What is positive deviance?

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Jodie Gary, PhD, RN, assistant professor at the Texas A&M College of Nursing, explains her research on positive deviance and how its study can help improve health care outcomes.

Episode Transcript

Christina Sumners: Welcome to Science Sound Off and I am Christina Sumners.

Tim Schnettler: And I’m her co-host Tim Schnettler.

Christina Sumners: And we’re here today with Dr. Jodie Gary from the Texas A&M College of Nursing. Welcome to the show!

Jodie Gary: Hi. Thanks for having me!

Christina Sumners: We’re excited to have you. So, you research something called positive deviance. What does that mean?

Jodie Gary: I do! So, positive deviance sometimes is kind of considered an oxymoronic term, because it doesn’t make sense to a lot of people, but consider it looking at outliers and toward the positive end. So, if you consider a bell curve, I really like to look at anything to the right of that bell curve toward that little tail end. So, in positive deviance, you really want to take, like in a health care issue, those who didn’t have the problem, but you would have expected to have the problem. So, if you consider who is least likely to succeed, but did—sometimes people want to refer to it as resilience, but it’s really not resilience. It’s going beyond resilience, because you have an exceptional outcome

Christina Sumners: …and even higher than the other people that maybe had better things to start with.

Jodie Gary: Right. So, if you look at kind of a level playing field, is everyone having the same access to the same resources? You want to look at those who didn’t have an exceptional outcome? Really the term was coined back in the 90’s in Vietnam. The Sternins, Jerry and Monique, who are lovely people, they were nutritionists and they were given a six-month visa. Monique started in and is still at Tufts University…lovely woman I met with her last summer. She was given this six-month visa to solve the malnutrition problem in Vietnam.

Christina Sumners: …in six months?

Jodie Gary: In six months as a Caucasian woman going into villages. So, a lot of what positive deviance looks at, instead of taking the traditional method and you diagnose a problem and you fix it, you go in and you work from the bottom up. So, they originally went in and were a little bit overwhelmed with how do we solve this problem. So, they started with the basics. They weighed everyone, they weighed all the kids and then were overwhelmed with the amount of new malnutrition that they could just see from the weights. But they started noticing little pockets of a kid that was a normative weight, and then they would find another village where another kid was a normative weight. So, what they did, instead of kind of implementing a whole anti-malnutrition program, they went into these homes and did a qualitative analysis of what are these people doing that is different? How do they have a normative weight child in this mass of malnutrition? And so, what they found is that there were some non-normative behaviors that were not really culturally accepted, but the families were doing them anyway, such as they were stirring the soup. Normally the men got fed from the bottom, because all the protein falls to the bottom and the women and children got fed from the top up, but they were stirring the soup. The women who worked in the rice fields were bringing a separate bag with them and they were picking up a little crabs and shrimp and adding them to the soup. They were using the tops of the sweet potato shoots, which are normally just thrown away, but they’re nutrient dense. They were throwing those in the soup. They found that older children were actively feeding their siblings. You know, normally, you put a two-year-old in a high chair or wherever in you put food in front of them, maybe 50 percent of it goes in the mouth, right? But if you actively feed them…so they found kind of all these little idiosyncrasies. And so, these families didn’t know that they were the positive deviants, but when you collected all this qualitative information after finding the quantitative outliers and they found that they could develop a program where the village themselves could feed the program back to their own villagers. So, women would meet with other women in huts and kind of share ‘this is what I did to get my child to be a normal weight’, then that innovation spreads and it is developed at the ground level, so that it’s more socially acceptable.

Christina Sumners: …and it’s taking practices that some people at least were already doing.

Jodie Gary: Yes, and they didn’t know they were deviants. So, my dissertation research, I actually looked at critical care nurses who had non-normative behavior, but their goal was providing patient-centered care. So really what I found, I did a concept analysis and I found that positive deviance requires intentional behavior. You’re intentionally doing something. So, it might be you’re intentionally breaking a rule, but it’s for the good of the patient, but it also involves some sort of creativity, innovation and adaptability. Then there’s also a little bit of a risk factor, because if you’re breaking a rule then you can put your license at line or these like these women in the village, they were going against some of their cultural norms.

Christina Sumners: Tell me more about your dissertation. You studied critical care nurses and how their patients did better expected?

Jodie Gary: I actually wanted to, one of the first things when I started looking at positive deviance in health care, it’s been studied looking at hospital acquired diseases…handwashing. They’ve used it in some instances with condom use and they’ve used it with some pregnancy outcomes. Anyway, I wanted to actually look at critical care nurses and see if this was happening. My background is critical care and I just knew that at the bedside at night there were decisions that I was making that were not necessarily in line with the kind of black and white policy I had in front of me. I look at complexity theory, so I consider the fact that people are complex adaptive systems. If you go into a room, everyone is a little bit different. So, if you can focus that on patient-centered care, every patient is a little bit different. If I go into your room and I look at what I consider a very gray patient, being not black and white, but then I only have a black and white policy to follow with which to care for you with, I might need to adapt that to be able to meet your needs. Probably a good example is I would go into a room to change a dressing on a patient for a central line, which is like a catheter that you can give medications through, and we have a specific kit and it has a little two by two piece of gauze and all very small little tegaderm to put on and there’s a very specific policy that you follow. So, I go into the room and my patient is 500 pounds and the line is in his groin, is in an artery in his groin or a vein in his groin…sorry. If I cover it, according to policy, well it’s really not going to stick. It’s going to roll up. It’s going to get caught up in skin and tissue. There is risk for infection. And so, I would find that I would slightly adapt that and we had these really big chest breath dressing, so I would use a big chest dressing. But then when I would go back and chart, I only had a little box to check that said, “did I follow policy to change the central line?” There was really no place to outline that “okay, I didn’t follow policy but here’s why.” During my PhD, I was taking a class looking at health outcomes from big data and I was considering the fact that if nurses don’t have a place to articulate their adaptable, creative, non-normative type of work that they did when they didn’t follow a policy, what are they doing? So, my first place to start in my dissertation, I did a concept analysis of positive deviance within nursing. Then I wanted to ask nurses, “what are you doing in these situations?” But I can’t…I can’t just ask you, “are you a positive deviant and what are you doing?” Because no, nobody knows what that term is.

Christina Sumners: And I’m sure if they hear the word deviant be like, “no!”

Jodie Gary: In fact, I did have someone on my dissertation committee that really, really asked me to change that term. I would not, it’s a real thing. There’s an international society looking at positive deviance. So, what I ended up asking these nurses, I used an electronic Delphi study, because I wanted them to have some anonymity because they were gonna tell me about times they were breaking rules. And so, I just asked them one open ended question in a national survey of critical care nurses: Tell me about a time where a policy didn’t fit the needs of your patient, whether a policy guideline or procedure. It didn’t fit the needs of your patient and what did you do? How did you handle that? It was fascinating to read these and I gave them open ended question, no word count. And so, going through and reading kind of this qualitative, you know, that of here is exactly what I did and what happened. And then really having to go in and break that down to what did they actually do. They gave fluids without an order. They might have changed a medication dose, they allowed more visitors at the bedside, they adapted care at end of life, lots of things. But in it, there was almost this guilt of that they knew they were breaking a rule. They would follow it up usually with, “I got an order later in the morning or consulted someone at a different time”, but it really came down to it is they were adapting care for the need of the patient. A lot of times they had the outcome that was great, but they had really no place to, to discuss kind of the rule breaking they were doing. So, it was pretty fascinating to read. I put them all into kind of a list of all the basic rule breaking things they were doing and it fell into some categories of care at the end of life care and emergent situations, which in critical care is pretty common. Medications. There were times where they were adapting medications. Some of it was patient preferences where a diabetic knew their own body and said, “you know, if you’d given me that much insulin, bad things are going to happen. So, can we try half?” Or sometimes they adapted it looking at, you know, the routine medication dose was really was a regular dose, but the patient may be a small stature and I thought let me try half of a dose. But then at the end of the day they’re putting their license at risk because they’re changing medication order, you know, outside their scope of practice.

Tim Schnettler: So, being from a critical care background, were you surprised when you saw this or was it something that you kind of expected going into this research?

Jodie Gary: You know, it’s funny cause I completely expected it, because it’s things that I had done. It’s things that I had worked with other people that had done, but we just didn’t talk about it. So really some of my goal in writing it up was making that undiscussable more discussable. Sometimes I frame positive deviance in looking at a wicked question. So, you kind of ask a wicked question. One of my favorite wicked questions in relation to nursing is “how in a caring profession do we eat our young?” You know, when new nurses come in to the hospital. So, you can kind of open up those things to make them a little bit more discussable.

Tim Schnettler: With your background in critical care nurse, is that what drove you to this? I mean, how did you get is that what brought on the desire to go into positive deviance?

Jodie Gary: It did. I started actually looking at, I had didn’t arrive on the term positive deviance immediately when I started my PhD program. I was playing around with the idea of how do we make decisions and how do we learn to make decisions? And there’s a lot of literature and a lot of research on decision making. But I really wanted to understand the “why I was making some of the decisions that I did where” and where to other nurses learn to make those decisions. When I did my study with critical care nurses, I only wanted experienced critical care nurses. I wanted those that could articulate why they were breaking a rule and how they were breaking it and what the outcome, I didn’t really want that novice nurse that would come in and, you know, sometimes you can just follow all the rules and still have a bad outcome.

Christina Sumners: Right? So, you wanted someone who knew enough to know when they should tweak things a little bit.

Jodie Gary: Right. One of my favorite terms that I found in doing a concept analysis was a term called ‘responsible subversion’. So, Hutchinson, out of Florida in the 90’s, had done a study looking at critical care nurses and their rule breaking. I really focused my literature search on positive rule breaking, if you will. So that term really resonated with me, that responsible subversion, that you know you’re breaking a rule but you can articulate why.

Christina Sumners: …and why that’s going to be better for your patient than right. So, what did you study next after you finish your dissertation? Did you keep going with positive deviance and critical care nurses?

Jodie Gary: I did not. I would like to go back and follow up on some of the things that I learned from the critical care nurses. When I started at the Health Science Center, we had a lot of time for building courses and getting the College of Nursing up and running. And so, I’ve really just of late really tried to get back into positive deviance and focus on it. I did meet with an international positive deviance group in Denmark a couple of years ago. There was about 50 people in the world that really focus and look at positive deviance. There’s a few in health care, but not a lot. There is a lot in communications that look at positive deviance and again, they look at hospital acquired diseases within positive deviance. Probably one of the most interesting things is to look at when they looked at spreading MRSA between hospital rooms, there was one unit where they were not having this problem. So, there’s your outlier. So, they went into that unit and said, “so how is this not happening?” They found that the guy who cleaned the rooms changed the mop heads between the rooms. So now it’s interesting. You go into hospitals now and you see those disposable mop heads that come off and they get laundered. So, some of that, some of the innovation that comes out of really looking, drilling down and looking at the front-line problem. The thing that I like most about positive deviance is probably the bottom up approach is looking at the people who have the problem, have the solutions. Most of the time they don’t realize they have the solutions. They figured out the workaround and you really have to find those that have had the uncommon success and then kind of drill down into how did they figure this out. So that’s why it fits well with mixed methodology because you’re finding the quantitative outlier and then you’re doing that qualitative piece to really go in there and look at it. I’ve submitted a grant currently to look at chronic diseases within this community. I really want to know those who are the sickest of the sick. Who is not accessing hospitals? Who is able to care for themselves and stay at home? And then how are they doing that within this community? Because I think that’s a really interesting piece that if we can feed that back, we can really help with the 30-day readmission rates. I’m currently looking at a scoping review of HIV patients in how patient centered care is represented within the HIV literature, because it’s a disease with a stigma. And so, if you are non-normative and you don’t want to be on the everyday regimen, because of very specific reasons and then how are you living this long, healthy life, you know, what kinds of things can we learn from people like that? So, there’s a lot of applications for positive deviance. Usually when I sit with a group of other researchers and they talk about their research interests, I view everything through that lens. So, you’re looking at this problem, and I want to look at those that don’t have the problem but you think should have the problem.

Tim Schnettler: So, they’re basically looking for the solution. Where is your going the opposite direction?

Jodie Gary: Yeah, sometimes I look at it as, you know, I think that the negative screams and the positive whispers. Sometimes that’s why it’s really hard to find the positive sometimes, especially in healthcare. That’s what we’re trained to do. We’re trained to find the deficit and then fix it and really positive deviance is very asset based. So, it’s finding what you do have and what is working well and then how can we amplify that. Sometimes I consider it is expanding a solution space. It’s really hard when you try to articulate a proposal sometimes because with positive deviance you don’t really have a hypothesis. You can maybe say, “I might bring you a basket of solutions that we can then work from and then develop an intervention, but I can’t tell you that X is going to be the answer.”

Christina Sumners: You can state the problem, but the research is finding the solutions and you don’t have an idea in your head going in of what those might be.

Jodie Gary: Right. Another interest I would love to look at with positive deviance, only because I have a girlfriend that looks at epiphanies in health care, so she wants to know how people get this…what she calls a health epiphany. Like how do they weigh 400 pounds and then suddenly one day they wake up and they’re like, “I’m going to fix this” and then they do and then they have this healthy lifestyle. And so, I keep thinking of that show the 600-pound life…“My 600 Pound Life”…but the beginning starts off and she actually called me, she’s at UT Tyler, her name is Jenny Chilton, and she called and said, “every time I watch that show, I think of you because they say less than 5 percent succeed”. And so, that’s my first question is “who are those 5 percent and how are they succeeding and what are they doing? How are they beating the odds?” Doctor Nowzaradan is in Houston and so, I think it would be fascinating to reach out to him and say, “okay, you have oodles of videotape footage and you obviously already have a population that has had their life followed. You could do just a qualitative analysis of just those videos to see.” So that’s kind of next on my…I think that would be cool to do.

Christina Sumners: Wonderful. So, you mentioned resilience and how that is not the same as positive deviance. What’s the difference between them and how would you explain that?

Jodie Gary: So, I’m actually working on a concept paper currently looking at the current concept analyses of positive deviance and then the concept analyses of resilience. There is a lot of work and literature on resilience and I’m not a resilience expert, so it’s taking me a little bit of time to get through that. But there are several concept analyses of resilience in health care and there’s actually only three concept analyses of positive deviance in health care, one of which is mine, so that’s probably a little self-serving. One is by a group of French Canadians, so I need to get the article translated, but it’s really fascinating. They do overlap in some instances with some of their concepts, but resilience is you’ve just overcome something like you overcame your cold. Positive deviance is you had an exceptional outcome and maybe you were in the direst of circumstances. So, they do overlap quite a bit, but I’m really excited to kind of get into that paper so there might be more to come for that.

Christina Sumners: Okay, well we’ll have to get you back on to talk about that, but in the meantime, thank you so much for being here.

Jodie Gary: Thank you for having me.

Christina Sumners: Great talking to you and thank you all so much for listening to another episode of Science Sound Off! We’ll see you next time!