1. Westman, Katie F. MS, RN-C, PHN, CNS

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I'm deeply concerned about AJN's recently published article about positive deviance. The concept has spread rapidly in nursing, but because it's still new, I understand that there continues to be discussion about its definition and place within nursing practice. However, as someone who has worked to create changes in pain management practices using positive deviance for the last three years, I disagree with the basic premise of the article.


The positive deviance "process," or change theory, celebrates nurses who, in the same situation and with the same resources, have figured out how to do their work more efficiently and effectively.1 At our hospital, a group of staff members meets to drive the process. The positive deviance process provides us with a way to share and establish new practices throughout the facility.


When coworkers are encouraged to look to each other to find positive behaviors they can emulate, we've found that more frequent and better communication occurs, change is absorbed rather than resisted, and practice changes are sustained over time. I believe this can only happen when these behaviors fall within accepted nursing practice, as defined by hospital policies and procedures. At our facility, practices outside those limits are acknowledged and shifted to another change process-but not celebrated.


We need to be clear that someone who deviates from practice standards isn't necessarily a "positive" deviant. Nor should we attach that label to someone who isn't following the established process.


Katie F. Westman, MS, RN-C, PHN, CNS


St. Paul, MN


Author Jodie C. Gary responds: I wrote this article with the intention of opening a dialogue about the use of positive deviance in nursing and welcome your comments. A concept analysis such as the one I undertook looks at all aspects of this term and led to an operational definition based on the characteristics of positive deviance that appear repeatedly in the literature: positive deviance features intentional and honorable behavior that departs or differs from an established norm; contains elements of innovation, creativity, or adaptability; and involves risk for the nurse.


The act of deviance is not considered to be positive unless it has been done intentionally and honorably. The focus is on providing care that is truly patient centered. In a time of increased emphasis on patient outcomes, it's important for nurses to report when and how they've deviated from established guidelines and practices in order to drive practice change.




1. Marra AR, et al. Positive deviance: a new strategy for improving hand hygiene compliance Infect Control Hosp Epidemiol. 2010;31(1):12-20 [Context Link]