Positive deviance and hand hygiene of nurses in a Quebec hospital: What can we learn from the best?

Using positive deviance to enhance HIV care retention in South Africa: development of a compassion-focused program to improve the staff and patient experience

BACKGROUND

HIV burden remains high in South Africa despite intensive efforts to curtail the epidemic. Public primary care facilities, where most people with HIV (PWH) in South Africa receive treatment, face myriad challenges retaining patients on antiretroviral therapy (ART). Nevertheless, some facilities manage to consistently retain PWH in care. We used a participatory positive deviance (PD) approach to discover characteristics of primary care facilities with above-average 12-month retention rates to develop an intervention.

METHODS

We conducted 11 in-depth leadership interviews, 9 staff focus groups with 29 participants, 11 patient focus groups with 45 participants, 23 patient shadowing visits, and multiple facility observations in each of 3 high- and 3 low-retention public primary care facilities in Cape Town, South Africa. Using PD, an asset-based approach to behavior change that consists of discovering how high-performing outliers succeed despite sizable barriers, and then using those data to develop interventions for low performers, we analyzed data to discover dominant characteristics of higher-retention facilities that might be contributing to higher retention rates.

RESULTS

Dominant themes found in higher-retention facilities were compassionate, respectful, and patient-centered care; higher staff morale, passion for the work, and team cohesion; efficient workflow procedures; and a welcoming physical environment. From these themes, we developed the multidimensional Connect intervention, consisting of strategies within three domains: (1) engage, encourage, and support staff (e.g., a monthly staff support huddle, a compassion training); (2) expedite and augment workflow procedures (e.g., adjust folder system to lower wait times); and (3) create a welcoming physical environment (e.g., fresh paint and plants in the waiting area).

CONCLUSIONS

A PD approach enabled us to identify factors that could be contributing to higher ART retention rates within low-resource public sector primary care facilities in Cape Town, South Africa, and to develop a multidimensional intervention. If effective after a future trial, the intervention could be a feasible, affordable complement to existing programs aimed at improving care for PWH.

Using Positive Deviance to Enhance HIV Care Retention in South Africa: Development of a Compassion-Focused Programme to Improve the Staff and Patient Experience

Background

HIV burden remains high in South Africa despite intensive efforts to curtail the epidemic. Public primary care facilities, where most people with HIV (PWH) in South Africa receive treatment, face myriad challenges retaining patients on antiretroviral therapy (ART). Nevertheless, some facilities manage to consistently retain PWH in care. We used a participatory Positive Deviance (PD) approach to discover characteristics of primary care facilities with above-average 12-month retention rates to develop an intervention. PD is an asset-based approach to behavior change that consists of discovering how high-performing outliers succeed despite sizable barriers, and then using those data to develop interventions for low-performers.

Methods

We conducted 11 in-depth leadership interviews, 9 staff focus groups with 29 participants, 11 patient focus groups with 45 participants, 23 patient shadowing visits, and 3 clinic observations in each of 3 high- and 3 low-retention public primary care facilities in Cape Town, South Africa, to discover characteristics of high-retention facilities that might be contributing to higher retention rates.

Results

Themes found to a greater degree in high-retention facilities were compassionate, respectful, patient-centered care; higher staff morale, passion for the work and team cohesion; efficient workflow procedures; and a welcoming physical environment. From these themes we developed the Connect intervention, consisting of strategies within three domains: (1) Engage, encourage, and support staff (e.g., a monthly staff support huddle, a compassion training); (2) Expedite and augment workflow procedures (e.g., adjust folder system to lower wait times); (3) Create a welcoming physical environment (e.g., fresh paint and plants in the waiting area).

Conclusions

A PD approach enabled us to identify factors that could be contributing to higher ART retention rates within low-resource public sector primary care facilities in Cape Town, South Africa. If effective, Connect could be a feasible, affordable complement to existing programmes aimed at improving care for PWH.

The use of positive deviance approach to improve health service delivery and quality of care: a scoping review

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.

Use of the positive deviance approach for healthcare system service improvement: a scoping review protocol

INTRODUCTION

Healthcare systems are currently facing challenges in enhancing access and improving the quality of healthcare services around the world, and one of the innovative strategies that have been used to address such challenges is the positive deviance (PD) approach. The approach assumes that identifying, examining, understanding and disseminating solutions to problems that are already available within the community and organisations including the healthcare system can help in bringing improvements at scale. However, to the best of the researcher's knowledge, there is no scoping review, that is, conducted to map and synthesise the available evidence on the use of the PD approach for healthcare system service improvements. Hence, this scoping review aims to map and synthesise resources on the methodologies and reported outcomes and identify gaps and potentials regarding the use of the PD approach in the healthcare system.

METHODS AND ANALYSIS

Articles will be searched and retrieved in research databases such as PubMed, Embase and Scopus. Retrieved articles will be screened independently for inclusion through a title and, or abstract review. Then, articles that passed the title and abstract review will be screened by reading the full texts. A descriptive mapping and synthesis of the literature will be employed to present data using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews checklist and data will be presented in text, figure and table formats.

ETHICS AND DISSEMINATION

The results of this scoping review will be published in peer-reviewed reputable international journals. Furthermore, it will also be disseminated through conference presentations, and popular press to the wider community. However, formal ethical approval is not required as primary data will not be collected.

Positive deviance in health and medical research on individual level outcomes - a review of methodology

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.

A pre-pandemic COVID-19 assessment of the costs of prevention and control interventions for healthcare associated infections in medical and surgical wards in Québec

Background

Healthcare-associated infections (HCAIs) present a major public health problem that significantly affects patients, health care providers and the entire healthcare system. Infection prevention and control programs limit HCAIs and are an indispensable component of patient and healthcare worker safety. The clinical best practices (CBPs) of handwashing, screening, hygiene and sanitation of surfaces and equipment, and basic and additional precautions (e.g., isolation, and donning and removing personal protective equipment) are keystones of infection prevention and control (IPC). There is a lack of rigorous IPC economic evaluations demonstrating the cost–benefit of IPC programs in general, and a lack of assessment of the value of investing in CBPs more specifically.

Objective

This study aims to assess overall costs associated with each of the four CBPs.

Methods

Across two Quebec hospitals, 48 healthcare workers were observed for two hours each shift, for two consecutive weeks. A modified time-driven activity-based costing framework method was used to capture all human resources (time) and materials (e.g. masks, cloths, disinfectants) required for each clinical best practice. Using a hospital perspective with a time horizon of one year, median costs per CBP per hour, as well as the cost per action, were calculated and reported in 2018 Canadian dollars ($). Sensitivity analyses were performed.

Results

A total of 1831 actions were recorded. The median cost of hand hygiene (N = 867) was 20 cents per action. For cleaning and disinfection of surfaces (N = 102), the cost was 21 cents per action, while cleaning of small equipment (N = 85) was 25 cents per action. Additional precautions median cost was $4.1 per action. The donning or removing or personal protective equipment (N = 720) cost was 76 cents per action. Finally, the total median costs for the five categories of clinical best practiced assessed were 27 cents per action.

Conclusions

The costs of clinical best practices were low, from 20 cents to $4.1 per action. This study provides evidence based arguments with which to support the allocation of resources to infection prevention and control practices that directly affect the safety of patients, healthcare workers and the public. Further research of costing clinical best care practices is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-01000-y.

A scoping review of rebel nurse leadership: Descriptions, competences and stimulating/hindering factors

AIMS

To (1) give an overview of rebel nurse leadership by summarising descriptions of positive deviance, tempered radicals and healthcare rebels; (2) examine the competences of nurse rebel leadership; and (3) describe factors that stimulate or hinder the development of rebel nurse leadership.

BACKGROUND

Research shows nurses have lower intention to leave their jobs when they can control their work practices, show leadership and provide the best care. However, organisational rules and regulations do not always fit the provision of good care, which challenges nurses to show leadership and deviate from the rules and regulations to benefit the patient. Three concepts describe this practice: positive deviance, healthcare rebels and tempered radicals.

DESIGN

Scoping review using the Joanna Briggs Institute methodology and PRISMA-ScR checklist.

METHODS

Papers describing positive deviance, healthcare rebels and tempered radicals in nursing were identified by searching Scopus, CINAHL, PubMed and PsycINFO. After data extraction, these three concepts were analysed to study the content of descriptions and definitions, competences and stimulating and hindering factors.

RESULTS

Of 2705 identified papers, 25 were included. The concept descriptions yielded three aspects: (1) positive deviance approach, (2) unconventional and non-confirmative behaviour and (3) relevance of networks and relationships. The competences were the ability to: (1) collaborate in/outside the organisation, (2) gain and share expert (evidence-based) knowledge, (3) critically reflect on working habits/problems in daily care and dare to challenge the status quo and (4) generate ideas to improve care. The factors that stimulate or hinder the development of rebel nurse leadership are as follows: (1) dialogue and reflection, (2) networking conditions and (3) the managers' role.

CONCLUSIONS

Based on our analysis, we summarise the descriptions given of rebel nurse leadership, the mentioned competences and provide an overview of the factors that stimulate or hinder rebel nurse leadership.

RELEVANCE TO CLINICAL PRACTICE

The descriptions produced in this review of rebel nurse leadership and the stimulating or hindering factors listed should help nurses and managers encourage rebel leadership.

Integrating staff nurses in antibiotic stewardship: Opportunities and barriers

BACKGROUND

Nursing has been called for greater participation in antibiotic stewardship. Although many of the functions that are integral to successful stewardship are within the scope of bedside nurses, data evaluating nursing engagement in stewardship are limited. The objective of this study was to identify nurses' roles and confidence in engaging in stewardship practices by conducting a survey of pediatric staff nurses employed at a 354-bed freestanding children's hospital with a well-established prospective audit and feedback stewardship program.

METHODS

An investigator-developed online survey was used to assess 10 identified practices that fall within the responsibility of inpatient nurses and contribute to the stewardship process.

RESULTS

One hundred and eighty nurses participated in the study. Nurses were highly confident assessing for an adverse drug reaction history, obtaining cultures prior to antibiotics, and participating in patient education. They were less confident in reviewing microbiology results to determine antibiotic appropriateness. Clinical practice and hospital culture influenced perceptions of the nursing role in stewardship. Reported barriers to stewarding included nurses not included in rounds, interdisciplinary power differentials, and nursing input not actively sought.

CONCLUSIONS

Barriers to nurse engagement were identified and could be addressed by improving education in microbiology and principles of antibiotic use along with more consistent inclusion of nurses in bedside rounds while also cultivating an environment where nurse contribution is actively sought.