Motivating healthcare professionals (nurses, nurse assistants, physicians) to integrate new practices for preventing healthcare-associated infections into the care continuum: turning Positive Deviance into positive norms
BMC Infectious Diseases volume 21, Article number: 495 (2021)
The literature examining healthcare-associated infections (HAI) points to two main problems in conforming to infection prevention and control (IPC) guidelines among healthcare professionals (HP). One is the discrepancy between HPs’ behavioral intentions and their implementation in practice. The other refers to how HPs maintain these practices after the intervention stage ends. The method proposed in this study seeks to address both these issues by using the Positive Deviance (PD) approach to focus on the dissemination stage of interventions. The study seeks to offer a method for disseminating 27 PD practices to 135 HPs, among them nurses, nurse assistants and physicians, so as to help them maintain IPC guidelines, offer feedback on the dissemination process and examine the impact of the dissemination stage on changes in their behavior.
The theoretical model underlying this qualitative research was the Recognition-Primed Decision (RPD) model, which we implemented in the field of healthcare-associated infections (HAIs). Moreover, we used the Discovery & Action Dialogue (DAD) and Think Aloud (TA) techniques to describe the methodological development of simulations for HPs. Feedback from the HP demonstrators underwent content analysis, while descriptive statistics were used to characterize behavioral changes.
HPs’ information processing regarding infection prevention shifts from peripheral/automatic processing to intuition and analytical/central processing, turning PD practices into positive norms. The HPs personally experienced finding a solution and made repeated corrections until they overcame the barriers. Most of the HPs (69.4%) reported that the practices were fully implemented, together with additional practices.
Implementation of the dissemination stage indicates that in order for HPs to integrate and assimilate practices that are not in the official guidelines, merely observing simulations is not sufficient. Rather, each staff member must personally carry out the procedures.
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.
This article focuses on Step 4 of the PD approach, namely the dissemination of practices. A necessary condition for disseminating practices among other HPs depends on how they assimilate their new knowledge. We used the TA technique to explain the learning process and the RPD model to illustrate how the participants process the information.
RPD served as the theoretical model underlying this research. The model focuses on decision-making under circumstances of stress and intense conditions. Thus it is suitable for the medical field, where HPs are required to find effective solutions. In this study we outlined the methodology of the theoretical model by using various tools that facilitate its use and accommodated it to the issue of reducing HAIs and maintaining IPC guidelines. The research model illustrated in Fig. 1 demonstrates the correction and repetition process, until the ultimate solution for the gray areas along the care continuum in hygiene maintenance is found.
We used a technique that integrated TA and retrospection, wherein TA protocols or behavioral observations during a session are used to obtain a retrospective protocol of any pauses in the TA session or fragments that were incomprehensible, incomplete, or odd and introspective. The TA method then uses more direct data for validation  and is supplemented by DAD. We added the element of dissemination by video recording via smartphones. The entire demonstration process was filmed, including repetitions and corrections made until the final product was obtained. We assumed that the video recording influenced the demonstrator’s assimilation process.
The study was conducted at three hospitals in Israel: Hadassah Ein Kerem Medical Center, Bnei Zion Medical Center, and Rambam Medical Center. Five departments/units participated: one Medical Intensive Care Unit (MICU), two internal medicine departments and two orthopedic departments.
The study included 135 HPs who participated in the dissemination stage; 27 of them served as the demonstrators (Table 1). Each of the demonstrators performed a single behavioral practice/procedure in the dissemination stage and documented it by video.
The research process
As noted, this study is part of a larger study conducted from 2017 to 2019 and is based on our previous published findings. Some of the PD practices discussed in this article came up in our earlier work (see details below), while three of them (Practices 1, 10 and 11) are mentioned here for the first time.
The 27 practices documented by video included 13 of the PD behavioral practices along the care continuum: (1) changing a surgical dressing; (2) removal of protective clothing when leaving an isolation room, and carrying out hand hygiene ; (3) taking a blood sample ; (4) sending blood samples to the laboratory ; (5) inserting a central line ; (6) washing a patient in bed ; (7) sterilizing a stethoscope ; (8) cleaning a patient’s unit and surroundings ; (9) taking a patient’s urine sample with a urine catheter and sending it to the laboratory ; (10) cleaning the nursing station; (11) mixing IV meds and bringing them to the patient; (12) replenishing disposable equipment in a patient’s room; and (13) instructing patients and families on how to maintain hygiene in the hospital .
Three of the 27 practices documented by video require maintaining sterility and using sterile equipment in addition to maintaining hygiene: (1) changing a dressing attached to a central line; (2) inserting a urine catheter; and (3) suctioning a respirated patient.
Building the setting
The procedures were performed in the hospital in their natural setting. In most cases, the facilitator/demonstrator was a medical staff member specializing in the procedure, while another HP who was a member of the research team filmed and documented the procedure. In some cases the facilitator guided, filmed and documented the procedure using a smartphone. Each HP worked on one of the 27 practices, and each of them conformed to the integrated three-stage model, as follows:
In the first stage, we asked each of the 27 HP demonstrators to demonstrate one procedure/practice. Prior to the demonstration, the PD facilitator explained the approach and performed the procedure. During the demonstration and filming, the facilitator applied the DAD method, asking the demonstrator to find solutions to situations for which there are no clear guidelines. In accordance with the TA method, the demonstrators were told to speak out loud about their problems and deliberations, while explaining their actions step-by-step. At any point when demonstrators stopped, the facilitator asked why they stopped and how they thought to continue. It is important to note that every time the demonstrators criticized themselves (e.g., by stating they had acted in a way that did not maintain a hygienic/sterile environment), they repeated the action again. In effect, they repeated the action again and again several times, making corrections until finding the optimal solution/frame.
In the second stage, which took place about 1 month after filming the procedure, we showed the demonstrators the videos again and interviewed them about the influence and effectiveness of the procedure, using the TA introspection prompting technique. We chose a time period of 1 month to allow the demonstrators to gain perspective about the process.
In the third stage, we asked all HP observers to rate each practice by indicating the extent to which it had changed their behavior and motivated them to implement the practice, on the following scale: 1 - I did not implement it; 2 - I implemented it partially; 3 - I implemented it fully; 4 - I implemented it fully and added my own practices.
The materials underwent content analysis as follows:
In the first stage we analyzed the transcripts of the texts spoken during the filming, including the correction stages, until the speakers found solutions during the medical procedure. We then constructed the following index of criteria for analyzing the processes: (1) identifying the gray area on the continuum of actions (defining the problem); (2) corrections made by the demonstrator; (3) quotes from the demonstrator’s correction process; and (4) thematic analysis of the demonstrator’s evaluation of the process.
The second stage entailed thematic analysis  of the 27 personal interviews held with the demonstrators that focused on the effectiveness of the method and its influence on them.
The thematic analysis was conducted independently by two researchers to ensure reliability. These researchers identified relevant themes and sub-themes concerning participation in the research model. The analysis began by reading through the transcripts for general and potential meanings. Then, each researcher created an initial coding structure based on the descriptive coding by coding units of text as themes and labeling them with a phrase related to the participant’s account. Next, the researchers conducted a joint analysis that entailed consolidating and prioritizing the independently identified themes, yielding the initial thematic framework of the analysis.
In the third stage, the behavioral changes reported by the HPs were analyzed using descriptive statistics. We pooled all practices identified at the three hospitals and assessed the proportion of participants who rated each of the implementation levels.
Validity and credibility of the procedure
The validity of each action performed by the demonstrator to prevent contamination was scientifically approved by the two HPs present at the event. In addition, an external HP from the infection control unit viewed the videos and approved the final results.
The interviews and videos were analyzed by three different researchers. These analyses were then compared, and agreed-up themes were identified. In the very few cases where there was disagreement, we went back to the transcripts and the videos.
Table 2 shows three examples of sterile procedures (inserting a urine catheter, changing a dressing for a central line, suctioning a respirated patient) performed by the demonstrators. For each example, the table indicates the gray areas (problem definition), solutions/corrections proposed by the demonstrators, quotes from the demonstrator’s statements during the correction process, and demonstrator feedback (in the form of retrospection about the effect of the demonstration). These elements describe how PD practices are disseminated to other HPs in order to maintain IPC guidelines.
Table 3 outlines the thematic analysis of the 27 demonstrators’ retrospective feedback.
The following is a brief explanation of the five key themes emerging from the demonstrators’ feedback:
General evaluation of the model of the proposed method: The demonstrators emphasized the applicability and accessibility of the model to other HPs in raising awareness.
HP information processing by the analytical route: The demonstrators emphasized the quick and effective assimilation of practices facilitated by using the model.
Contribution of filming: (1) promotes assimilation of practices more effectively than merely reading a procedure; (2) actively involves the staff; (3) empowers and enhances sense of professionalism.
Bringing up difficulties along the care continuum and filling in the gray area: The demonstrators noted that during the practice demo, they were able to address and find solutions to the problems that arose during the demo, whereas in day-to-day work they failed to notice “problems.”
Contribution of TA: The TA technique in which demonstrators are asked to speak aloud caused them to plan and think about every step they took during the demo and encouraged a sense of security and sharing among the observers.
Figure 2 shows the distribution (%) of the overall implementation of PD practices as ranked by all the HPs after participating in the demonstration simulation. According to Fig. 2, most of the HPs (69.4%) rated the practices as fully implemented and fully implemented + additional practices.
The model proposed in the present study overcomes two discrepancies noted in the introduction regarding the maintenance of IPC guidelines: 1) the gap between intentions and practical implementation, and 2) the problem of maintaining behaviors after the intervention stage, namely assimilation and practical maintenance without external oversight . As we noted, the literature focuses on intervention rather than on maintenance. The methodological model proposed in our study suggests a method to overcome this issue by applying the RPD theoretical model to the field of infection control . In the dissemination process examined in our study, the demonstrators were exposed to barriers and defects in the care procedure and overcame these while receiving facilitator support.
Reay and Rankin  claim that, in contrast to other abstract theories, the RPD model takes into account dynamic and stressful situations such as those found in the medical field. In RPD Variation 3, a person knowledgeable about the situation must choose the optimal course of action. The decision-maker engages in mental simulation that entails testing different scenarios using the “if … then …” format. After testing a number of scenarios, the decision-maker chooses a course of action that appears appropriate to the goals and priorities of the situation. Since the RPD model is predicated on time constraints, the decision-maker chooses the first course of action that appears appropriate to the situation. Our proposed methodological model implements RPD Variation 3: Each of the demonstrators must undergo a process in which the topic of maintaining a hygienic environment moves from the peripheral route to the central route, in accordance with the Elaboration lLikelihood mModel .
Unlike studies that examine analytical versus intuitive decision-making , we chose the RPD model as a path toward combining both. Identifying patterns requires intuition, whereas analytical reasoning is needed for mentally simulating options. Klein  argues that both are necessary because intuition alone may lead to faulty options and using only analytical reasoning would be too slow in time-pressured situations.
In other words, our findings show that in processing information concerning infection prevention, HPs move from peripheral/automatic processing to intuitive and analytical/central processing. The HPs’ personal experience in finding a solution while verbalizing their considerations using the TA technique and repeatedly correcting themselves until they overcome the barriers encountered shifted the issue of infection prevention from the automatic peripheral to the central analytical route. This increases the likelihood that the demonstrators will continue to maintain IPC guidelines while performing this procedure in the future. In addition, documenting the procedures by videotaping with smartphones, a readily available device, raises the likelihood that other HPs will watch the filmed procedures. Indeed, this is what happened based on our interviews with the demonstrators and the other HPs who observed the simulation. The interviewees reported that they incorporated the demonstrated practice into their routine work, and 69.4% of them reported that they changed their behavior in line with the PD intervention.
In addition, note that a growing body of research has been conducted using Video-Reflexive Ethnography (VRE) [34, 35] to assist healthcare workers understand IPC practices and devise solutions to these. This approach is similar to the dissemination method we described above in that it uses video for documenting HPs’ IPC practices. Yet unlike our method, VRE documents practices that are demonstrated without any interference. The HPs then view the video documentation in reflective focus group sessions where they discuss how to find solutions that are adapted to the changing reality.
Moreover, while the literature describes how the PD method identifies exceptional people who find solutions to complex situations along the care continuum and disseminate their practices to the rest of the staff members, exactly how this transfer process takes place was not discussed. The method introduced in the current study points out the different stages in the transformation process, thus motivating other HPs to be as creative as the PDs and transforming the desirable behavior from a deviance to a norm. This is because the HPs who participated in the PD study not only implemented the practice, but added to it during the intervention process, and some even offered their own tips. Therefore, the proposed model raises the likelihood that HPs will not only maintain hygiene in the practices they watched or experienced, but will also apply the approach and the skills they acquired to other procedures along the care continuum. Follow-up studies in the future can examine whether the HPs who participated in the demonstration in the dissemination stage implemented the approach in their ongoing work.
The research limitation is that the study examined and evaluated the PD intervention in specific hospitals. Therefore, further research is needed to explore the impact of this methodological model at other hospitals. In addition, beyond the research and evaluation stage, the assimilation and maintenance of the behavior change should be studied and evaluated over time.
The implementation of the dissemination stage indicates that in order for HPs to integrate and assimilate practices that are not in the official guidelines, they must carry out the procedures themselves. It is important to note that implementation of this methodology does not require special resources on the part of the hospital system. The procedures can be demonstrated and practiced at different times in the hospital wards. Smartphones can be used for documentation and filming, and all the instructions can be delivered by the HPs themselves.
Availability of data and materials
Requests for more detailed information regarding the study can be addressed to the corresponding author.
Infection prevention and control
Intensive care unit
World Health Organization
Discovery & Action Dialogue
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The authors would like to thank all the participants in this study. We are grateful to the Israel National Institute for Health Policy Research for funding the research. In addition, the authors would like to thank Prof. Arvind Singhal for his ongoing consultancy to the research.
This research was funded by the Israel National Institute for Health Policy Research (NIHP(, grant number 2016\134\א. The NIHP had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
Ethics approval and consent to participate
This study was approved by the ethics committee of The Faculty of Social Welfare and Health Sciences at the University of Haifa (confirmation number 392/17) and by the Bnai Zion Medical Center Helsinki Committee (confirmation number 135–16-BNZ). Verbal informed consent was obtained from all the study participants as the research was performed during the participants’ routine on the job training, making written consent procedure difficult to perform. The verbal consent procedure was approved by the ethics committee of The Faculty of Social Welfare and Health Sciences at the University of Haifa (confirmation number 392/17) and by the participants’ medical heads of units. The research does not provide any medical or personal information by which each participant can personally be identified, thus ensuring anonymity.
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Gesser-Edelsburg, A., Cohen, R., Halavi, A.M. et al. Motivating healthcare professionals (nurses, nurse assistants, physicians) to integrate new practices for preventing healthcare-associated infections into the care continuum: turning Positive Deviance into positive norms. BMC Infect Dis 21, 495 (2021). https://doi.org/10.1186/s12879-021-06215-3