The wicked question answered: positive deviance delivers patient-centered care.
BACKGROUND
How nurses respond when faced with the dilemma of providing patient-centered care in the absence of patient-centered practice guidelines remains relatively unreported. Standards may not be available to guide nurses or may not be realistic for implementation at the point of care. Nurses may be forced to react creatively to meet the needs of their patients.


OBJECTIVE
The purpose was to understand nursing care when standard practice guidelines did not meet patient-specific care needs and to develop various viewpoints related to the use of positive deviance in providing patient-centered care.


METHODS
Complexity theory and the framework of a wicked question were used to guide a 3-round online national Delphi study from November 2011 to February 2012. The panel was accessed through the American Association of Critical Care Nurses to expose the care provided when standard practice guidelines were lacking.


RESULTS
Findings support the presence of positive deviance and expose care provided by nurses when standard practice guidelines lacked the ability to provide patient-centered care. Dominant themes of positive deviance are recommended as priorities for future research.


CONCLUSIONS
Better guidelines are needed that work for nurses, instead of against them, that would not force a nurse into actions that are not patient centered. Guidelines should guide practice and assist in allowing nurses to provide care that is centered on the best needs of the patient in the specific care situation.
Jodie C. Gary, PhD, RN, has more than 20 years of healthcare experience, including field emergency medical management (from emergency dispatch to paramedic), clinical and laboratory research experience, and hospital-based primary care nursing including supervisory positions in telemetry and critical care. Her primary research is aimed at bedside nursing practice and the delivery of patient-centered care within the framework of Complexity Science. Currently, she is a faculty member for the Texas A&M University Health Science Center College of Nursing. She teaches adult health/medical-surgical and research didactic contact as well as in clinical content in the acute care setting.
Jodie C
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D000328:Adult; D000368:Aged; D003142:Communication; D064648:Critical Care Nursing; D003657:Decision Making; D003697:Delphi Technique; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D024802:Nurse's Role; D018802:Patient-Centered Care; D017410:Practice Guidelines as Topic; D013727:Terminal Care; D014789:Visitors to Patients