Awareness of the term “positive deviance” is rising, as a way of solving tough problems by finding what already works. It’s been the topic of seminars for health leaders. It’s been frequently mentioned by Helen Bevan, Chief Transformation Officer, NHS England, as part of a repertoire of approaches to front-line change, and by Jo Bibby in her Health Foundation Blog. It is the subject of a slide show by Bob Sutton, and gets a brief mention as a possible new option in a recent article about the limitations of quality improvement projects in the NHS by Prof Mary Dixon Woods and Graham P Martin.
There is, however, no available comparison of the various interpretations and applications of “positive deviance,” and some authors mix up the various conceptual frameworks. This article aims to put this right, and offer tips to leaders for implementation.
Why think about positive deviance?
There are a number of schools of thought about positive deviance – what it is, and how to use it to the benefit of organisations and communities. The basic term, positive deviance, just means performing better than one standard deviation above the norm. Deviants act differently from the norm. Positive deviants act differently, and cope better than their peers in the same context.
The value of positive deviance to any community or organisation, particularly in health, is all about harnessing it, to make the most of what you already have and give people a sense of value, purpose and control; a great idea in times of austerity.
Harnessing positive deviance is not that easy, because it seems to go against the top-down, power-based hierarchical way of working.
Different kinds of positive deviance
I have identified three main types of positive deviance concept/study or project. I believe that each can all add value, but in different ways. Here are some observations, and views about the practical applications of the approaches to change and leadership:
- The personality and values based approach
1.a The honourable exceptions
The Michigan Ross School has a Center for Positive Organizations dedicated to positive organisational scholarship. It features Positive Leadership and Positive Ethics and Virtues. For them, a positive deviant is someone who has the values or personal and moral characteristics to be an outlier in a positive way. At the heart of their normative approach is this definition of positive deviance: intentional behaviours that depart from the norms of a referent group in honourable ways. (Spreitzer & Sonenshein, 2003), (Spreitzer & Sonenshein, 2004). Their version of positive deviance focuses on behaviours with honourable intentions, independent of outcomes. These honourable activities may be hidden from their organisations. Their leadership model, and positive organisational scholarship, seek to understand why and how these behaviours emerge and encourage people to follow suit. One of the tools used is the Competing Values Questionnaire.
Sara Parkin identifies a particular kind of Positive Deviant in her book of the same name; one who leads in an environmentally sustainable way.
1.b. The awkward squad
Helen Bevan’s and Bob Sutton’s presentations also include references to those staff who may be perceived as difficult by management, but who have something valuable to contribute. They may perform better, but actually go against official procedure and policy. Presumably, whistle-blowers would come into this category; and there is much discussion still about ensuring they have protection and a voice. These kind of “deviants” are not seen as positive by their peers and may or may not be able to demonstrate evidence of a better way of working, even if they hold valuable opinions, insights and observations.
The research project approach
The research project approach is used to discover positive deviants and rigorously assess the impact of their unusual and exceptional practices on outcomes. The people doing the research are specialist researchers, not the people who are in the environment under review. The work can focus either on the people themselves and their characteristics, as in the section above, or on observing and documenting their unusual practices.
In these projects, comparison can also be at organisation or unit level, for example, to find out why some hospitals have a better track record of patient safety than others, (Bradley, et al., 2009) or why some children’s homes have a better outcome with immigrant children (Bouman, Lubjuhn, & Singhal, 2014). The project is structured to:
- Identify the norm
- Discover positive exceptions (values, behaviour or practice)
- Record the differences in behaviour and practice in detail and find common themes
- Measure the impact of these differences on results
The benefit of this way of working is to have scientifically rigorous proof that the different behaviours do indeed create the better outcomes, and prove that small differences in practice can deliver significantly better results.
This approach to discovering and spreading positive deviance has been tried in the NHS under the banner of improvement science. (Bradley, et al., 2009). Whilst good practice is found, problems can arise when organisations try to spread the successful behaviours and practices. They experience the typical resistance to change. There is no ownership within the teams whose behaviours have to change. (Lawton, Taylor, Clay-Williams, & Braithwaite, 2014). This way of working is similar to benchmarking and carries the same risks of transferring practices between different contexts – the systems and processes may not support the better practices, and they are seen as alien, creating a rejection response. The transfer also requires effective top-down leadership as well as bottom-up adoption.
The facilitated group problem-solving approach
Positive Deviance (or more accurately, Amplifying Positive Deviance) is a facilitation process to discover and spread unusual successful behaviours within a given community. The definition of a community is broad – any group of people that self-identify as a community.
The methodology emerged when Jerry and Monique Sternin were presented with the issue of solving childhood malnutrition in Vietnam without recourse to external resources or traditional aid solutions. They drew on a research paper by Dr Marian Zeitlin, (Zeitlin, Ghassemi, & Mansour, 1990), of the Friedman School of Nutrition, Tufts University, Boston. This showed how some mothers were able to improve their “maternal technology” without socio-economic aid and formal, professional interventions by making better use of what was already around them. It highlighted the importance of researching what worked well and how, not just understanding what did not and why.
This inspired Jerry and Monique Sternin to facilitate a process to discover and spread what already worked. It follows similar steps to those identified above, but the steps are carried out by community members themselves.
Define the problem
The first step was to enable community members themselves to recognise and come to a consensus about the issues. They tested common assumptions and used data to get better understanding.
Discover the norm and any exceptions
Then they facilitated the community members to discover if everyone did the same, and to reveal hidden solutions already in the community.
Determine what the exceptions do and how they do it
This involves detailed enquiry and observation to understand the small and significant differences in practice and behaviour.
Through peer to peer “learn by doing” activities.
This enabled Vietnamese communities to discover better ways of using what they already had and led to a sustainable 60% reduction in malnutrition, without getting bogged down in the huge underlying issues and causes.
From the early 1990s the Sternins started to use this way of engaging communities in finding solutions to “wicked” (Rittel & Webber, 1973) global health and social issues such as malnutrition, girl trafficking and female genital mutilation (FGM). Again, the aim is to bring together key actors affected by an issue, to create consensus about the definition of the problem and desired outcomes – a much harder task than to get agreement that child health is important. This creates significant shifts in understanding and not only uncovers solutions “hidden in plain sight” and spreads them, but achieves significant culture change. (Pascale, Sternin, & Sternin, 2010).
It is recognised in the literature of leadership and change (Grint, 2008), (Heath & Heath, 2010) as a solution to complex issues and collaboration, especially in a complex world where sustainability and resilience are important and resources of time and money are increasingly scarce. It has a number of benefits:
- Solutions within existing resources
- Breakthroughs for tough problems
- Rapid culture change and relationship development
- Individual (often hidden) difference as a resource
The process does take time, particularly at the beginning, but is a way of building networks, collaboration and trust across organisations; working from the bottom up and including the whole system. Helen Bevan’s presentation highlights that the people at the front line are those with the ability to make a real difference to delivery. This is a way to enable them to see for themselves what works and the benefits to them of change. Once they see what works and spread it, changes are adopted very quickly and culture change and engagement happens “on the job” rather than as separate initiatives, without additional costs.
This way of working is engaging and fun – but needs good facilitation and genuine sponsorship from leaders. It’s a holistic way of working that brings together many tools and techniques for engaging people, dealing with complexity and sharing learning. Our advice, developed from Sternin’s guidance for leaders is:
- Create an environment that makes it it safe to learn
- Have patience while people engage with the problem – you will learn too
- Set clear boundaries for the work (i.e. that the practices are safe, ethical and legal)
- Ensure there is supporting evidence – which can be qualitative as well as quantitative – for the nature of the problem under review and that the practices discovered will work and are tested
The groundwork necessary for success means building leadership, working within new principles, and reworking relationships. Its success in creating culture change, is obvious in the USA MRSA reduction programme, which has spread across the Americas. (Singhal, Bruscell, & Lindberg, 2010). The key is in the title of the study – Healing Healthcare by changing relationships.
Critical success factors for facilitators, to make this kind of PD project work, and enable leaders to keep the faith, are:
- Understand that the community involved in solving the problem will shift as the project moves forward – as will the understanding and framing of the problem itself.
- Integrate into day to day activity
- Separate the practice and its owner – people can’t learn to be other people very easily, but if you break down practices and behaviours, you can copy them; people are more likely to open up about an unusual way of working if this is kept confidential
- Facilitate as an “expert non-expert” – constructively challenging views, seeking evidence and encouraging openness
- Recognise that the early stages of building relationships and networks are vital to success, especially in creating the environment for this kind of activity to succeed
As we have shown, the Sternin form of amplifying PD is about behaviours and practices that work (“the practice not the person”), rather than about the nature of the positive deviants themselves. The positive deviants are often totally unaware that what they do is different (or else want to hide it); their practices just evolve from trial and error or learning a useful tip from a friend, rather than from any moral or values-based character or decision.
Our experience is working with the Sternin version and adapting it to local conditions. We have seen its impact in delivering behaviour change within a relatively short time across organisations. It would, however, be possible to use some of the same or similar techniques to discover the “personality and values” positive deviants, and show evidence of the benefits of holding the values that they have, rather than the unusual practices and better outcomes. Our sense is that this kind of research is best done by independent researchers.
If tried by their fellows, our feeling is that this could be divisive and that communities would write off any better practices as not being possible by “ordinary people”. You would also encounter the same resistance to top down change, unless the positive deviants were also recognised as leaders and role models by their peers. It would be interesting to hear of examples where this has been done.
Bouman, M., Lubjuhn, S., & Singhal, A. (2014). What explains enhanced psychological resilience of students at VMBO schools in the Netherlands? Gouda: Center for Media and Health.
Bradley, E. H., Curry, L. A., Ramanadhan, S., Rowe, L., Nembhard, I. M., & Krumholz, H. M. (2009, May). Research in action: using positive deviance to improve quality of health care. Implementation Science, 4(25).
Grint, K. (2008, December). Wicked Problems and Clumsy Solutions – the Role of Leadership. Clinical Leader, 1(2).
Heath, C., & Heath, D. (2010). Switch – how to change things when change is hard. New York: Broadway Business Books.
Lawton, R., Taylor, N., Clay-Williams, R., & Braithwaite, J. (2014). Positive Deviance: a different approach to achieving patient safety. Retrieved January 30th, 2017, from BMJ Quality and Safety Online First: http://qualitysafety.bmj.com/content/early/2014/07/21/bmjqs-2014-003115.full.pdf+html
Parkin, S. (2010). The Positive Deviant, Sustainability Leadership in a Perverse World. London: Earthscan Ltd.
Pascale, R., Sternin, J., & Sternin, M. (2010). The Power of Positive Deviance – how unlikely innovators solve the world’s toughest problems. London, UK: Harvard Business Press.
Rittel, H. W., & Webber, M. M. (1973). Towards a General Theory of Planning. Policy Sciences, 4, 155-169.
Singhal, A., Bruscell, P., & Lindberg, C. (2010). Inviting Everyone: healing healthcare through positive Deviance. Borden, New Jersey: Plexus Press.
Spreitzer, G., & Sonenshein, S. (2003). Positive deviance and extraordinary organizing. In K. Cameron, J. Dutton, & R. Quinn, Positive organizational scholarship (pp. 207-224). San Francisco: Berrett Kohler.
Spreitzer, G., & Sonenshein, S. (2004, February). Toward the Construct Definition of Positive Deviance. AMERICAN BEHAVIORAL SCIENTIST, 47, 828-847.
Zeitlin, M. F., Ghassemi, H., & Mansour, M. (1990). Positive Deviance in Child Nutrition. New York: United Nations University Press.