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R E V I E W A scoping review of rebel nurse leadership: Descriptions, competences and stimulating/hindering factors

Authors:
  • Fontys University of Applied Sciences

Abstract

Aims To (1) give an overview of rebel nurse leadership by summarising descriptions of positive deviance, tempered radicals and healthcare rebels; (2) examine the competences of nurse rebel leadership; and (3) describe factors that stimulate or hinder the development of rebel nurse leadership. Background Research shows nurses have lower intention to leave their jobs when they can control their work practices, show leadership and provide the best care. However, organisational rules and regulations do not always fit the provision of good care, which challenges nurses to show leadership and deviate from the rules and regulations to benefit the patient. Three concepts describe this practice: positive deviance, healthcare rebels and tempered radicals. Design Scoping review using the Joanna Briggs Institute methodology and PRISMA‐ScR checklist. Methods Papers describing positive deviance, healthcare rebels and tempered radicals in nursing were identified by searching Scopus, CINAHL, PubMed and PsycINFO. After data extraction, these three concepts were analysed to study the content of descriptions and definitions, competences and stimulating and hindering factors. Results Of 2705 identified papers, 25 were included. The concept descriptions yielded three aspects: (1) positive deviance approach, (2) unconventional and non‐confirmative behaviour and (3) relevance of networks and relationships. The competences were the ability to: (1) collaborate in/outside the organisation, (2) gain and share expert (evidence‐based) knowledge, (3) critically reflect on working habits/problems in daily care and dare to challenge the status quo and (4) generate ideas to improve care. The factors that stimulate or hinder the development of rebel nurse leadership are as follows: (1) dialogue and reflection, (2) networking conditions and (3) the managers’ role. Conclusions Based on our analysis, we summarise the descriptions given of rebel nurse leadership, the mentioned competences and provide an overview of the factors that stimulate or hinder rebel nurse leadership. Relevance to clinical practice The descriptions produced in this review of rebel nurse leadership and the stimulating or hindering factors listed should help nurses and managers encourage rebel leadership.
J Clin Nurs. 2021;00:1–21.
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1wileyonlinelibrary.com/journal/jocn
Received: 4 Septem ber 2020 
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Revised: 1 March 2021 
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Accepted: 4 March 20 21
DOI : 10.1111/jocn .15765
REVIEW
A scoping review of rebel nurse leadership: Descriptions,
competences and stimulating/hindering factors
Eline de Kok MSc, RN1,2 | Anne Marie Weggelaar- Jansen PhD3|
Lisette Schoonhoven PhD, RN2,4 | Pieterbas Lalleman PhD, RN5
This is an op en access arti cle under the ter ms of the Creative Commons Attribution L icense, which pe rmits use, dis tribu tion and reprod uction in any med ium,
provide d the original wor k is properly cited.
© 2021 The Authors . Journal of Clinical Nursing published by John Wiley & S ons Ltd.
1Dutch Nurses’ A ssociation Utrecht,
Utrecht, The Netherlands
2Julius Ce nter for Health Sciences and
Primar y Care, University M edica l Center
Utrecht, Utrecht University, Utrecht, The
Netherlands
3Erasmus School of Health Policy and
Managem ent, Er asmus Un iversity,
Rotterd am, The Nether lands
4School of Health S cience s, Faculty
of Environmental and Life S cience s,
University of Southampton, Southampton,
United Kingdom
5HU Univer sity of A pplie d Sciences
Utrecht, Utrecht, The Netherlands
Correspondence
Anne Marie Weggel aar- Jansen, Erasmus
School of Health Policy and Management,
Erasmus University, Rotterdam, The
Netherlands.
Email: weggelaar@eshpm.eur.nl
Abstract
Aims: To (1) give an overview of rebel nurse leadership by summarising descriptions
of positive deviance, tempered radicals and healthcare rebels; (2) examine the compe-
tences of nurse rebel leadership; and (3) describe factors that stimulate or hinder the
development of rebel nurse leadership.
Background: Research shows nurses have lower intention to leave their jobs when
they can control their work practices, show leadership and provide the best care.
However, organisational rules and regulations do not always fit the provision of good
care, which challenges nurses to show leadership and deviate from the rules and regu-
lations to benefit the patient. Three concepts describe this practice: positive devi-
ance, healthcare rebels and tempered radicals.
Design: Scoping review using the Joanna Briggs Institute methodology and PRISMA-
ScR checklist.
Methods: Papers describing positive deviance, healthcare rebels and tempered radi-
cals in nursing were identified by searching Scopus, CINAHL, PubMed and PsycINFO.
After data extraction, these three concepts were analysed to study the content of
descriptions and definitions, competences and stimulating and hindering factors.
Results: Of 2705 identified papers, 25 were included. The concept descriptions
yielded three aspects: (1) positive deviance approach, (2) unconventional and non-
confirmative behaviour and (3) relevance of networks and relationships. The com-
petences were the ability to: (1) collaborate in/outside the organisation, (2) gain and
share expert (evidence- based) knowledge, (3) critically reflect on working habits/
problems in daily care and dare to challenge the status quo and (4) generate ideas to
improve care. The factors that stimulate or hinder the development of rebel nurse
leadership are as follows: (1) dialogue and reflection, (2) networking conditions and
(3) the managers’ role.
Conclusions: Based on our analysis, we summarise the descriptions given of rebel
nurse leadership, the mentioned competences and provide an overview of the factors
that stimulate or hinder rebel nurse leadership.
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1 | INTRODUCTION
Th e inc rea si ng de man d for nu rse s (Ma rć et al., 2019) and th eir high
turnover (Duffield et al., 2014; Fasbender et al., 2019; Li et al.,
2018) have resulted in a workforce shortage that has an adverse
impact on healthcare qualit y (Aiken et al., 2018; Ball et al., 2014).
Research shows that reasons for nurses to resign include the high
workload, job stress and little control over their own professional
practice (Aiken et al., 20 02; Fasbender et al., 2019; Li et al., 2018).
Several studies indicate that nurses have lower intentions to leave
their profession if they can control their daily practice and show
leadership (Blake et al., 2013; Ducharme et al., 2017; Li et al.,
2018). Fully understanding the role of nurse leadership in daily
practice is crucial, especially with the current challenge of retain-
ing nurses.
There are many studies on nurse leadership in the literature.
These studies often highlight nurse leadership from a leader–
follower perspective and resonate with the transformational lead-
ership paradigm (Hutchinson & Jackson, 2013). Transformational
leadership focuses on the cultural aspects of an organisation and
leaders establishing followers with their vision, norms and belief
systems (Hutchinson & Jackson, 2013) that create meaning and
motivation for the followers (Bass & Steidlmeier, 1999). Many
transformational leadership studies in nursing focus on the hier-
archical leader, a designated position of leadership of individuals
(e.g. nurse manager and nurse executive) versus healthcare pro-
fessionals (e.g. nurses) as followers (Reichenpfader et al., 2015;
Sfantou et al., 2017; Wong et al., 2013). However, these papers
direct ‘little attention […] towards understanding how leadership
may be enabled in those not in formally designated leadership po-
sit ions or how organis at ional proce ss es can be change d to lib er ate
follower's potential to lead’ (Jackson & Parr y, 2011 in Hutchinson
& Jackson, 2013, p. 14). Many nurses do not have a designated
posi tion of le ad ers hip, but any nurs e can ex hib it le ad ers hip in t he ir
practices. Clark observes (Clark, 2008, p. 30): ‘Some nurses may
not think of themselves as leaders because they equate leader-
ship with authority or with specific job titles rather than as a way
of thinking or behaving’ in daily work at the frontline. To under-
stand more about leadership in everyday practices, Leadership- as-
practice (LAP) theory provides insights into the moral, emotional
and relational aspects of leadership in daily working life (Raelin,
2011). Rather than envisioning leadership by its rational, objective
and technical aspects (Carroll et al., 2008), LAP helps us under-
stand how leadership is enacted by those not in designated posi-
tions. It shines light on how the context influences leadership and
the dy namics within organisations that foster leadership. The lens
of LAP might provide valuable new insights into nurse leadership
in daily practice, how it can be supported and how it could influ-
ence the retainment of nurses.
Nurses want to provide the best care for their patients, but
they work in organisations with rules and regulations that might
not always fit their norms and beliefs on what the best care is. In
terms of LAP theory, rules and regulations influence the moral,
emotional and ultimately relational aspects of leadership in daily
practice (Raelin, 2011). Wallenburg et al. (2019) found that nurses
may find it challenging to co mpl y with the organisation's rules and
regulations and sometimes also feel that the professional guide-
line s hin de r t he pr ov is io n of be s t qua li ty car e for the in di vid ua l p a-
tien t. Ga bbay an d L e May (2016) st at e tha t if pr of essiona ls wa nt to
make a goo d clinical decisi on for their patients’ ca re t he vari ability
of the multifarious considerations becomes part of their clinical
decisions. The authors stated that no theoretical, research- based
knowledge or clinical guide line coul d ever be expected to cover all
these considerations (Gabbay & Le May, 2016). Therefore, nurses
sometimes deviate from the professional norms and organisa-
tional rules and regulations to generate bet ter outcomes for their
patients or to improve processes on their wards. However, hier-
archical leaders do not always permit deviation, which requires
Relevance to clinical practice: The descriptions produced in this review of rebel nurse
leadership and the stimulating or hindering factors listed should help nurses and man-
agers encourage rebel leadership.
KEYWORDS
behaviour, communication, competence, health care, leadership, nurses, qualit y improvement,
review
What does this paper contribute to the wider global clinical community?
• Organisational rules and regulations do not always fit the provision of good care, which chal-
lenges nurses. When nurses show more leadership in daily practice it will influence and en-
hance the quality of care and help retain nurses.
• The understanding of positive deviants, tempered radicals and healthcare rebels, their com-
petences and the factors that stimulate or hinder the development of rebel nurse leader-
ship will help management and nurses to support and develop rebel nurse leadership in daily
practice.
  
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KOK et al.
in dividual nu r s e s to sh o w le a d e r shi p as th e y mu s t ba lance b etween
conformit y and compliance in order to be a ‘good’ employee and
deviation to benefit their patients and the organisation of their
wards (Berwick et al., 2017). The literature also describes ‘bad re-
belism’ and ‘wr ong deviation’ (Be van, 2010); deviating in your ow n
interest and breaking the rules out of anger only undermines the
quality of care (NHS, 2016, slide 66).
Several studies describe professionals showing leadership in
daily practice as ‘positive deviance’. Gary defines positive devi-
ance as ‘an intentional and honorable behavior that departs or dif-
fers from an established norm; contains elements of innovation,
creativity, adaptability, or a combination thereof; and involves risk
for the person deviating’ (Gary, 2013, p. 29). Bevan's description
of deviating professionals in health care (Bevan, 2010) formed the
basis of the online School for Health and Care Radicals, estab-
lished in 2014, nowadays called the School for Change Agents.
The purpose of the school was ‘to develop effective change
agents, ultimately contributing to fast, large- scale, sustainable
improvement in health and social care, leading to better patient
outcomes’ (Grifford et al., 2015). Bevan defines ‘healthcare reb-
els’ as ‘committed to the patient- centred mission and values’ of
their organisation and see ‘many possibilities for doing things in
different ways’ (Bevan, 2013). The set- up of the school was in-
spired by Meyerson's book explaining her research on tempered
radicals, individuals who ‘navigate the often murky organisational
waters to pursue their ideals while fitting in enough to succeed’
(Meyerson, 20 08, p. 8). In addition, several other studies in health
care describe professionals showing leadership in daily practice
as ‘positive deviants’. The concepts of positive deviance, health-
care rebels and tempered radicals describe nurses who deviate
creatively from formal rules and regulations, not in their own
interests, but for better health care (quality). Wallenburg et al.
(2019) observe that deviating healthcare professionals— nurses—
tend to ‘stay under the radar’ of management to achieve their
goal of improved patient care. To deviate and find another, better
way demands experimentation, tr ying things out and evaluating
the results (Clancy, 2010; Meyerson, 2008; Wallenburg et al.,
2019). Given that positive deviants, healthcare rebels and tem-
pered radicals ‘stay under the radar’, it is not surprising that these
concepts are seldom mentioned in the nursing leadership litera-
ture. However, if rebel nurse leadership is better understood, it
might be possible to study this more closely in nursing practice.
Therefore, this scoping review provides an overview of perspec-
tives on nurse rebel leadership based on the literature on positive
deviance, healthcare rebels and tempered radicals.
2 | AIMS
In this study, we aim to (1) give an overview of the concepts and
descriptions of positive deviants, tempered radicals and healthcare
rebels in nursing, (2) examine the competences of rebel nurse lead-
ers, (3) describe factors that stimulate or hinder the development of
rebel nurse leadership, resulting in (4) a description of the concept of
rebel nurse leadership.
3 | METHODS
3.1  |  Literature search
A scoping review is a method which provides a preliminar y assess-
ment of the potential size and scope of available research literature
to identify the nature and extent of research evidence (Grant &
Booth, 2009). In conducting our scoping review, we used the Joanna
Briggs Institute (JBI) Reviewers’ manual (Peters et al., 2017) and the
PRISMA Extension for Scoping Reviews (PRISMA- ScR) checklist
(Tricco et al., 2018; File S1).
First, we under took a limited search to identif y relevant key-
words and synonyms to develop an a priori search protocol with
a set of inclusion and exclusion criteria. We included three con-
cepts: positive deviance, healthcare rebels and tempered radicals.
Vigilantes and Mavericks were excluded, because the definitions
and descriptio ns gi ven in the papers did not match the positive devi-
ating professionals we were aiming for, based on this limited search.
Second, we searched for all the identified keywords and index
terms in four databases: Scopus, CINAHL (Cumulative Index to
Nursing and Allied Health Literature), PubMed and PsycINFO. The
keywords used in the search strings included the following: ‘Rebel*’,
‘Tempered Radical*’, ‘Positive Deviance*’ and ‘Health*’ (see also
Appendix S1). One researcher (EdK) developed the search strings,
and the whole research team checked and discussed them. The
search period ranged from 1 Januar y 1995 (first publication on tem-
pered radicals by Meyerson and Scully [1995]) to 1 April 2020.
Third, we selected additional papers from the reference lists
of the included papers. Relevant papers were checked to identif y
any research specifically on the three concepts (positive deviance,
healthcare rebels and tempered radicals) that matched the eligibilit y
criteria.
3.2  |  Review process and data extraction
One researcher (EdK) screened the titles and abstracts of the re-
trieved papers. Then, two other researchers (PL or AW) indepen-
dently reviewed a randomly selected sample of ten titles and
abstracts. The Fleiss Kappa measure of inter- rated reliability re-
sulted in 1.0. Inclusion criteria were primary research papers writ-
ten in English, methodology papers, discussion papers and reviews
focusing on nurses or nursing practice in all healthcare sectors, in-
cluding all patient or disease groups. Exclusion criteria were poster
presentations, books, policy papers and interviews with researchers
about their research.
Next, the three researchers independently read and assessed the
full papers. Any disagreements on assessment were discussed by the
research team up to consensus. Papers were excluded if their focus
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was on the related deviant behaviour or rebelism of patient s and if
healthcare professional teams or healthcare professionals were dis-
cussed in general. Papers focusing on organisational structures and
not on the professionals were also excluded. Of the included papers,
the literature references were checked, and additional papers were
added.
Using a sheet developed by the research team to standardise the
data extraction process, one researcher extracted details from the
selected papers: author(s), year of publication, country, record type,
research aim, study participants, methods, findings related to the
aim of the scoping review (descriptions, competences and factors
stimulating or hindering the development of rebel nurse leadership)
and conclusions. Another researcher checked the extractions. Then,
working together, all four researchers sorted the extracted data and
accompanying narratives into a form that reflec ts the aims of this
scoping review (see Table 1).
3.3  |  Quality appraisal
To evaluate the qualit y of the included papers and the degree of
evidence in a transparent and unbiased way, the research meth-
odology (see Appendix S2) involved using the Mixed Methods
Appraisal Tool (MMAT; Hong et al., 2018). However, quality as
such was not a criterion to exclude papers from the review. The
quality appraisal was conducted independently by two research-
ers (EdK and AW).
4 | RESULTS
The initial search strategy generated 2705 papers (Figure 1). After
removing duplicates and screening the titles and abstracts in the first
stage of screening, 66 papers were selected. In the second stage, all
66 papers were read in full, and following assessment, 21 papers
were agreed upon for inclusion. The references of these 21 papers
were reviewed, and four relevant papers were added. In total, 25
papers were analysed further. Table 1 presents the data from these
papers. Because of the wide variety of methodological approaches,
we present the content findings of our scoping review as narratives.
Below we discuss the three concepts (positive deviance, healthcare
rebels and tempered radicals) separately and show their similarities.
4.1  |  Descriptions of the concepts
In the 25 selected papers, ‘positive deviance’ was mentioned 23
times and ‘tempered radicals’ (Brandi & Naito, 2006) and ‘healthcare
rebel’ (Wallenburg et al., 2019) once each. Content analysis of the
various descriptions showed that three aspects are often mentioned
(Table 2).
Most of the studies identify positive deviant healthcare profes-
sionals, departments and/or organisations. Determining who the
positive deviants are is done by researchers (Gesser- Edelsburg et al.,
2018; Sheard et al., 2017), by colleagues (Gesser- Edelsburg et al.,
2018; Law ton et al., 2014; Marra et al., 2011) and performance fig-
ures; for example, hospitals that are within the top and bottom 5%
of Centers for Medicare and Medicaid services (Baxter et al., 2018,
2019; Chang et al., 2018; Létourneau et al., 2018). In the healthcare
rebe l stu dy, pe rfo rm anc e figur es and pu blic op in ion wer e us ed to se-
lect the healthcare organisation while colleagues selected the rebel
groups (Wallenburg et al., 2019). However, the methodolog y used
to assess or determine positive deviants, healthcare rebels and tem-
pered radicals by researchers and colleagues is seldom described.
Only the study by Wallenburg et al. (2019) mentioned interviews
with colleagues. Despite the unclear methodology, most papers de-
fine positive deviants, healthcare rebels, tempered radicals and their
competences.
4.1.1  |  Concept descriptions
Most of the papers (17/25) describe using positive deviance as a
method to initiate conscious and systematic (behavioural) change
in an organisation. The positive deviance method is based on the
assumption that in each community, individuals or groups can find
better solutions and achieve better results than their peers by ex-
ecuting unusual behaviour even though the circumstances and avail-
ability of materials and resources are the same for all (Ausserhofer
et al., 2016; Baxter et al., 2018; Bonuel et al., 2009; Bristol et al.,
2018; Clancy, 2010; de MacEdo et al., 2012; Gary, 2013; Gesser-
Edelsburg et al., 2018; Létourneau et al., 2018; Lindberg & Clancy,
2010; Lindberg & Schneider, 2013; Marra et al., 2011, 2013; Sheard
et al., 2017; Sreeramoju, 2019; Sreeramoju et al., 2018). These indi-
viduals or groups can be identified and pushed for ward, and organi-
sations can learn from their approaches (Baxter et al., 2018, 2019).
Wallenburg et al. (2019) use the term rebels to describe the same
deviant behaviour in healthcare professionals striving for the best
quality. Rebels (groups) consciously deviate to accomplish change
in organisations. Brandi and Naito (2006) complement this view by
noting that tempered radicals pursue changes that go against the
norms of dominant groups for bet ter results.
To achieve better result s under the same circumstances, pos-
itive deviants demonstrate behaviour and working methods that
de viate fr om the no rm (C lan c y, 2010; Cr ewe & Gi rar di, 20 20; Ga r y,
20 13; Lét o u r n e au et al., 201 8; L indb erg & S chnei der, 201 3; Melny k
& Davidson, 2009; Smith & Plunkett, 2019). The study on tem-
pered radicals also mentions this (Brandi & Naito, 20 06). The be-
haviour of deviating healthcare professionals is often described in
the literature as unconventional and non- confirmative behaviour
(Bonuel et al., 2009; Gar y, 2013; Gesser- Edelsburg et al., 2018;
Lindberg & Schneider, 2013; Melnyk & Davidson, 2009; Sheard
et al., 2017; Wallenburg et al., 2019). The study by Bristol et al.
(2018) shows, for example, that nurses display positive abnormal
behaviour when faced by system requirements of an electronic
patient record that do not meet the needs of the patient. Nurses
  
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KOK et al.
make various ‘workarounds’ to meet their patient's needs and do
not comply with the restrictions of the electronic patient record
(Bristol et al., 2018).
The literature on both positive deviants and healthcare rebels
describes the relevance of social networks and personal relation-
ships in and outside the organisation (Bristol et al., 2018; Crewe &
Girardi, 2020; Gary, 2013; Gesser- Edelsburg et al., 2018; Lawton
et al., 2014; Létourneau et al., 2018; Lindberg & Clancy, 2010;
Lindberg & Schneider, 2013; Sheard et al., 2017; Wallenburg et al.,
2019). These networks and relationships spread successful prac-
tices, allowing nurses to share strategies and ideas (Bonuel et al.,
2009; Gar y, 2013; Létourneau et al., 2018; Lindberg & Clancy, 2010;
Marra et al., 2013). Positive deviants and healthcare rebels often
serve as influential role models who can exert peer pressure in these
networks (Clancy, 2010; Gary, 2013; Marra et al., 2011; Sreeramoju,
2019; Sreeramoju et al., 2018).
4.1.2  |  Competences
Of the 25 papers, 15 describe the competences of healthcare re-
bels, positive deviants or tempered radicals (Table 1). The most
frequently mentioned competence is the ability to collaborate and
network (12/25 papers; Table 2; Baxter et al., 2018; Bristol et al.,
2018; Clancy, 2010; Crewe & Girardi, 2020; Gary, 2013; Lawton
et al., 2014; Lindberg & Clancy, 2010; Lindberg & Schneider, 2013;
Marra et al., 2011, 2013; Sheard et al., 2017; Wallenburg et al.,
2019). Deviating healthcare professionals collaborate with peers
(i.e. nurse colleagues in the same position), colleagues from di-
verse disciplines or in management positions (Crewe & Girardi,
2020; Lindberg & Clancy, 2010; Sheard et al., 2017; Wallenburg
et al., 2019) and colleagues from other depar tments and even
other organisations (Bristol et al., 2018; Clancy, 2010; Lindberg
& Schneider, 2013; Wallenburg et al., 2019). Deviating healthcare
professionals know who to approach in their large network when
help is needed (Wallenburg et al., 2019). Also mentioned are the
competences to connect people and encourage others to take
ownership of a problem (Clancy, 2010; Gar y, 2013; Lawton et al.,
2014; Marra et al., 2011; Sheard et al., 2017).
Other competences include using expert knowledge, scientific
evidence, to improve care. Healthcare professionals who deviate
actively seek evidence and spread this information. Therefore, col-
leagues regard them as experts and valuable, reliable sources of in-
formation (Bristol et al., 2018; Clancy, 2010; Gary, 2013; Marra et al.,
2013; Wallenburg et al., 2019). If positive deviants want to convince
others, they use collected data or scientific evidence (Baxter et al.,
2018; Marra et al., 2011; Sheard et al., 2017).
Healthcare rebels characteristically have the courage to chal-
lenge the status quo (Wallenburg et al., 2019). Marra et al. (2013)
describe this as an ability to reflect on working habits, organisational
logistics and problems in daily care and generate ideas to improve
care. Deviating healthcare professionals are determined to improve
(Gary, 2013; Sheard et al., 2017) and dare to stretch the boundaries
by for example breaking the rules (Gary, 2013). Wallenburg et al.
(2019) describe how they make trade- offs between short- term im-
provements by breaking the rules and disobeying regulations while
trying to achieve a more structural solution so that deviance is no
longer needed.
The solutions to complex problems are often sold as elegant
and efficient (Bristol et al., 2018). According to Gary (2013) and
Wallenburg et al. (2019), deviating from the norm or breaking the
rules is always done in the interests of the patient and the aim is to
find better ways to get things done with the same or fewer resources
(Jaramillo et al., 2008; Marra et al., 2013). Despite their deviant be-
haviour, rebels are committed to the mission and goals of the organ-
isation and want to provide the best care (Gary, 2013).
Research shows nurses do not always see themselves as a pos-
itive deviant, healthcare rebel and or tempered radical (Lindberg &
Schneider, 2013). Sometimes, in talking about their work and what
they do, they discover that they are deviant or rebellious. Thus, this
kind of leadership is of ten unconscious and unintentional (Lindberg
& Schneider, 2013).
In summary, based on the descriptions and competences de-
scribed above, rebel nurse leaders can be characterised as networkers
who collaborate with their peers, other disciplines and management
in and outside the organisation, using both formal and informal con-
versations. They are seen as experts based on their (evidence- based)
knowledge. Their courage and competence in reflection help them to
challenge the current status quo, deviating from the rules and regula-
tions to achieve their goal of (solving problems which) improve daily
care in both the short and longer term.
4.2  |  Factors stimulating and hindering the
development of rebel nurse leadership
The included papers were also screened for factors that stimulate
or hinder the development of rebel nurse leadership. 22 of the 25
papers describe three important factors (Table 2).
4.2.1  |  Dialogue and reflection
In the posi ti ve devian ce literature, de vi an ce is stimulate d by organis-
ing and conducting planned conversations such as meetings (Crewe
& Girardi, 2020; de MacEdo et al., 2012; Létourneau et al., 2018;
Lindberg & Schneider, 2013; Marra et al., 2011, 2013; Sreeramoju
et al., 2018), structured reflective dialogue, and informal and spon-
taneous conversations (Sreeramoju, 2019). An example mentioned
in the literature of a planned conversation is a Discover y and Action
Dialogues (DAD; Lindberg & Schneider, 2013). DAD are small-
grouped facilitated conversations with healthcare professionals
from different professional backgrounds to identify positive devi-
ant practices on a specific topic. The aim of these DAD is to reveal
positive deviance actions and to discuss the obstacles for broader
implementation.
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TABLE 1 Key competences of included papers
Title paper, author (s), year Country Research aim Study participants Methods Description Competences
Stimulating/
hindering
factors Study conclusions
1Combating infec tions at Maine
Medical Center: Insight s into
complexity- informed leadership
from positive deviance (Lindberg
& Schneider, 2013)
USA To study organisational change
process k nown as positive
deviance (PD) which sheds
light on leadership in a complex
organisational context
N = 3 pilot inpatient nursing units
(oncolog y, nephrology and dialysis
service) at Maine Medical Center in
Portland, and a tertiary care centre
for northern New England
Exploratory case study
Open- ended, reflexive
observation and a
grounded theory
approach
X X X Non- managerial employees now have a louder and stronger
voice and management does listen to them. But there is an
underlying acceptance that while managers might not dominate
the conversation as much as they did in the past, their words
might matter more than those who have only recently found
their voice. All have a voice, but all voices are not equal
2Beyond the hospit al infec tion
control guidelines: A qualitative
study using positive deviance
to characterize gray areas and
to achieve ef ficacy and clarity
in the prevention of healthc are-
associated infections (Gesser-
Edelsburg et al., 2018)
Israel To study the gray areas in the
care continuum in ICUs where
systematic guidelines are
adhered to only partially by
the staff, and where there are
no prac tices of PD individuals
that address these gray areas as
reported by the staff
N = 82 participant s at Hadassah Hospital
from the GICU and MICU (N = 47
nurses , N = 14 physicians, N = 5
nursing aides, N = 5 nursing students,
N = 2 social workers, N = 2 physical
therapists, N = 1 respiratory technician,
N = 2 secretaries, N = 1 national service
volunteer, N = 3 cleaning s taff
Qualitative constructivist
research method.
Interviews, observations
and video recordings
of identif ied positive
behavioural practices
X X X The study characterised the gray areas in the care continuum
identif ied by staff, where solutions were found through PD
practices. Instead of investing in producing additional, specific
guidelines for different situations and developing training
programmes to implement them, it is impor tant to encourage
hospital personnel to create their own solutions for different
situations on the c are continuum, and to disseminate them in
the unit s to achieve a bottom- to- top change
3Methicillin- resistant Staphylococcus
aureus (MRSA) prevention
through facility- wide culture
change (Bonuel et al., 2009)
USA To study one hospital's fight
against methicillin- resistant
Staphylococcus aureus by
implementing a facility- wide
program aimed at changing
and standardizing the hospital
culture
N.A. N.A. X X 1 year after implementing our best practices and the MRSA
bundle in all our 15- inpatient nursing units, we have 4 months
of zero healthcare- acquired MRSA infe ction in all 3 intensive
care units (36 beds). We reduced our MRSA- positive culture
from a mean of 30 in 2005– 2006 to a mean of 21 in 2007–
2008 . The Joint Commission has recognised our institution for
best practices in infection prevention
4Nurses’ Use of Positive Deviance
When Encountering Electronic
Health Re cords- Related
Unintended Consequences
(Bristol et al., 2018)
USA To study nurses’ experiences with
the unintended consequences
of using an Electronic Health
Record (EHR )
N = 144 nurses working for various
healthcare organisations
Qualitative descriptive
methods. Survey with
quantitative questions
and 5 open- ended
qualitative questions
X X X Nurses’ experiences with EHR sys tems offer insight into an
organisation's shift toward Resilience Engineering (RE). The
ability to recognise the unique needs of nurses during design
and implementation of an EHR system may support bet ter
resilience in nurses. EHR enhancements based on the result s
of this research could facilitate better patient care through
improved nursing use of the EHR and improved patient safety
applications
5Positive deviance and hand hygiene
of nurses in a Quebec hospit al:
What can we learn from the
best? (Létourneau et al., 2018)
USA To study PD at the level of a care
team, to shed light on d ynamics
within the group
N = 21 nurses (N = 6 medical- surger y
unit) (N = 15 palliative care unit) at a
Montreal university hospital
Focused ethnogr aphy
design. Systematic
observations, individual
interviews, field
notes, and informal
conversations
X X It can be useful to apply the positive deviance approach to
healthcare teams rather than individuals to bet ter understand
the ideologic and structural differences linked to bet ter hand-
hygiene performance by nurses
6How is success achieved by
individuals innovating for patient
safety and quality in the NHS?
(Sheard et al., 2017)
UK To study how individuals working in
the NHS manage to implement
innovations that benefit patient
safety
N = 15 Health S ervices Journal (HSJ)
innovators (selected from the awards
list of 2014 and 2013 working in the
area of patient safety and quality in the
NHS)
Explorator y qualit ative
research design
Semi- structured in- depth
interviews
X X X Main fac tors: i) personal deter mination of individuals, including
their ability to challenge the status quo, ii) their c apacity
to connec t people and teams and encourage collaborative
working , iii) the ways in which some innovators used
organisational culture to their advantage and iv) using
evidence to influence other s. While innovation in health
care seems hard to achieve, we have uncovered several key
aspects which we believe may lead to successful innovation by
individuals working in the NHS
7Positive deviance: a program for
sustained improvement in hand-
hygiene compliance (Marra et al.,
2011)
Brazil To study the sustainability of a
PD strategy for improving
hand- hygiene compliance in
two similar adult s tepdown
units (SDUs) using electronic
handwashing counters
All healthcare workers of two 20- bed adult
SDUs with the same physical layout
Observational study X X X Based on our findings, PD can be considered an intervention
to sustain improved hand- hygiene compliance and can be
associated with a de creased incidence of device- associated
hospital acquired infec tions
8Improving the safety and quality
of nursing care through
standardized operating
procedures in Bosnia and
Herzegovina (Ausserhofer et al.,
2016)
Bosnia and
Herzego-
vina
To study if a consistent
approach/model was used
for development, adaptation,
implementation, monitoring and
evaluation of nursing standard
operating procedures (SOPs)
N = 4 healthcare facilities: N = 1 hospital
and N = 1 primary healthcare centre in
Republic of Srpska, and N = 1 hospital
and N = 1 primary healthcare centre in
Fed. of Bosnia and Herzegovina
Multiple- case study design,
that is an in- depth
empirical inquiry
X X The cer tification/accreditation process is enabling necessary
changes in institutions’ organis ational cultures, empowering
nurses to take on advanced roles in improving the safet y and
qualit y of nursing care
(Continues)
  
|
 7
KOK et al.
TABLE 1 Key competences of included papers
Title paper, author (s), year Country Research aim Study participants Methods Description Competences
Stimulating/
hindering
factors Study conclusions
1Combating infec tions at Maine
Medical Center: Insight s into
complexity- informed leadership
from positive deviance (Lindberg
& Schneider, 2013)
USA To study organisational change
process k nown as positive
deviance (PD) which sheds
light on leadership in a complex
organisational context
N = 3 pilot inpatient nursing units
(oncolog y, nephrology and dialysis
service) at Maine Medical Center in
Portland, and a tertiary care centre
for northern New England
Exploratory case study
Open- ended, reflexive
observation and a
grounded theory
approach
X X X Non- managerial employees now have a louder and stronger
voice and management does listen to them. But there is an
underlying acceptance that while managers might not dominate
the conversation as much as they did in the past, their words
might matter more than those who have only recently found
their voice. All have a voice, but all voices are not equal
2Beyond the hospit al infec tion
control guidelines: A qualitative
study using positive deviance
to characterize gray areas and
to achieve ef ficacy and clarity
in the prevention of healthc are-
associated infections (Gesser-
Edelsburg et al., 2018)
Israel To study the gray areas in the
care continuum in ICUs where
systematic guidelines are
adhered to only partially by
the staff, and where there are
no prac tices of PD individuals
that address these gray areas as
reported by the staff
N = 82 participant s at Hadassah Hospital
from the GICU and MICU (N = 47
nurses , N = 14 physicians, N = 5
nursing aides, N = 5 nursing students,
N = 2 social workers, N = 2 physical
therapists, N = 1 respiratory technician,
N = 2 secretaries, N = 1 national service
volunteer, N = 3 cleaning s taff
Qualitative constructivist
research method.
Interviews, observations
and video recordings
of identif ied positive
behavioural practices
X X X The study characterised the gray areas in the care continuum
identif ied by staff, where solutions were found through PD
practices. Instead of investing in producing additional, specific
guidelines for different situations and developing training
programmes to implement them, it is impor tant to encourage
hospital personnel to create their own solutions for different
situations on the c are continuum, and to disseminate them in
the unit s to achieve a bottom- to- top change
3Methicillin- resistant Staphylococcus
aureus (MRSA) prevention
through facility- wide culture
change (Bonuel et al., 2009)
USA To study one hospital's fight
against methicillin- resistant
Staphylococcus aureus by
implementing a facility- wide
program aimed at changing
and standardizing the hospital
culture
N.A. N.A. X X 1 year after implementing our best practices and the MRSA
bundle in all our 15- inpatient nursing units, we have 4 months
of zero healthcare- acquired MRSA infe ction in all 3 intensive
care units (36 beds). We reduced our MRSA- positive culture
from a mean of 30 in 2005– 2006 to a mean of 21 in 2007–
2008 . The Joint Commission has recognised our institution for
best practices in infection prevention
4Nurses’ Use of Positive Deviance
When Encountering Electronic
Health Re cords- Related
Unintended Consequences
(Bristol et al., 2018)
USA To study nurses’ experiences with
the unintended consequences
of using an Electronic Health
Record (EHR )
N = 144 nurses working for various
healthcare organisations
Qualitative descriptive
methods. Survey with
quantitative questions
and 5 open- ended
qualitative questions
X X X Nurses’ experiences with EHR sys tems offer insight into an
organisation's shift toward Resilience Engineering (RE). The
ability to recognise the unique needs of nurses during design
and implementation of an EHR system may support bet ter
resilience in nurses. EHR enhancements based on the result s
of this research could facilitate better patient care through
improved nursing use of the EHR and improved patient safety
applications
5Positive deviance and hand hygiene
of nurses in a Quebec hospit al:
What can we learn from the
best? (Létourneau et al., 2018)
USA To study PD at the level of a care
team, to shed light on d ynamics
within the group
N = 21 nurses (N = 6 medical- surger y
unit) (N = 15 palliative care unit) at a
Montreal university hospital
Focused ethnogr aphy
design. Systematic
observations, individual
interviews, field
notes, and informal
conversations
X X It can be useful to apply the positive deviance approach to
healthcare teams rather than individuals to bet ter understand
the ideologic and structural differences linked to bet ter hand-
hygiene performance by nurses
6How is success achieved by
individuals innovating for patient
safety and quality in the NHS?
(Sheard et al., 2017)
UK To study how individuals working in
the NHS manage to implement
innovations that benefit patient
safety
N = 15 Health S ervices Journal (HSJ)
innovators (selected from the awards
list of 2014 and 2013 working in the
area of patient safety and quality in the
NHS)
Explorator y qualit ative
research design
Semi- structured in- depth
interviews
X X X Main fac tors: i) personal deter mination of individuals, including
their ability to challenge the status quo, ii) their c apacity
to connec t people and teams and encourage collaborative
working , iii) the ways in which some innovators used
organisational culture to their advantage and iv) using
evidence to influence other s. While innovation in health
care seems hard to achieve, we have uncovered several key
aspects which we believe may lead to successful innovation by
individuals working in the NHS
7Positive deviance: a program for
sustained improvement in hand-
hygiene compliance (Marra et al.,
2011)
Brazil To study the sustainability of a
PD strategy for improving
hand- hygiene compliance in
two similar adult s tepdown
units (SDUs) using electronic
handwashing counters
All healthcare workers of two 20- bed adult
SDUs with the same physical layout
Observational study X X X Based on our findings, PD can be considered an intervention
to sustain improved hand- hygiene compliance and can be
associated with a de creased incidence of device- associated
hospital acquired infec tions
8Improving the safety and quality
of nursing care through
standardized operating
procedures in Bosnia and
Herzegovina (Ausserhofer et al.,
2016)
Bosnia and
Herzego-
vina
To study if a consistent
approach/model was used
for development, adaptation,
implementation, monitoring and
evaluation of nursing standard
operating procedures (SOPs)
N = 4 healthcare facilities: N = 1 hospital
and N = 1 primary healthcare centre in
Republic of Srpska, and N = 1 hospital
and N = 1 primary healthcare centre in
Fed. of Bosnia and Herzegovina
Multiple- case study design,
that is an in- depth
empirical inquiry
X X The cer tification/accreditation process is enabling necessary
changes in institutions’ organis ational cultures, empowering
nurses to take on advanced roles in improving the safet y and
qualit y of nursing care
(Continues)
8 
|
   KOK et al.
Title paper, author (s), year Country Research aim Study participants Methods Description Competences
Stimulating/
hindering
factors Study conclusions
9 Positive deviance: Using a nurse call
system to evaluate hand- hygiene
practices (de MacEdo et al.,
2012)
Brazil To study the application of PD in
2 stepdown units (SDUs) and
evaluate the adherence of nursing
staff to hand- hygiene practices
based on the ratio bet ween the
number of uses of alcohol- based
hand rub and the number of
nurse visits to patient rooms
N = 2 SDUs in Alb ert Einstein Hospital in
São Paulo, Brazil. East SDU is a 22- bed
unit for patients with mixed clinical
conditions; west SDU is a 22- bed
unit for patients with cardiovascular
conditions
Quasi- experiment al study X X The PD approach to hand hygiene produced positive results
in terms of compliance to this practice, with increased
consumption of alcohol hand r ubs, improved ratio of alcohol
rub use to nurse visits to patient rooms in the eas t SDU, and
a>2 ratio in both the east and west SDUs. Using this approach
led to a reduction in the rate of device- related infections in
both unit s, with sustained results over 2 years
10 Hospital Strategies for Reducing
Emergency Department
Crowding: A Mixed- Methods
Study (Chang et al., 2018)
USA To study strategies among high-
performing, low- performing and
high per formance- improving
hospitals to reduce ED crowding,
using a PD met hodology
2619 hospitals that reported both ED length
of stay and boarding time metrics to
CMS Hospital Compare in 2012
Interviews, N = 60 staff members,
including hospital executives, ED chairs
and directors, nurse managers, and
hospitalists
Mixed- methods
comparative case study
XOrganisational characteristics are associated with ED decreased
length of stay. Specific interventions targeted to reduce ED
crowding were more likely to be successfully executed at
hospitals with these characteristics. These organisational
domains represent identifiable and actionable changes that
other hospitals may incorporate to build awareness of ED
crowding
11 Creating a culture of innovation
in nursing education through
shared vision, leadership,
interdisciplinary partnerships,
and positive deviance (Melnyk &
Davidson , 2009)
USA To study barriers and facilitators to
innovation in colleges of nursing
and healthcare professions
along wit h recommendations for
creating a culture of innovation
in these academic settings
N.A. N.A. X X A shared vision for innovation by faculty and staff in colleges of
nursing and health sciences is essential to drive innovative
cultures, progr ammes and initiatives. Aligning the vision to
measurable goals and outcomes, role modelling innovation,
facilit ating interdisciplinar y collaboration and encouraging
positive deviance and risk taking are key ingredients for
success. Cultures take time to change. Patience and persis tence
in working through ‘character- building’ times are needed to
achieve the outcomes established as part of the vision
12 Hospital nurse adminis trators in
Japan: a feminist dimensional
analysis (Brandi & Naito, 20 06)
Japan To study key findings from a
qualitative study that explored
the views of 16 Japanese senior
nurse administrators in hospit als
to learn what was happening in
their working situations and how
they were managing
N = 16 female participants, including N = 1
nursing vice president, N = 14 nursing
directors and N = 1 assistant direc tor,
from middle or large- sized hospitals.
Hospital types: private (N = 11), public
(N = 5), general (N = 14), specialty
(N = 2) and university (N = 4)
Dimensional analysis
strategies for data
collection and analysis.
Semi- structured
interviews
X X Nursing administration as a recognised specialty must rapidly
develop to bring nur sing and midwifery to the forefront of
international healthc are delivery. Nurse administrators are
in a position to challenge tradition, but they need advanced
education, mentorship and the suppor t of their organis ations
to enact a role that meets today's goals of patient- centred care
13 A qualitative positive deviance study
to explore exceptionally safe
care on me dical wards for older
people (Baxter et al., 2019)
UK To study how multidisciplinar y
teams deliver exceptionally safe
care on me dical wards for older
people (i.e. per form best on a
broad safety outcome)
N = 70 multidisciplinary staff from 8
medical wards for older people
clustered in 13 NHS Trust s in the
Yorkshire and the Humber region of
England
Qualitative PD study. Focus
groups and brief field
notes
X X X There are no ‘silver bullets’ to achieving exceptionally s afe patient
care on me dical wards for older people. Healthcare leaders
should encourage truly integrated multidisciplinary ward
teams where staf f know each other and work well together.
Focusing on underpinning charac teristics may f acilit ate
exceptional per formances across a range of s afety outcomes
14 Reducing Infections ‘Together’:
A review of Socioadaptive
Approaches (Sreeramoju, 2019)
N.A. To study modern- day physicians and
physicians in training expected
to participate in interventions
to reduce hospital acquired
infections and for those who
serve as physician champions or
lead these initiatives, to gain an
understanding of socioadaptive
approaches that help reduce
these infections
N.A. N.A. X X Socioadaptive interventions are necessary additions to technical
interventions in an overall multicomponent strategy to reduce
healthcare- associated infections. Assessment of local social
and cultural context and needs is key to choosing t he right
socioadaptive approach for any improvement initiative
15 People, systems and safety:
resilience and excellence in
healthcare practice (Smith &
Plunkett, 2019)
N.A. To study the evolution of safety
science, describing historical
approaches, comparing them
with recent concepts in safety,
and describing how they affect
staff working in the healthcare
system
N.A. N.A. X X The unspoken expectation is that healthcare practitioners should
under take three roles: 1) to take on the clinic al function for
which they are engaged, whatever that might be; 2) to not
only maintain and enhance patient safety in their own work
but also by intervening when needed in their organis ational
systems; and 3) to seek out opportunities for improving quality
and make sure that positive changes are made
TABLE 1 (Continued)
(Continues)
  
|
 9
KOK et al.
Title paper, author (s), year Country Research aim Study participants Methods Description Competences
Stimulating/
hindering
factors Study conclusions
9 Positive deviance: Using a nurse call
system to evaluate hand- hygiene
practices (de MacEdo et al.,
2012)
Brazil To study the application of PD in
2 stepdown units (SDUs) and
evaluate the adherence of nursing
staff to hand- hygiene practices
based on the ratio bet ween the
number of uses of alcohol- based
hand rub and the number of
nurse visits to patient rooms
N = 2 SDUs in Alb ert Einstein Hospital in
São Paulo, Brazil. East SDU is a 22- bed
unit for patients with mixed clinical
conditions; west SDU is a 22- bed
unit for patients with cardiovascular
conditions
Quasi- experiment al study X X The PD approach to hand hygiene produced positive results
in terms of compliance to this practice, with increased
consumption of alcohol hand r ubs, improved ratio of alcohol
rub use to nurse visits to patient rooms in the eas t SDU, and
a>2 ratio in both the east and west SDUs. Using this approach
led to a reduction in the rate of device- related infections in
both unit s, with sustained results over 2 years
10 Hospital Strategies for Reducing
Emergency Department
Crowding: A Mixed- Methods
Study (Chang et al., 2018)
USA To study strategies among high-
performing, low- performing and
high per formance- improving
hospitals to reduce ED crowding,
using a PD met hodology
2619 hospitals that reported both ED length
of stay and boarding time metrics to
CMS Hospital Compare in 2012
Interviews, N = 60 staff members,
including hospital executives, ED chairs
and directors, nurse managers, and
hospitalists
Mixed- methods
comparative case study
XOrganisational characteristics are associated with ED decreased
length of stay. Specific interventions targeted to reduce ED
crowding were more likely to be successfully executed at
hospitals with these characteristics. These organisational
domains represent identifiable and actionable changes that
other hospitals may incorporate to build awareness of ED
crowding
11 Creating a culture of innovation
in nursing education through
shared vision, leadership,
interdisciplinary partnerships,
and positive deviance (Melnyk &
Davidson , 2009)
USA To study barriers and facilitators to
innovation in colleges of nursing
and healthcare professions
along wit h recommendations for
creating a culture of innovation
in these academic settings
N.A. N.A. X X A shared vision for innovation by faculty and staff in colleges of
nursing and health sciences is essential to drive innovative
cultures, progr ammes and initiatives. Aligning the vision to
measurable goals and outcomes, role modelling innovation,
facilit ating interdisciplinar y collaboration and encouraging
positive deviance and risk taking are key ingredients for
success. Cultures take time to change. Patience and persis tence
in working through ‘character- building’ times are needed to
achieve the outcomes established as part of the vision
12 Hospital nurse adminis trators in
Japan: a feminist dimensional
analysis (Brandi & Naito, 20 06)
Japan To study key findings from a
qualitative study that explored
the views of 16 Japanese senior
nurse administrators in hospit als
to learn what was happening in
their working situations and how
they were managing
N = 16 female participants, including N = 1
nursing vice president, N = 14 nursing
directors and N = 1 assistant direc tor,
from middle or large- sized hospitals.
Hospital types: private (N = 11), public
(N = 5), general (N = 14), specialty
(N = 2) and university (N = 4)
Dimensional analysis
strategies for data
collection and analysis.
Semi- structured
interviews
X X Nursing administration as a recognised specialty must rapidly
develop to bring nur sing and midwifery to the forefront of
international healthc are delivery. Nurse administrators are
in a position to challenge tradition, but they need advanced
education, mentorship and the suppor t of their organis ations
to enact a role that meets today's goals of patient- centred care
13 A qualitative positive deviance study
to explore exceptionally safe
care on me dical wards for older
people (Baxter et al., 2019)
UK To study how multidisciplinar y
teams deliver exceptionally safe
care on me dical wards for older
people (i.e. per form best on a
broad safety outcome)
N = 70 multidisciplinary staff from 8
medical wards for older people
clustered in 13 NHS Trust s in the
Yorkshire and the Humber region of
England
Qualitative PD study. Focus
groups and brief field
notes
X X X There are no ‘silver bullets’ to achieving exceptionally s afe patient
care on me dical wards for older people. Healthcare leaders
should encourage truly integrated multidisciplinary ward
teams where staf f know each other and work well together.
Focusing on underpinning charac teristics may f acilit ate
exceptional per formances across a range of s afety outcomes
14 Reducing Infections ‘Together’:
A review of Socioadaptive
Approaches (Sreeramoju, 2019)
N.A. To study modern- day physicians and
physicians in training expected
to participate in interventions
to reduce hospital acquired
infections and for those who
serve as physician champions or
lead these initiatives, to gain an
understanding of socioadaptive
approaches that help reduce
these infections
N.A. N.A. X X Socioadaptive interventions are necessary additions to technical
interventions in an overall multicomponent strategy to reduce
healthcare- associated infections. Assessment of local social
and cultural context and needs is key to choosing t he right
socioadaptive approach for any improvement initiative
15 People, systems and safety:
resilience and excellence in
healthcare practice (Smith &
Plunkett, 2019)
N.A. To study the evolution of safety
science, describing historical
approaches, comparing them
with recent concepts in safety,
and describing how they affect
staff working in the healthcare
system
N.A. N.A. X X The unspoken expectation is that healthcare practitioners should
under take three roles: 1) to take on the clinic al function for
which they are engaged, whatever that might be; 2) to not
only maintain and enhance patient safety in their own work
but also by intervening when needed in their organis ational
systems; and 3) to seek out opportunities for improving quality
and make sure that positive changes are made
TABLE 1 (Continued)
(Continues)
10 
|
   KOK et al.
Title paper, author (s), year Country Research aim Study participants Methods Description Competences
Stimulating/
hindering
factors Study conclusions
16 Using a Positive Deviance Approach
to Influence the Culture of
Patient Safety Related to
Infection Prevention (Sreeramoju
et al., 2018)
USA To study the impact of PD on the
patient safety culture related
to infection prevention among
healthcare personnel
N = 6 wards in Parkland Memorial Hospital,
an academic medical centre in Dallas.
All nurses, patient care technicians,
ward managers, and clerk s and all
patient s receiving care in the study
wards were included
Observational prospective
study with a
retrospective baseline
period. Outcome of
PD intervention was
measured with the
hospital survey of
patient safety climate,
adapted to infection
prevention
X X A positive deviance approach appeared to have a significant
impact on patient safety culture among healthcare personnel
who received the intervention. Social net work analysis
identif ied healthcare personnel who are likely to help
disseminate infec tion prevention information. System- wide
interventions independent of PD resulted in hospital acquired
infections reduction in both intervention and control wards
17 Identifying positively deviant
elderly medical wards using
routinely collected NHS
Safety T hermometer data: an
observational study (Baxter
et al., 2018)
UK To study a pragmatic method for
identifying positively deviant
wards using a routinely
collected, broad measure of
patient safety
Phase 1: N = 34 elderly medical wards
clustered in N = 13 NHS Trust s in the
northern region of England, UK
Phase 2: Multidisciplinary staff (N = 161)
and patients (N = 188) clustered
in N = 9 positively deviant and
comparison wards
Two- phased observational
study. Phase 1,
cross- sectional and
temporal analyses of
Safety T hermometer
data. Phase 2,
multidisciplinary staff
and patient surveys
X X X A distinct group of positively deviant wards that per form
exceptionally well on a routinely collected, broad measure of
safety can be identified using a robust yet pragmatic method.
Staff and patient perceptions of safety mainly support their
identif ication. The study highlights the challenges f aced when
selecting a source of routinely collected data that provides a
valid and reliable measure at the appropriate level in order to
facilit ate per formance comparisons across wards or units in
several organisations
18 Positive Deviance: A New Tool for
Infection Prevention and Patient
Safety (Marra et al., 2013)
N.A N.A. N.A. N.A. X X X The PD approach is par ticularly appropriate in situations where
organisations c an track the results with valid performance
measures and where there is substantial natural variation in
performance. This creates a good environment for discussion
of practices and interventions to achieve improvements in
patient safety
19 Exploring the concept and use of
positive deviance in nursing
(Gary, 2013)
N.A. To study the essence of PD in the
nursing practice environment,
using the Walker and Avant
procedure for concept analysis
N.A. Concept analysis of positive
deviance
X X X The goal was to provide an operational definition for the concept
of positive deviance in nursing practice, which can offer nurse s
a basis for de cision- making when the normal or expected
actions in a given situation collide with the nurse's view of
the right thing to do. A s nurses become more autonomous
providers of primary healthcare ser vices, the use of positive
deviance must become a goal
20 Positive deviance: An elegant
solution to a complex problem
(Lindberg & Clancy, 2010)
USA To study one example of how
concept s taken from complex
systems theor y can be applied
to real- world problems facing
nurses today
N.A. N.A. X X
21 Diamonds in the rough: positive
deviance and complexity (Clancy,
2010)
N.A. To study the idea of PD and how
it can be applied in developing
elegant solutions to complex
problems
N.A. N.A. X X
22 Positive deviance: a different
approach to achieving patient
safety (Lawton et al., 2014)
N.A. N.A. N.A. N.A. X X A myopic focus on errors, harm and near misses has long
been sen ding negative messages. Politicians, bureaucr ats,
managers, the media and those leading enquiries as far back
as Bristol Royal Infirmar y and earlier, and more recently
Mid- Staffordshire, have essentially indicated to clinicians: you
are prone to making mistakes, and we must insist that you
reduce the harm or potential harm you cause. If you do not,
we will regulate your activities, tightening the rules over time.
While no one would argue against the need to identify those
people and organisations whose performance is consistently
or deliberately negatively deviant, there is a clear obligation to
recognise that health care is delivered in complex, uncert ain
settings, and although clinicians are time- pressured and
resource- constrained, things go right ver y often, even in times
of austerity
TABLE 1 (Continued)
(Continues)
  
|
  11
KOK et al.
Title paper, author (s), year Country Research aim Study participants Methods Description Competences
Stimulating/
hindering
factors Study conclusions
16 Using a Positive Deviance Approach
to Influence the Culture of
Patient Safety Related to
Infection Prevention (Sreeramoju
et al., 2018)
USA To study the impact of PD on the
patient safety culture related
to infection prevention among
healthcare personnel
N = 6 wards in Parkland Memorial Hospital,
an academic medical centre in Dallas.
All nurses, patient care technicians,
ward managers, and clerk s and all
patient s receiving care in the study
wards were included
Observational prospective
study with a
retrospective baseline
period. Outcome of
PD intervention was
measured with the
hospital survey of
patient safety climate,
adapted to infection
prevention
X X A positive deviance approach appeared to have a significant
impact on patient safety culture among healthcare personnel
who received the intervention. Social net work analysis
identif ied healthcare personnel who are likely to help
disseminate infec tion prevention information. System- wide
interventions independent of PD resulted in hospital acquired
infections reduction in both intervention and control wards
17 Identifying positively deviant
elderly medical wards using
routinely collected NHS
Safety T hermometer data: an
observational study (Baxter
et al., 2018)
UK To study a pragmatic method for
identifying positively deviant
wards using a routinely
collected, broad measure of
patient safety
Phase 1: N = 34 elderly medical wards
clustered in N = 13 NHS Trust s in the
northern region of England, UK
Phase 2: Multidisciplinary staff (N = 161)
and patients (N = 188) clustered
in N = 9 positively deviant and
comparison wards
Two- phased observational
study. Phase 1,
cross- sectional and
temporal analyses of
Safety T hermometer
data. Phase 2,
multidisciplinary staff
and patient surveys
X X X A distinct group of positively deviant wards that per form
exceptionally well on a routinely collected, broad measure of
safety can be identified using a robust yet pragmatic method.
Staff and patient perceptions of safety mainly support their
identif ication. The study highlights the challenges f aced when
selecting a source of routinely collected data that provides a
valid and reliable measure at the appropriate level in order to
facilit ate per formance comparisons across wards or units in
several organisations
18 Positive Deviance: A New Tool for
Infection Prevention and Patient
Safety (Marra et al., 2013)
N.A N.A. N.A. N.A. X X X The PD approach is par ticularly appropriate in situations where
organisations c an track the results with valid performance
measures and where there is substantial natural variation in
performance. This creates a good environment for discussion
of practices and interventions to achieve improvements in
patient safety
19 Exploring the concept and use of
positive deviance in nursing
(Gary, 2013)
N.A. To study the essence of PD in the
nursing practice environment,
using the Walker and Avant
procedure for concept analysis
N.A. Concept analysis of positive
deviance
X X X The goal was to provide an operational definition for the concept
of positive deviance in nursing practice, which can offer nurse s
a basis for de cision- making when the normal or expected
actions in a given situation collide with the nurse's view of
the right thing to do. A s nurses become more autonomous
providers of primary healthcare ser vices, the use of positive
deviance must become a goal
20 Positive deviance: An elegant
solution to a complex problem
(Lindberg & Clancy, 2010)
USA To study one example of how
concept s taken from complex
systems theor y can be applied
to real- world problems facing
nurses today
N.A. N.A. X X
21 Diamonds in the rough: positive
deviance and complexity (Clancy,
2010)
N.A. To study the idea of PD and how
it can be applied in developing
elegant solutions to complex
problems
N.A. N.A. X X
22 Positive deviance: a different
approach to achieving patient
safety (Lawton et al., 2014)
N.A. N.A. N.A. N.A. X X A myopic focus on errors, harm and near misses has long
been sen ding negative messages. Politicians, bureaucr ats,
managers, the media and those leading enquiries as far back
as Bristol Royal Infirmar y and earlier, and more recently
Mid- Staffordshire, have essentially indicated to clinicians: you
are prone to making mistakes, and we must insist that you
reduce the harm or potential harm you cause. If you do not,
we will regulate your activities, tightening the rules over time.
While no one would argue against the need to identify those
people and organisations whose performance is consistently
or deliberately negatively deviant, there is a clear obligation to
recognise that health care is delivered in complex, uncert ain
settings, and although clinicians are time- pressured and
resource- constrained, things go right ver y often, even in times
of austerity
(Continues)
12 
|
   KOK et al.
Sharing experiences with professionals from different back-
grounds support personal relationships and understanding and re-
spect for one another, resulting in improved collaboration (Baxter
et al., 2018; Lindberg & Schneider, 2013). Wallenburg et al. (2019)
found that in planned conversations, healthcare rebels reveal their
normativity and the normative work involved in what they con-
sider is ‘good’ care and how it should be organised. Papers mention
that professionals feel heard in conversations, with an openness
encourages them to talk about the problems they encounter and
share new insight s and solutions to improve the quality of care
(Lindberg & Schneider, 2013; Melnyk & Davidson, 2009). Research
by Sreeramoju et al. (2018) adds the importance of confidence in
both formal reflective dialogue and informal conversations. Smith
and Plunkett (2019) explain the relevance of a work environment in
which professionals feel safe, so they dare to ask reflective ques-
tions, ask for help and take risks. An important effect of spreading
new ideas and actions is an environment of eagerness to find even
more constructive ideas (Gesser- Edelsburg et al., 2018).
4.2.2  |  Networking
In the positive deviance approach, networks are used to spread new
ideas and deviant actions. These are the individuals’ own networks
and/or developed in conversations, both structured (as DAD) and
informal (Brandi & Naito, 2006; Lindberg & Schneider, 2013; Marra
et al ., 2013). The paper on tem pere d radicals ela bo rate s on net wo rk-
ing and describes collaborations and alliances to change things by
finding likeminded people and supportive relationships (Brandi &
Naito, 2006).
Baxter et al. (2019, p. 622) describe the nature of these net-
works: ‘It helped them to support one another to deliver safe patient
care. Friendly, personal connections between staff members were
perceived to facilitate dialogue, influence their ability to contribute
different perspectives, encourage them to work beyond silos and
to be more broadly involved in patient care’. In the rebel paper, net-
working is a part of what they call ‘contexting, [which] is about net-
working and encouraging others to act in line with rebels’ practices
of caring’ (Wallenburg et al., 2019, p. 877).
4.2.3  |  Role of management
Although the positive deviance approach seems to be a bottom- up
movement, several papers show the importance of management in-
volvement and suppor t (Ausserhofer et al., 2016; Bonuel et al., 2009;
Chang et al., 2018). This is also found in the literature on tempered
radicals (Brandi & Naito, 2006) and healthcare rebels (Wallenburg
et al., 2019). Managers play a role in stimulating dialogue among
professionals, by asking critical questions, challenging the current
status quo and stimulating rebel behaviour if they feel things can
be improved ( Wallenburg et al., 2019). Especially in the rebel paper
Title paper, author (s), year Country Research aim Study participants Methods Description Competences
Stimulating/
hindering
factors Study conclusions
23 Positive deviance: innovation from
the inside out (Jar amillo et al.,
2008)
N.A. To study PD theor y and how
it relates to innovation;
an ever- present need for
transformational leaders
N.A. N.A. X X Positive deviance is a powerful strategy for nursing leaders to
effec t positive change. This is especially relevant for those on
the Magnet journey. We present 7 strategies to assist leaders
in recognizing positive deviants in the current environment
and for optimizing innovation provide guidance for both
experienced and emerging leaders. These strategies support
a culture in which creativit y, collaboration and knowledge
sharing are essential for optimal perfor mance
24 Walking the tightrope: how rebels
‘do’ quality of care in healthcare
organisations ( Wallenburg et al.,
2019)
NL To study how healthcare
professionals and manager s
give shape to the increasing c all
for compassionate c are as an
alternative for system- based
qualit y management sys tems
3 Dutch hospitals, studying clinical groups
identif ied as deviant: a ward for
infectious diseases, a mother– child
department and a dialysis depar tment
Ethnographic research
120 h of obser vation,
41 semi- struc tured
interviews and 2 focus
groups.
X X X Rebels’ quality practices are an emerging set of collaborative
activities to improve health care and meet (individual) patient
needs. Rebels conduct ‘contexting work’ to achieve their
qualit y aims by expanding their normative work to out side
domains. As rebels deviate from hospital policies, they are
sometimes forced to act ‘under the radar’, risking ‘groupthink
and may undermine the aim of public accounting
25 Nurse managers: Being deviant to
make a difference (Crewe &
Girardi, 2020)
Australia To study how positive nurse-
manager behaviours that deviate
from ‘business as usual’ promote
positive nursing outcomes
N = 7 nurse managers from a private
hospital in Australia and N = 17 from
the public health sector in Seychelles
An interpretivist
methodology
X X X Study addresses the call for the ‘study of positive outcomes,
processes, and attributes of organizations and their members’
deemed valuable in health care. Interview data suppor t that
positive leader ship strategies and practices that facilitate
meaningful wor k, relationships, positive climates and
suppor tive communication, c an impact organisational and
individual outcomes. Import antly, positive leadership, not
just interventions alone, leads to interventions that influence
organisational outcomes
N.A ., not available.
TABLE 1 (Continued)
  
|
  13
KOK et al.
Title paper, author (s), year Country Research aim Study participants Methods Description Competences
Stimulating/
hindering
factors Study conclusions
23 Positive deviance: innovation from
the inside out (Jar amillo et al.,
2008)
N.A. To study PD theor y and how
it relates to innovation;
an ever- present need for
transformational leaders
N.A. N.A. X X Positive deviance is a powerful strategy for nursing leaders to
effec t positive change. This is especially relevant for those on
the Magnet journey. We present 7 strategies to assist leaders
in recognizing positive deviants in the current environment
and for optimizing innovation provide guidance for both
experienced and emerging leaders. These strategies support
a culture in which creativity, collaboration and knowledge
sharing are essential for optimal perfor mance
24 Walking the tightrope: how rebels
‘do’ quality of care in healthcare
organisations ( Wallenburg et al.,
2019)
NL To study how healthcare
professionals and manager s
give shape to the increasing c all
for compassionate c are as an
alternative for system- based
qualit y management sys tems
3 Dutch hospitals, studying clinical groups
identif ied as deviant: a ward for
infectious diseases, a mother– child
department and a dialysis depar tment
Ethnographic research
120 h of obser vation,
41 semi- struc tured
interviews and 2 focus
groups.
X X X Rebels’ quality practices are an emerging set of collaborative
activities to improve health care and meet (individual) patient
needs. Rebels conduct ‘contexting work’ to achieve their
qualit y aims by expanding their normative work to out side
domains. As rebels deviate from hospital policies, they are
sometimes forced to act ‘under the radar’, risking ‘groupthink
and may undermine the aim of public accounting
25 Nurse managers: Being deviant to
make a difference (Crewe &
Girardi, 2020)
Australia To study how positive nurse-
manager behaviours that deviate
from ‘business as usual’ promote
positive nursing outcomes
N = 7 nurse managers from a private
hospital in Australia and N = 17 from
the public health sector in Seychelles
An interpretivist
methodology
X X X Study addresses the call for the ‘study of positive outcomes,
processes, and attributes of organizations and their members’
deemed valuable in health care. Interview data suppor t that
positive leader ship strategies and practices that facilitate
meaningful wor k, relationships, positive climates and
suppor tive communication, c an impact organisational and
individual outcomes. Import antly, positive leadership, not
just interventions alone, leads to interventions that influence
organisational outcomes
N.A ., not available.
FIGURE 1 Flow chart of inclusion
process
Papersidentified
through database
searching
(n=2,705)
Search
Screening
Eligibility
Include
d
Additional records
identified through
other sources
(n=0)
Papersafter duplicates removed
(n=1,870)
Papersscreened
(n=1,870)
Papersexcluded
(n=1,804)
Full-text papers
assessed for
eligibility (n=66)
Full-text papers
excluded, with reasons
(total n=45)
Did not match the
eligibility criteria
(n=43)
Full-text not in English
(n=1)
Full-text unavailable
(n=1)
Papersincluded
(n=25)
Additional papers
selected from
referencelists of
includedpapers
n= 4
14 
|
   KOK et al.
TABLE 2 Results: descriptions, competences and stimulating/hindering factors
Paper Concept
Descriptions Competences Stimulating/hindering factors
PD approach Behaviour
Networks/
Relationships Collaborate
Expert (evidence- based)
knowledge
Courage/Challenge
status quo
Dialogues/
Reflection Networking
Role of
management
Hindering
factors
1Combating infec tions at Maine Medical Center: Insights into
complexity- informed leadership from positive deviance
(Lindberg & Schneider, 2013)
PD X X X X X X X
2Beyond the hospit al infec tion control guidelines: A qualitative study
using positive deviance to characterise grey areas and to achieve
effic acy and clarit y in the prevention of healthcare- associated
infections (Gesser- Edelsburg et al., 2018)
PD X X X X
3Methicillin- resistant St aphylococcus aureus (MRSA) prevention
through facility- wide culture change (Bonuel et al., 2009)
PD X X X X
4Nurses’ Use of Positive Deviance When Encountering Elec tronic
Health Re cords- Related Unintended Consequences (Bristol
et al., 2018)
PD X X X X X X X
5Positive deviance and hand hygiene of nurses in a Quebec hospital:
What can we learn from the best? (Létourneau et al., 2018)
PD X X X X
6How is success achieved by individuals innovating for patient safet y
and quality in the NHS? (Sheard et al., 2017)
PD X X X X X X X
7Positive deviance: a programme for sustained improvement in hand-
hygiene compliance (Marra et al., 2011)
PD X X X X X
8Improving the safety and quality of nursing care through
standardised operating procedures in Bosnia and Herzegovina
(Ausserhofer et al., 2016)
PD X X
9 Positive deviance: Using a nurse call system to evaluate hand-
hygiene pr actices (de MacEdo et al., 2012)
PD X X
10 Hospital Strategies for Reducing Emergency Department Crowding:
A Mixed- Methods Study (Chang et al., 2018)
PD X
11 Creating a culture of innovation in nursing education through shared
vision, leadership, interdisciplinar y partnerships, and positive
deviance (Melnyk & Davidson, 2009)
PD X X
12 Hospital nurse adminis trators in Japan: a feminis t dimensional
analysis (Brandi & Naito, 20 06)
Tempered radicals X X X X
13 A qualitative positive deviance study to explore exceptionally safe
care on me dical wards for older people (Baxter et al., 2019)
PD X X X
14 Reducing Infections ‘Together’: A review of Socioadaptive
Approaches (Sreeramoju, 2019)
PD X X X
15 People, systems and safety: resilience and excellence in healthcare
practice (Smith & Plunket t, 2019)
PD X X
16 Using a Positive Deviance Approach to Influence the Culture of
Patient Safety Related to Infection Prevention (Sreeramoju et al.,
2018)
PD X X X X
17 Identif ying positively deviant elderly medical wards using routinely
collected NHS Safety Thermometer data: an observational study
(Baxter et al., 2018)
PD X X X X
18 Positive Deviance: A New Tool for Infection Prevention and Patient
Safety (Marra et al., 2013)
PD X X X X X X X
19 Exploring the concept and use of positive deviance in nursing (Gary,
2013)
PD X X X X X X
20 Positive deviance: An elegant solution to a complex problem
(Lindberg & Clancy, 2010)
PD X X X
21 Diamonds in the rough: positive deviance and complexity (Clancy,
2010)
PD X X X X X X
22 Positive deviance: a different approach to achieving patient safety
(Lawton et al., 2014)
PD X X
(Continues)
  
|
  15
KOK et al.
TABLE 2 Results: descriptions, competences and stimulating/hindering factors
Paper Concept
Descriptions Competences Stimulating/hindering factors
PD approach Behaviour
Networks/
Relationships Collaborate
Expert (evidence- based)
knowledge
Courage/Challenge
status quo
Dialogues/
Reflection Networking
Role of
management
Hindering
factors
1Combating infec tions at Maine Medical Center: Insights into
complexity- informed leadership from positive deviance
(Lindberg & Schneider, 2013)
PD X X X X X X X
2Beyond the hospit al infec tion control guidelines: A qualitative study
using positive deviance to characterise grey areas and to achieve
effic acy and clarit y in the prevention of healthcare- associated
infections (Gesser- Edelsburg et al., 2018)
PD X X X X
3Methicillin- resistant St aphylococcus aureus (MRSA) prevention
through facility- wide culture change (Bonuel et al., 2009)
PD X X X X
4Nurses’ Use of Positive Deviance When Encountering Elec tronic
Health Re cords- Related Unintended Consequences (Bristol
et al., 2018)
PD X X X X X X X
5Positive deviance and hand hygiene of nurses in a Quebec hospital:
What can we learn from the best? (Létourneau et al., 2018)
PD X X X X
6How is success achieved by individuals innovating for patient safet y
and quality in the NHS? (Sheard et al., 2017)
PD X X X X X X X
7Positive deviance: a programme for sustained improvement in hand-
hygiene compliance (Marra et al., 2011)
PD X X X X X
8Improving the safety and quality of nursing care through
standardised operating procedures in Bosnia and Herzegovina
(Ausserhofer et al., 2016)
PD X X
9 Positive deviance: Using a nurse call system to evaluate hand-
hygiene pr actices (de MacEdo et al., 2012)
PD X X
10 Hospital Strategies for Reducing Emergency Department Crowding:
A Mixed- Methods Study (Chang et al., 2018)
PD X
11 Creating a culture of innovation in nursing education through shared
vision, leadership, interdisciplinar y partnerships, and positive
deviance (Melnyk & Davidson, 2009)
PD X X
12 Hospital nurse adminis trators in Japan: a feminis t dimensional
analysis (Brandi & Naito, 20 06)
Tempered radicals X X X X
13 A qualitative positive deviance study to explore exceptionally safe
care on me dical wards for older people (Baxter et al., 2019)
PD X X X
14 Reducing Infections ‘Together’: A review of Socioadaptive
Approaches (Sreeramoju, 2019)
PD X X X
15 People, systems and safety: resilience and excellence in healthcare
practice (Smith & Plunket t, 2019)
PD X X
16 Using a Positive Deviance Approach to Influence the Culture of
Patient Safety Related to Infection Prevention (Sreeramoju et al.,
2018)
PD X X X X
17 Identif ying positively deviant elderly medical wards using routinely
collected NHS Safety Thermometer data: an observational study
(Baxter et al., 2018)
PD X X X X
18 Positive Deviance: A New Tool for Infection Prevention and Patient
Safety (Marra et al., 2013)
PD X X X X X X X
19 Exploring the concept and use of positive deviance in nursing (Gary,
2013)
PD X X X X X X
20 Positive deviance: An elegant solution to a complex problem
(Lindberg & Clancy, 2010)
PD X X X
21 Diamonds in the rough: positive deviance and complexity (Clancy,
2010)
PD X X X X X X
22 Positive deviance: a different approach to achieving patient safety
(Lawton et al., 2014)
PD X X
(Continues)
16 
|
   KOK et al.
(Wallenburg et al., 2019), managers show the same kind of behaviour
as healthcare rebels.
The respect and endorsement of CEOs and support by middle man-
agers prevent healthcare professionals from being penalised by pow-
erful people in the organisation who might view deviant behaviour as
intrusive, threatening or inappropriate (Lindberg & Schneider, 2013).
Knowing management has your back allows healthcare professionals
to talk about their deviant actions to innovate and improve patient
care (Jaramillo et al., 2008) without fearing negative consequences
(Sreeramoju et al., 2018). Management can also play a pivotal role in
promoting deviant action and to spread these good practices (Lindberg
& Schneider, 2013).
4.2.4  |  Hindering factors
A few papers (4/25) describe the obstacles to being a positive devi-
ant, healthcare rebel or tempered radical. First, a nurse who acts like
a positive deviant risks facing negative perceptions by management,
punishment and the ultimate consequence of losing their job or li-
cence (Bristol et al., 2018). The fear of damage to their reputation or
career keeps healthcare professionals from talking about deviating
from organisational policy (Lindberg & Schneider, 2013). Wallenburg
et al. (2019) observed the same; healthcare rebels ‘stay under the
radar’ to avoid these negative consequences. However, keeping
deviant actions hidden impedes the innovative spirit and ability to
spread the innovation (Sheard et al., 2017; Wallenburg et al., 2019).
The research by Brandi and Naito (2006) describes the harmful con-
sequences for the organisation and/or the individual tempered radi-
cal nurse who may feel ‘trapped’ in their position. ‘Alternatives to
tempered radicalism are to seek other jobs, surrender to silence and
disempowerment, or assimilate to the conflicting dominant view-
point or values of an organization’ (Brandi & Naito, 20 06, p. 64).
Put together, the supporting factors are as follows: (1) confidential
conversations (both planned and spontaneous) and reflective dialogue
in a safe work environment to reveal positive deviant behaviour of
rebel leadership support the exchange of normative points of view on
the current situation and collectively find new solutions for points of
improvement; (2) networking in and outside the organisation to spread
the deviant actions and ideas that help to encourage others; and (3)
management respect and support that stimulates professionals to de-
viate. Hindering factors are the negative consequences for personal
reputation and/or career that urge professionals deviating from the
rules and regulations to ‘stay under the radar’.
5 | DISCUSSION
This scoping revi ew pr ovides an overview of (1) descriptions of posi-
tive deviance, healthcare rebels and tempered radicals in nursing; (2)
the competences of rebel nurse leaders; and (3) factors that stimu-
late the development of rebel nurse leadership.
Most studies included in the review identify positive deviant
healthcare professionals, departments and/or organisations. However,
they seldom describe their exact selection criteria. Selection is meth-
odologically challenging, as deviant or rebel behaviour requires a
comparison with something regarded as ‘normal’ and is thus highly
normative depending on the eye of the beholder. Besides, the meth-
odology applied to ‘organise’ learning from positive deviant behaviour
and/or methods might not be all- encompassing as healthcare profes-
sionals prefer or even need to ‘stay under the radar’ to perform deviant
behaviour (Wallenburg et al., 2019). Additionally, the selected papers
make no mention of ‘negative’ deviation as all perspectives are highly
appreciative on the topic. Numerous studies showed that deviating
from clinical guidelines (without a proper reason) results in low quality
of care (e.g. Rice et al., 2012; Sargen & Kingsnorth, 2001).
Nevertheless, the findings of this scoping review demonstrate a
variety of descriptions and definitions on positive deviance, health-
care rebels and tempered radicals. Analysing these descriptions and
definitions has made the overlap between these concepts appar-
ent. All descriptions in the literature focus on deviant behaviour by
healthcare rebels who, as a result, achieve better outcomes under
the same circumstances than their peers, according to the authors.
Only a few authors specify the better outcomes (by making a com-
parison), and no paper shows evidence that these better outcomes
can be attributed to the positive deviant(s), healthcare rebel(s) or
tempered radical(s) studied. Only the study by Wallenburg et al.
(2019) used ethnographic methodology (observations, informal con-
versations and semi- structured interviews), to study moreobjec-
tively’ the results of rebel leadership.
Paper Concept
Descriptions Competences Stimulating/hindering factors
PD approach Behaviour
Networks/
Relationships Collaborate
Expert (evidence- based)
knowledge
Courage/Challenge
status quo
Dialogues/
Reflection Networking
Role of
management
Hindering
factors
23 Positive deviance: innovation from the inside out (Jaramillo et al.,
2008)
PD X X
24 Walking the tightrope: how rebels ‘do’ quality of care in healthcare
organisations ( Wallenburg et al., 2019)
Healthcare rebels X X X X X X X X X
25 Nurse managers: Being deviant to make a difference (Crewe &
Girardi, 2020)
PD X X X X
Abbreviation: PD, positive deviance.
TABLE 2 (Continued)
  
|
  17
KOK et al.
Although the concepts of positive deviance, healthcare rebels
and tempered radicals are similar, they also have important dif-
ferences. The positive deviance approach purposefully identifies
positive deviants, makes them visible and gives them an exem-
plary role with the aim of learning from them. Healthcare rebels
or tempered radicals, on the other hand, are less visible in organ-
isations as they prefer to ‘stay under the radar’ to avoid criticism
(Wallenburg et al., 2019). Allen (2014) describes this as the invisi-
ble work of nurses to ‘keep things on track’ and serve as a ‘Jack of
all trades’. Our study focuses on rebel nurse leadership from the
perspective of ‘good rebels’ who can ‘rock the boat while staying
in it’, as Bevan (2010) and Meyerson (2008) put it. The ‘bad reb-
els’ who deviate and break the rules for personal gains or because
of angry assertations and complaints were hardly mentioned in
the included literature. There is a thin line between a ‘good’ and
‘bad’ rebel, and assessing the difference is a subjective matter.
This matter fell outside the scope of our review; more empirical
research in this direction would help enrich the literature on rebel
(nurse) leadership.
LAP theory (Raelin, 2011) helps us to understand how leadership
is enacted in the nursing workplace and how the contex t influences
leadership and the dynamics within organisations that fos ter leader-
ship (Raelin, 2011). However, the included papers do not describe the
daily practices of nurses in terms of LAP, and thus, it is unclear what
is actually enacted in the practices of positive deviants, healthcare
rebels and tempered radicals. We regard this lack of transparency
on the context and dynamics within the organisations concerned as
a missed opportunity.
Further, we expected more papers to describe the practices of
healthcare rebels, as the work of Helen Bevan and her colleagues
has resonated in the healthcare sector worldwide. Bevan's edu-
cational programme, School for Health and Care Radicals, was
launched by the UK National Health Service (NHS) in 2014. The
purpose of this education programme is to teach employees ‘to
rock the boat and stay in it ’ (Bevan & Fairman, 2016). The School
for Health and Care Rebels ex tended ‘beyond the NHS and across
global healthcare networks. More than 1,500 people enrolled
across 40 countries’ in its first year (Nesta, 2014). In the years
following it was transformed into the School for Change Agents,
offering free webinars and modules in a Massive Online Open
Course (Bevan, 2018). Despite all the attention, there is a lack of
scientific papers describing the practices of nurse rebel leaders
and healthcare organisations that deliberately support the de-
velopment of these healthcare rebels. This limits our knowledge
about the programme. Only Grifford et al. (2015) have studied the
results of the programme and changes in work environments of
nurses after the first year. Unfortunately, only one paper in our
sco pi ng review ( Wallenburg et al., 2019) de scribes the prac tice s of
hea lthc are rebels. As mentioned earlie r, one reason for this lac k of
information might be the difficult y of studying nurse rebel leader-
ship and deviant behaviour because rebels tend to ‘stay under the
radar’. To capture actual practice is thus challenging.
Most included papers define the competences of positive devi-
ants, healthcare rebels and tempered radicals. This review demon-
strated four aspects of competence in rebel nurse leaders, of which
two are interpersonal: (1) collaboration (networking); (2) communica-
tions (gain and share expertise knowledge and challenge the current
status quo); and two are intrapersonal: (3) the ability to critically as-
sess and reflect (on working habits, organisation logistics, problems
in daily care); and (4) come up with innovative ideas. Bevan (2013)
and Meyerson (2008) also describe these four competences. Note
that the competences listed by the included papers are not unique
to rebel nurse leaders; they also arise in concepts of leadership both
inside and outside healthcare.
Note that one relevant aspect influencing rebel nurse leaders
previously described in literature was not found in the 25 papers.
According to Meyerson (20 08, p. 5), ‘they [tempered radicals] are
treated as outsiders because they represent ideals or agendas that
are somehow at odds with the dominant culture’. The included pa-
pers regard positive deviants, healthcare rebels and tempered rad-
icals as role models for their peers and not as outsiders. Possibly,
the ‘outsider ’ was not found in the included paper because of their
process- oriented approach to positive deviance methodolog y.
This scoping review might help researchers bind together the
concepts of positive deviance, healthcare rebels and tempered rad-
icals so that studies of nurse rebel leadership will enter the nursing
(leadership) literature. Leadership in individual nurses is required
when nurses need to balance between being a ‘good’ employee
and ‘deviating’ for the benefit of patient care or the organisation.
Nurses must streamline processes aimed at bet ter service provision,
Paper Concept
Descriptions Competences Stimulating/hindering factors
PD approach Behaviour
Networks/
Relationships Collaborate
Expert (evidence- based)
knowledge
Courage/Challenge
status quo
Dialogues/
Reflection Networking
Role of
management
Hindering
factors
23 Positive deviance: innovation from the inside out (Jaramillo et al.,
2008)
PD X X
24 Walking the tightrope: how rebels ‘do’ quality of care in healthcare
organisations ( Wallenburg et al., 2019)
Healthcare rebels X X X X X X X X X
25 Nurse managers: Being deviant to make a difference (Crewe &
Girardi, 2020)
PD X X X X
Abbreviation: PD, positive deviance.
TABLE 2 (Continued)
18 
|
   KOK et al.
intert wining the professional and organisational logics as natural
aspects of professional action (Noordegraaf, 2015). To gain an un-
derstanding of rebel nurse leaders in their daily practice of doing
compassionate and good care, studying rebel nurse leadership
would be a useful addition to the current nursing leadership litera-
ture, especially when blended with LAP.
5.1  |  Strengths and limitations
This scoping review used precise, transparent methods based on
study and reporting guidelines (Peters et al., 2017; Tricco et al., 2018).
However, it has three limitations. First, most of the included papers
concerned positive deviance, describing a positive deviance meth-
odology and the results it gained, without any focus on individual
positive deviants. Our data extraction required close reading to un-
derstand the relevant competences of rebel nurse leaders and aspects
that support or hinder their positive deviant behaviour. We might have
put too much emphasis on this, as it was not the stated aim of most
of the positive deviant papers. We found very few papers on the con-
cepts of healthcare rebels and tempered radicals in nursing and this
also influenced the validity of our findings.
The second limitation is the method of document selection. The
selection criteria were designed to include relevant papers focusing
on nurses. Hence, papers describing healthcare professional teams
or healthcare professionals in general were excluded. However,
nurses could have been members of such teams, and as a result, se-
lection bias may have occurred.
The third limitation is that papers not based on scientific re-
search were excluded, which means we may have missed potentially
relevant information. For instance, the work of Helen Bevan on
healthcare rebels was not included, because she writes only blogs
and white papers (Bevan, 2013; Bevan & Fairman, 2016).
Despite these limitations, this is the first scoping review based
on a comprehensive literature search to assess the current state of
what we call rebel nurse leadership. Our study provides a lens for
studying rebel nurse leadership in that it describes what it entails
and the competences that contribute to it.
5.2  |  Future research
The findings of this scoping review can be used in further studies on
nurse rebel leadership in daily practice to gain more understanding
of its influence on improving the quality of care. Shadowing could
help accurately describe the practices of rebel nurse leaders and
reveal more about their working context, strategies and behaviour
(Lalleman et al., 2017).
Exploring the experiences of nurses seen as rebel leaders could
be useful. Interviewing these nurses to study their perception and
interpretation of rebel nurse leadership would help refine the de-
scription of the concept and apply the findings of this review in daily
practice.
The stimulating and hindering factors this review describes
could also be useful. For instance, studying interventions that foster
communication among nurses— dialogue, reflection and networking
competences— as well as interventions that change the role of the
management could help us understand how these factors influence
rebel nursing leadership.
6 | CONCLUSION
Nurses’ leadership plays a crucial role in daily practice, especially
given the current challenge of retaining nurses and maintaining
healthcare quality. This scoping literature review aimed to provide
an over view of rebel nurse leadership, culled from the literature on
positive deviance, healthcare rebels and tempered radicals. Our re-
view gives insights into nurse rebel leadership, describes the compe-
tences of rebel nurse leaders and explains the factors that stimulate
or hinder the development of rebel nurse leadership.
After synthesising the descriptions and competences mentioned
in the three concepts, we identified several common aspects. Rebel
nurse leaders show unconventional nonconformist behaviour that
varies or dif fers from norms, rules, codes of conduct, practices or
strategies. They challenge the status quo with their ability to de-
velop and use social networks (peers, other disciplines and manage-
ment) in- and outside their organisation to obtain evidence- based
knowle dge. The y sh ar e info rmation and gai n the eng agem en t of oth -
ers to provide better outcomes for patients and organisations. As a
result, these nurse leaders consistently outperform their peers using
the same resources.
Important competences are the ability to: (1) collaborate and
network with diverse professionals and management in- and
outside the organisation, (2) obtain and share expert (evidence-
based) knowledge, (3) critically reflect on working habits, organi-
sational logistics and problems in daily care and dare to challenge
the status quo and (4) generate ideas to improve care. Factors
supporting rebel nurse leadership are as follows: (1) formal and
informal communication— dialogues and reflection— to reveal
positive deviant behaviour, to suppor t the exchange of norma-
tive point s of view on the current situation and collectively find
new solutions to improve quality, (2) networking in- and outside
the organisation to share deviant activity and ideas that help to
encourage others and (3) management's willingness to stimulate
professional deviation.
7 | RELEVANCE TO CLINICAL PRACTICE
This scoping review describes rebel nurse leaders, their compe-
tences, and provides an overview of fac tors that stimulate or hinder
the development of rebel nurse leadership. This understanding will
help management and nurses to support and develop rebel nurse
leadership. More nurse leadership will influence and enhance the
quality of care and help retain nurses.
  
|
  19
KOK et al.
ACKNOWLEDGEMENTS
We would like to thank Gusta Drenthe, Librarian, for her assistance
with the search strategy.
CONFLICT OF INTEREST
The authors declare that they have no conflicts of interest .
AUTHOR'S CONTRIBUTION
EdK, PL and AW designed the study. EdK performed the scoping
review. EdK, PL and AW analysed and interpreted the data. EdK and
AW prepared the manuscript. PL and LS commented on the manu-
script. All authors approved the final version for submission.
ORCID
Eline de Kok https://orcid.org/0000-0001-5915-298X
Anne Marie Weggelaar- Jansen https://orcid.
org/0000-0002-7786-6326
Lisette Schoonhoven https://orcid.org/0000-0002-7129-3766
Pieterbas Lalleman https://orcid.org/0000-0003-4520-8756
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SUPPORTING INFORMATION
Additional supporting information may be found online in the
Supporting Information section.
How to cite this article: de Kok E, Weggelaar- Jansen AM,
Schoonhoven L, Lalleman P. A scoping review of rebel nurse
leadership: Descriptions, competences and stimulating/
hindering factors. J Clin Nurs. 2021;00:1–21. h t t p s: //d o i .
org /10.1111/jocn.15765
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De coronacrisis en de nasleep daarvan onderstrepen het belang van verpleegkundig leiderschap. Twee concepten zijn volgens ons cruciaal bij het verder ontwikkelen van dit leiderschap, namelijk het concept van Magnet Hospitals en het concept van rebels verpleegkundig leiderschap. Beide worden in dit artikel kort uitgelegd, om vervolgens stil te staan bij de REBEL-V-studie, waarin dit rebels verpleegkundig leiderschap verder wordt onderzocht.
... In contrast, deviating nurse leadership practices to improve patient outcomes or ward processes have been described as "passionate enough to dissent against practices seen as stagnant, ineffective, or even dangerous to those around them" (Dahling et al., 2017(Dahling et al., , p. 1167. In their review, De Kok et al. (2021) said "it is unclear what is actually enacted in the practices of positive deviants, healthcare rebels and tempered radicals," a statement that emphasize the need for more empirical studies. However, studying these practices in daily practice is not easy as nurse leadership often occurs "under the radar" (De Kok et al., 2021) or "invisibly" (Allen, 2014). ...
... In their review, De Kok et al. (2021) said "it is unclear what is actually enacted in the practices of positive deviants, healthcare rebels and tempered radicals," a statement that emphasize the need for more empirical studies. However, studying these practices in daily practice is not easy as nurse leadership often occurs "under the radar" (De Kok et al., 2021) or "invisibly" (Allen, 2014). ...
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