Nosocomial infections, also known as health-care associated infections (HAIs) and hospital-acquired infections, constitute one of the most critical and investigated issues in public health worldwide [1, 2]. Despite accumulated knowledge and implementation of varied strategies in this field, hand hygiene (HH) compliance remains low, infection rates are high, and there is still a gap between recommendations and implementation [3, 4].
Numerous and diverse programs have been designed throughout the world to reduce the rate of HAIs, but there is still uncertainty regarding the effectiveness of each specific strategy relative to others or the effectiveness of a number of combined strategies [4,5,6,7]. A systematic review and network meta-analysis conducted in 2015 sought to evaluate the relative efficacy of the World Health Organization’s 2005 campaign (WHO-5) and of other interventions to promote HH among healthcare workers in hospital settings. The review found WHO-5 to be effective, yet additional interventions in conjunction with elements of the WHO campaign have the potential to lead to further improvements . Strategies alone are clearly insufficient to achieve the goals. Indeed, behavior motivation factors must be incorporated in order to devise effective intervention programs [4, 8,9,10,11,12].
Even though HPs working in public settings are aware of the importance of maintaining infection prevention and control (IPC) guidelines, here too, as in other fields, there are still significant discrepancies between intentions and actual behaviors [13, 14]. Some of these discrepancies arise from what we termed “gray areas” in our previous study . This term refers to the lack of solutions at different points along the care continuum (i.e., the range of medical procedures carried out during the course of a patient’s hospitalization(. At these gray areas, some HPs do not know what is required of them, leading to confusion, frustration, and various interpretations. Therefore, despite the importance of written guidelines, they cannot cover all the situations that may arise along the care continuum that may cause hospital infections to spread. The findings of our previous study indicate that written guidelines cannot be totally comprehensive, as they fail to account for the dynamic nature of the work and therefore are hard to translate into the work environment . The pPositive dDeviance (PD) approach can help find solutions along the care continuum that are not contained in the official guidelines, thus narrowing the gap between intentions to maintain hygiene and actual behavior.
The PD approach is an innovative behavioral approach to solving complex problems (e.g., HP compliance in maintaining IPC guidelines). The approach addresses two key parameters that emerge from the literature: 1) the need to find solutions from within the community’s existing resources, and 2) the need to empower HPs by identifying individuals who behave in exceptionally positive ways. These individuals (i.e., people within the community whose behavior instills change) serve as role models by virtue of the fact they have developed successful solutions and strategies for dealing with problems without resorting to additional resources unavailable to fellow members of their community . In the current study, these individuals are nurses and physicians who have developed unique and successful solutions and strategies. Since PD is a community-based approach that operates from the bottom up (from members of the community to management), it takes into account all the “situational factors” (i.e., factors in the social and physical environment that block or facilitate processes of change) associated with the organizational culture of medical teams in their daily reality. By identifying positive behaviors, the approach is able to offer sustainable solutions to many situations.
Implementing the PD approach has the potential to reduce the gap between intentions and actual behavior reported in the literature, increase the rates of HP compliance with infection prevention rules, and reduce infection and mortality rates .
The PD methodology consists of four basic steps carried out by members of a community.
Step 1: Identify “positive deviants,” i.e., individuals who consistently demonstrate exceptionally high performance in an area of interest.
Step 2: Study these individuals in depth using qualitative methods to generate hypotheses about practices that enable organizations to achieve top performance.
Step 3: Test hypotheses statistically in larger representative samples of individuals.
Step 4: Work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices.
This article focuses on Step 4 of the PD approach, namely the dissemination of new practices. Disseminating practices among other HPs depends on how they assimilate their new knowledge. The process of internalization and assimilation can be explained by the Recognition-Primed Decision (RPD) model [17, 18], which demonstrates how information is processed. The RPD model describes how professionals use their experience to make rapid decisions in time-pressured settings under conditions of uncertainty [17, 19, 20]. In accordance with this model, we seek to demonstrate how HPs make decisions in complex situations related to IPC guidelines.
The RPD model encompasses two steps individuals must adopt in making decisions. First, they must recognize which course of action makes sense. After that, they must evaluate this course of action by imagining whether the actions resulting from the decision make sense. In this decision-making process, experience plays a major role.
HPs must move from one complex task to another. In such a reality, identifying specific situations that require conforming to IPC guidelines presents a challenge. The literature offers a number of techniques that can help HPs complete their behavioral intentions of maintaining IPC guidelines. For example, the study by Fuller et al.  attempted to address the complex ongoing problems faced by HPs by creating hints to help them remember hygiene procedures. The study suggests that future interventions should be developed in cooperation with HPs to build “if-then” programs: “If X happens then I will do Y ….” This technique, which can help HPs shift from one task to another and choose the best solution, is implemented through the Think Aloud (TA) method, a research method used to study cognition that is considered the optimal method for capturing thought processes, particularly for problem-solving. In the current study, TA was applied to the implementation of IPC guidelines.
While using TA, individuals verbalize how they are using available information to generate a solution to a problem. Unlike other techniques for gathering verbal data, TA entails no interruptions or suggestive prompts or questions. The TA participant is encouraged to concentrate on the tasks being performed while verbalizing a continuous stream of thoughts and avoiding interpretation or explanations . TA can transform the thought processes of expert clinicians, which are usually automatic and implicit, into explicit and concrete explanations. TA reveals steps in the reasoning process and makes explicit how decisions are made. It emphasizes the process of making a diagnosis, rather than just focusing on the diagnosis .
The TA process can help nurse educators teach nursing students how to identify and correct reasoning that is not up to par and show them scenarios that might arise during their clinical assignments. The educators can use the TA approach to help promote clinical reasoning strategies, such as hypothesizing, judging, and inductive and deductive logic. Nursing students can be evaluated on how they comprehend and verbalize what is taught in classroom lectures and how they connect scientific facts with health-related outcomes in order to identify problems and concerns. Not only must nurses be able to use diagnostic reasoning, they must also be flexible, knowledgeable, and capable of reflecting on approaches to clinical work while developing reasoning skills.
Other studies suggest that physicians undergo a similar cognitive process in making clinical decisions [23,24,25]. Chan et al. (2020) demonstrated that emergency physicians interviewed according to TA protocols engaged in iterative and dynamic decision-making processes that changed throughout their encounters with patients, in accordance with multiple contextual features . Thus, the TA method helps connect the clinical experience to an array of strategies that affect patient-centered healthcare outcomes .
The current study is based on a large-scale study conducted in 2017–2019 in three Israeli hospitals and focuses on the information dissemination stage of PD practices (Stage 4) in reducing healthcare-associated infections (HAIs). To the best our knowledge, no studies have investigated how HPs assimilate new behavioral practices demonstrated by PDs who maintain IPC guidelines. We also found nothing in the literature examining the work of HPs who use RPD to prevent acquired infections. This article describes an application of the model and suggests methodological developments in the context of maintaining IPC guidelines.
The first goal of the research is to offer a method for disseminating PD practices for maintaining IPC guidelines to other HPs. The method is based on a number of tools that have been used in other fields, as specified below. The second research goal is to examine feedback from the demonstrators regarding the proposed method. The third goal is to examine the impact of PD intervention on HPs’ reported behavioral changes in maintaining IPC guidelines.