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Disseminating positively deviant strategies through creative co-design

Disseminating positively deviant strategies through creative co-design

The study investigated how creative practice and co-design methods could be used to support the dissemination of positively deviant strategies for improving quality and evidence about newly characterised best practice within elderly patient medical wards. The research was funded through the Evidence Based Transformation Theme of the NIHR (National Institute for Health Research) CLAHRC (Collaborations for Leadership in Applied Health research and Care) YH (Yorkshire and Humber) and is supported by the Translating Knowledge into Action (TK2A) theme

Funded by : 

University of Leeds

Project team:
Paul Chamberlain
Claire Craig
Anne Marie Moore

Positive deviance is an asset-based, bottom-up approach to behavioural and social change within communities. It draws on individual and community strengths and pre-existing resources considered positively deviant (Tuhus- Dubrow, 2009, Sternin and Choo, R., 2000; and Singhal et al., 2010). 

The approach assumes that problems can be overcome using solutions that already exist within communities. Despite facing the same constraints as others, ‘positive deviants’ identify solutions and succeed by demonstrating uncommon or different behaviours (Baxter et al 2016 p.2).

This approach holds much promise and attention has turned to how it might be applied within health service contexts.

If the potential of the positive deviance approach within healthcare is to be realized it is necessary to find ways to identify positive deviant wards, cultures and individuals within complex and ever-changing systems and create mechanisms to communicate what these are to create the potential for their implementation.

Baxter et al. (2015) examined whether a positive deviance approach could be used to identify ward teams that were performing exceptionally well on patient safety and explored strategies for achieving success.

Hypotheses about strategies, behaviours, team cultures and dynamics that facilitated the delivery of safe patient care were generated and 14 key themes representative of positively deviant elderly patient medical wards were identified. These were; Knowing Each Other, Trust, A Multidisciplinary Approach, Integrated Ward Based AHPs, Working Together, Feeling Able to Ask Questions or for Help, Setting Expectations, It’s a Pleasure to Come to Work, Learning from Incidents, Acquiring Additional Staff, Stable and Static Teams, Focus on Discharge, Directorate Support, and Keeping Patients and Relatives Informed. 

Baxter’s study raises interesting research questions, particularly in relation to dissemination and adoption of findings. If the strength of the positive deviance approach is its focus on community engagement and involvement, seeing solutions located within existing resources, how is it possible to translate these findings to other communities/settings/wards which have not been involved in the process? If solutions are internally generated rather than externally imposed how can they be regarded as feasible within the resources of other contexts? What are the implications of this in relation to dissemination and knowledge mobilization?

Co-design workshops were undertaken with participants recruited from a local ward team (site 1). The research team used findings from the co-design workshops to develop a set of interventions and artefact installations designed to embody some of the positively deviant strategies and characteristics. 

The project involved the intervention and installation of the co-created artefacts into sites 1 and 2 (not involved in the co-design):

The study research questions were as follows: 

1)  Can creative co-design help ward teams to disseminate positively deviant strategies? 

2)  Does using creative practice and co-design methods to support the dissemination of positively deviant strategies have an impact on the ward? 

3)  What is the experience of being involved in this process for staff on the units?

4)  Is there a difference in the experience and impact of the critical artefacts between wards engaged in creative practice and co-design of creative interventions and those that were not? 

5) Which types of creative co-design methods work well in this context? 

‘The books have gone down a treat with established members of the team as well as new starters’..

An evaluation is currently being undertaken with participants from both sites to explore whether there was a difference in the experience and impact between wards engaged in the creative practice and co- design of the critical artefacts in comparison to the ward that was not. It will reflect on  how the artefacts had been utilised and any possible strategies that the wards have found useful in relation to identifying and implementing positive deviant behaviours

The Life Café

The Design to Care Programme seeks to rethink how palliative and end of life care can be provided equitably, efficiently and sustainably for future generations. The Life Café Kit is a result of the programme, and is designed to promote and support conversations about what individuals find meaningful in life and in care. For more information visit

Funded by Marie Curie
Partnered with University of Cambridge

Team: Helen Fisher, Claire Craig, Paul Chamberlain

Drawing on long-established ethical principles, the UK General Medical Council articulates good end of life care as that which ‘helps patients with life-limiting conditions to live as well as possible until they die and to die with dignity’ (GMC 2009 p.3).

The last decade has witnessed a demographic change on unprecedented scale.

People are living longer and with more complex, long term conditions such as cancer and dementia. Our palliative and end of life care services will be required to meet the needs of our ageing population under increasing pressure.

The Life Café is one of the outputs of the Design to Care programme which seeks to rethink how palliative and end of life care can be provided equitably, efficiently and sustainably for future generations.

The community engagement aspect of the Design to Care programme focuses on understanding what is important to different individuals in life, in care, and towards end of life. A methodology has been developed by researchers at Sheffield Hallam University’s Lab4Living, to enable research to be gathered in an informal, comfortable manner within existing community groups and familiar environments. This has been named the Life Café.

“This has made an incredible difference to me today to share these things and listen to you all.”

Life Café Participant

“Good care is ‘talking, listening, communicating, trusting, consistency, choice and time.”

Life Café Participant 

Taking the method of ‘exhibition in a box’, a form of object elicitation developed by Chamberlain and Craig (2013) as the starting point, this study curated a series of creative activities, to scaffold thinking and to prompt conversation. The Life Café is comprised of a variety of critical artefacts, activities and resources, co-developed with community members, that have been used to gather stories, experiences and ideas to support the design phase of the project. 

Our iterative methodology of using resources and artefacts, analysing data, generating themes, then modifying the resources has been a form of behind-the-scenes co-design. Participants have shaped the contents of the Life Cafe and enabled others to talk about sensitive topics more easily, without really realizing. This iterative co-design process has occurred through every element, activity and resource included in the Life Café Kit, even the graphic design and the packaging design.

11 Life Cafés facilitated 141 participants 

In the first phase of the Design to Care Programme, 11 Life Cafés have been facilitated with a total of 141 participants (from groups including chaplains, faith groups, coffee morning socials and mixed community groups), using convenience sampling. 

The Life Café Kit

Life Cafés were continued to develop a kit for independent facilitation. The life café has since been independently facilitated within 2 community groups, a care home and a hospice. The feedback from this will be consolidated and incorporated into the final version of the Kit. We have increasing interest in the Life Café Kit, not only for community groups but for use in schools, carer groups, staff training etc. to open the conversation up and bring awareness to organisations.

The Life Café as a method of eliciting the experiences of individuals in the context of meaning and care has been very successful. Particularly notable was its ability to enable community groups through this process to identify strength and mobilise knowledge and action. This sits well in the context of building compassionate communities.

The Life Café has elicited insights into how individuals conceptualise and describe good care, and a recognition of the pressure points in relation to delivery. The research offers glimpses of what better care might and could look like in the future. Future research will continue to utilise this method with other groups (health and social care staff, trusts and CCGs, carer groups, community groups etc.) to continue to build understanding in order to inform the redesign of end of life care provision. For more information or to order a Life Cafe Kit please visit


Related research on Sheffield Hallam University’s Research Archive

GRIP: Developing an education resource for people with Low back pain.

This project, funded through the Getting Research into Practice (GRIP) programme, used co-production and creative methods to inform the design of an educational resource for people with lower back pain in Sheffield.

Funded by:
Getting Research into Practice (GRIP) funding programme through National Institute for Health Research Collaborations for Leadership in Applied Research and Care Yorkshire and Humber (NIHR CLAHRC YH).

Rebecca Partridge

Rick Webber – specialist physiotherapist, Sheffield Teaching Hospitals NHS Trust
Cheryl Grindell- Sheffield Teaching Hospitals NHS Trust.

Current UK NICE low back pain guidance recommends patient education to improve self-management, however current evidence on how best to provide this education is unclear. Beliefs associated with a traditional biomedical view of lower back pain can

be a barrier to recovery.
Education that helps people reframe their problem as complex and multifactorial may help patients accept and engage with more positive attitudes and behaviours. Passive information rarely leads to these behaviours.

The creative co-design process applied in this project provided a different approach to the traditional top down method of research and intervention development. It encouraged a collaborative problem-solving approach and fostered a non-hierarchical inclusive approach to knowledge mobilisation.

Stakeholders involved

Sheffield Teaching Hospitals NHS foundation Trust
Physioworks Sheffield


Methods used

To develop the education resource, service users and providers were brought together in two co-production workshops. In the first workshop, we explored the lived experience of back pain. Participants were invited to share their experiences to generate a shared understanding of the complexities of living with and managing back pain.

The second workshop focused on idea generation to support and manage some of the complexities highlighted in the previous workshop. From these ideas, a series of prototypes were developed and tested within Sheffield Physio works.

Project Outcome

New educational resources were developed and have now been implemented within Physio works, Sheffield. The resources include a patient workbook and a series of information leaflets. All these resources are available physically and online.

As a result of patient feedback during the workshop, an improved interactive education session was developed to align to the new resources.