The Positive Deviance Approach for Preventing Healthcare Associated Infections Using Creative Solutions by Staff

Background: The phenomenon of nosocomial infections worldwide is considered one of the most critical and investigated issues in public health. Despite the accumulated knowledge and the implementation of varied strategies in the field, hand hygiene (HH) compliance remains low, infection rates are high and there is still a gap between recommendations and implementation in practice. It is therefore clear that it is not enough to combine several strategies in order to achieve the goals, but rather to take into account the factors that motivate the behavior of building effective intervention programs. To address this issue, we chose a unique bottom-up approach "The positive deviance approach" (PD), which is defined as a process that identifies the individuals that succeed despite lacking additional resources when compared to their peers, therefore leading to solve a problem within a community.

Objectives: To characterize the gaps between attitudes and behavioral intentions, to the actual behavior of physicians and nurses; To characterize the barriers and difficulties of physicians and nurses in performing HH; Identify "positive deviations" (PD's) among physicians and nurses who exhibited positive behaviors and/or ideas.

Methods: The research was conducted using a qualitative constructivist method. We used Triangulation-combinations of data received from various sources: Face-to-face interviews based on questions from Discovery & Action Dialogue (DAD), direct observations and video footages for documenting the practices from the field. Data were analyzed using Thematic Content Analysis.

Population: A total of 50 healthcare workers were interviewed (25 nurses,12 physicians and 4 students, 1 nurse aid, 3 cleaners, 2 social workers, 2 transporters and 1 physiotherapist), from Internal and Orthopedic departments at the Bnai Zion Medical Center- Israel.

Results: The findings of this study revealed barriers that explain the low compliance of staff to maintain hygiene, as well as the gaps between knowledge and intentions and their actual behavior, related to: demanding work environment, staff shortage, the external population, lack of uniformity in guidelines, organizational culture and risk perceptions. This can lead to different interpretations in different care situations among staff members. 24 individuals were found to be PD's (14 from Internal department & 11 from Orthopedic department).

Significance & Conclusions: Traditional approaches to preventing infections are based mostly on best practice. In contrast, the PD approach focuses on the strengths and resources that arise from the community (bottom-up). The findings of this study provide insight into the specific barriers that specifically characterize the departments discussed, and provide creative solutions on the care continuum that were identified during the study.

The recommendations of the present study are to encourage hospital personnel to create their own solutions for various situations on the care continuum, and to disseminate them within their units to achieve a bottom up change. Nevertheless, those findings will serve as a basis for building future community-based behavioral models adjusted to the current hospital profile. Implementation of these models will be a significant step in reducing infection rates and increasing compliance with HH in hospitals. It should be noted that this is a pioneering study in Israel that uses the PD approach while conducting in-depth research within the community.