Our Voices, Our Strength: The Power of Positive Deviance

Incoming American Association of Critical-Care Nurses (AACN) President Lisa Riggs unveiled the 2018 President’s theme, “Our Voice, Our Strength,” in her keynote speech on May 23, 2018, at the National Teaching Institute (NTI).¹  President Riggs urged AACN members to use our voices to improve the lives of our patients and to make positive changes in the work environment. She also spoke about the power of positive deviance—practices that deviate from the norms of the culture in ways that make monumental and lifesaving differences.

Voice commonly refers to verbal speech, but the dictionary includes “right of expression” and “influential power” as additional definitions of voice.²  Our voices make visible new ideas that can improve clinical practice. Voice encompasses not only verbal speech, but also written expression of ideas. Our strength and influential power depend upon our voices in both spoken and written forms. Our spoken and written words are important in the clinical setting as we advocate for patients and their families and as we work to build healthy work environments. Dissemination is a crucial component of research and quality improvement, and it can occur through the spoken word (eg, conversations in the work environment or presentations at conferences) as well as through the written word (publications). Publications are powerful because they extend the reach and power of our voices. They provide a lasting legacy of knowledge that can extend our voices beyond our local colleagues to new audiences and beyond the present time to the future. This dissemination of our voices is a primary goal for the American Journal of Critical Care and other AACN publications.

Each health profession has a distinct voice, and the individuals within a profession have unique voices. On some matters, members of a profession speak in unison; for example, critical care nurses resonate with AACN’s statement that nursing excellence means, “Helping nurses make their optimal contribution to patients and their work environments and the recognition of their efforts.”³  In other cases, multiple perspectives preclude a single unitary voice for the profession; the diversity of multiple voices can be a reflection of our strength, as it enables us to confront difficult issues and consider different perspectives.

Voices provide a lovely metaphor for perspectives of interdisciplinary work as well. As each profession has a distinct voice, the professions may also speak in unison, in harmony, or in dissonance. The Critical Care Societies Collaborative (CCSC) is an exemplar of 4 professional societies (AACN, American College of Chest Physicians, American Thoracic Society, and Society for Critical Care Medicine) speaking in unison. They describe their purpose explicitly as “The CCSC speaks with a unified voice representing more than 150,000 critical care professionals to bring important issues to the forefront in public policy and in the healthcare arena.”⁴  Professions speak in harmony when their voices are distinct but complementary to each other. This harmony is an essential component of interdisciplinary work, where the voice of each discipline provides a unique perspective that enriches holistic care and improves patient outcomes. Harmony is the “sweet spot” of interdisciplinary work, requiring that we each contribute our unique voice, that we listen to each other and the patient, and that we work collaboratively with each other toward excellence. There remain areas of disagreement between professions; if we stay true to our own voices while respecting the voices of others, these areas of discord provide opportunities for interdisciplinary growth.

Positive deviance requires unique voices. In speaking about positive deviance, President Riggs told the germinal story that launched the positive deviance approach in public health.¹  In the 1970s, public health professionals noted that certain children in Vietnam suffered less from malnourishment. In studying the families of these children, it was discovered that small changes in the children’s diets had large effects; the addition of small amounts of greens and shellfish to children’s food was outside the cultural dietary norms, but effectively improved nutrition.⁵  Subsequent work disseminated these practices throughout villages in the 1990s. Building on earlier research, 4 primary components of a positive deviance approach have been characterized: identifying high-performing individuals, groups, or organizations (“positive deviants”), who achieve better results than others with the same resources; understanding the uncommon or special practices of the positive deviants; driving change toward positive deviant practices from within rather than externally imposing change; and sustaining change in the face of existing resources.⁶ 

Positive deviance has driven improvements in clinical care, although we may not have recognized positive deviance as a factor in the improvements. Every unit has expert clinicians who are admired for their ability to innovate and improve processes. It may take careful observation to identify these positive deviants. Positive deviants on your unit may actively champion change, or they may share their innovations only when asked. Positive deviants have unique voices, but they may or may not be able to identify what they do differently that drives better outcomes. It is important to note that positive deviance is not an all-or-nothing trait.⁵  It is possible to excel in one area without excelling in everything!

High performance is a hallmark of positive deviance but is not synonymous with positive deviance, because high performers may achieve better results from conventional practices even without deviant approaches. The differentiating factor for positive deviance is the contrast in practices between high performers and low performers.⁵  Both high performers and low performers will share many common practices that are not responsible for the better outcomes; practices that differ between high performers and low performers are most likely to be the cause of the positive deviance effect. Practices that confront existing norms may be candidates for positive deviance, but a departure from the norm may just be a variance that does not contribute to better outcomes. Practices that define positive deviance are found in high performers, and those practices must be both different from and better than practices of lower performing individuals.

In settings outside of health care, implementation of positively deviant practices has historically been based on involvement of the community and usually occurs through a “bottom-up” approach rather than being implemented administratively. However, studies of positive deviance in health care have demonstrated little involvement of clinicians in the process.⁶  Involving bedside clinicians, patients, and patients’ families is important. Clinicians can be inspired to embrace practices that arise from positive deviance, but it is usually less successful to direct them to do so. Administration can, however, support identification and investigation of positive deviant practices and remove barriers to implementation.

Much work remains to take advantage of positive deviance to improve clinical care. The research examining positive deviance in health care is not well developed. A recent meta-analysis concluded that the research base for application of positive deviance to health care suffers from poor quality of studies, lack of detail in reporting, and limited guidance on implementation.⁶  Positive deviance arises from and is applicable to local context, and it is constrained or enabled by local resources and culture. This makes generalizability more difficult, and practices that are successful in one unit may not be successfully replicated in others. Research about how to propagate positive deviant practices is needed to broaden their impact beyond the local work environment.

The unique voices of positive deviants hold great promise for uncovering new ways of delivering care that improves outcomes. Our voices—unique, in harmony, and in dissonance—are indeed our strength.