outcomes data, to ensuring patient safety, and indeed to furthering the profession.


Furlong has stated that in making decisions about patient care, nurses must balance "what evidence-based practice dictates, what the law mandates, and what the ethical dilemma calls for."44 She added that in certain situations, fearing the penalty of law, a nurse might violate the professional code of ethics and fail to be a patient advocate. For example, if a terminally ill patient refuses hydration but has no advance directive, the nurse might feel compelled to administer hydration anyway. Positive deviance, on the other hand, might focus more on the patient's wishes. Indeed, when the usual or expected nursing actions collide with the nurse's view of the right thing to do for the patient, the concept of positive deviance can provide a basis for decision making.


Marsh and colleagues suggested that insights into how and why positive deviants behave differently from their peers can help us to develop strategies that promote desirable behaviors in health care.21 Dowding and Thompson pointed out that because nurses' decisions have a tremendous impact on patient outcomes and experiences, "how we measure the accuracy or 'goodness' of nurses' judgements and decisions is... of prime importance."45 A core challenge in studying positive deviance, then, is linking quantitative measures of variables that might influence "top performance" with qualitative findings.19


In his book The Checklist Manifesto, Gawande acknowledged the enormous complexity of health care, and noted that "there are often times when a clinician has to just do what needs to be done. Forget the paperwork. Take care of the patient."46 In his view, the question of when to follow protocol and when to follow personal judgment is a crucial one: "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 difficulties." Similarly, Benner noted that a nurse's everyday ethical and clinical conduct are guided "not so much by quandary and extreme cases that fall outside the boundaries of good practice" but by the ability to make qualitative distinctions between "worthy competing goods."32 This decisional aspect of positive deviance is what makes it essential that the dialogue be brought out into the open. No matter how well developed "best practice" standards and evidence-based protocols become, "clinical puzzles that arise everyday cannot be solved without engaged thinking and clinical reasoning in and through the specific context of each individual situation."34



Nurses' clinical decisions are clearly crucial to patient outcomes; so transparency about those decisions is vital. Koerner described nurses as "walk[ing] between two worlds: the concrete world of a scientist and the abstract world of an artist."27 A more comprehensive understanding of creative acts of positive deviance in nursing will help to foster the development and implementation of strategies that support nurses in their clinical decision making and practice; and it will improve our knowledge of how positive deviance affects patient outcomes.


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. Accurate data about practice and outcomes are vital. If outcomes are improved, then the quality of patient care is improved. Nurses who are positive deviants may be generating new knowledge on the fly; we need to be able to access that knowledge. Proper documentation of deviations will in turn facilitate the development or improvement of guidelines for specific patient care situations.


Increased nursing input on policy issues that affect the delivery of patient care is also needed. Gawande spoke to the need to push decision-making power from the center out to the periphery when confronted with complex and unusual problems: "You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works."46


The ultimate goal of this exploration was to provide an operational definition for the concept of positive deviance within the practice of nursing. Such a definition can offer nurses a basis for decision making when the normal or expected actions in a given situation collide with the nurse's view of the right thing to do.


As nurses become more autonomous providers of primary health care services, I believe the use of positive deviance must become a goal. Although better documentation and further research are needed, it seems likely that patient care and outcomes will improve when nurses have the courage to make intentional, honorable decisions to provide innovative, creative, and adaptive care in situations that demand it.




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