ABSTRACT This study explores how questioning functions as a communicative practice in managing everyday problems and negotiating expertise and communication competence in an interprofessional healthcare team. High-quality collaboration in such teams is essential, but hierarchies and time pressures may hinder joint development of competence. Drawing on Grounded Practical Theory and employing Action-Implicative Discourse Analysis, we analyze audio-recorded team meetings and focus group data from a Finnish orthopedic team serving as a positive deviance case. Findings shows that questioning addresses problems related to patient needs, inefficient structures, and voicing expertise in a top-down organization. Three questioning strategies were identified: asking for and answering to the patient, making expertise visible through questions, and questioning the organization. Situated ideals included prioritizing patients, encouraging organizational critique, and allowing the display of inexpertise. Questioning functioned as a key practice for linking organizational levels, constructing collective expertise, and for metacommunicative negotiation of shared communication competence in interprofessional teamwork.

To identify modifiable surgical practices associated with reduced sternal wound infection rates following isolated coronary artery bypass grafting (CABG) using positive deviancy methodology. Retrospective cohort study with prospectively collected data (January 2021-June 2025). Single tertiary referral cardiac surgery center. 3,087 consecutive patients undergoing isolated CABG. Primary outcome was total sternal wound infection (deep and superficial combined) within 30 days. Risk-adjusted surgeon performance was evaluated using mixed-effects logistic regression with observed-to-expected (O/E) ratios. Positive deviants were defined as surgeons with O/E ratios <1.0 with 95% confidence intervals excluding unity. Surgical techniques were systematically reviewed through anonymized surveys, and volume-weighted analysis compared techniques of better and worse performers. Total sternal wound infection occurred in 175 patients (5.7%). Nine surgeons were stratified: better performers (O/E <1.0, n = 5), worse performers (O/E ≥1.2, n = 3), and average performers (O/E 1.0-1.19, n = 1). One surgeon achieved statistically significant superior performance (O/E = 0.590, 95% CI: 0.39-0.91), representing 41% fewer infections than expected across 543 cases. Four protective techniques were identified: wound irrigation at closure (100% vs 0%), double skin preparation with chlorhexidine and povidone (100% vs 0%), superior Ioban adherence quality (5/5 vs 3.7/5 vs 3.2/5, P < .001), and minimal cautery usage (1.0/5 vs 3.2/5 vs 3.5/5, P < .001). Positive deviancy methodology successfully identified four modifiable surgical practices associated with reduced total sternal wound infections. These techniques represent immediately implementable interventions for infection prevention in cardiac surgery. Further study is needed to validate these findings across multiple institutions and evaluate implementation outcomes.

A Synthesis of Principles and Approaches From the Field of Implementation Science for Studying Midwifery Integration in the United States.

This study explores how organizations successfully adopt and scale Artificial Intelligence (AI) across their operational processes, identifying the key factors influencing effective AI integration. Drawing on Dynamic Capabilities Theory (DCT), this research investigates strategic, organizational, and managerial dimensions critical to AI implementation. Through a qualitative approach utilizing podcast-based secondary data and employing positive deviance sampling, we analyzed insights from senior executives across diverse industries. The analysis yielded three central dimensions crucial for effective AI scaling: (1) Strategic Leadership and Governance, emphasizing executive prioritization, capability development, and ethical oversight; (2) Foundations for AI Adoption, highlighting the necessity of robust technical infrastructures, comprehensive data governance, and supportive organizational cultures, and practices that foster human interaction and knowledge sharing; and (3) Adaptive Implementation Approaches, reflecting the importance of agile methodologies, cross-functional collaboration, democratization of AI, and decentralized innovation. Our findings reveal that successful AI adoption is not merely a technical achievement but involves dynamic and iterative processes where organizations continuously sense opportunities, strategically allocate resources, and flexibly reconfigure internal capabilities. This study contributes to the literature by presenting a holistic framework that underscores the interplay of leadership, organizational readiness, and adaptive execution strategies, enabling organizations to effectively scale AI and achieve sustained competitive advantages. Managerially, this research provides actionable insights for organizational leaders seeking to strategically navigate AI transformation within their firms.

Background:Improving operating room (OR) throughput is a constant challenge. Given evidence that positive deviance (PD) sessions to identify excelling individuals and disseminate their strategies lead to improvements in a tertiary care institution, we sought to use PD sessions to increase the success in completing 4 joint arthroplasties in a day in a rural hospital.Methods:We conducted PD sessions for 13 OR nurses, 4 family physician anesthetists or anesthesiologists, and 2 orthopedic surgeons. Best-performing staff shared strategies. We measured efficiency and agreement, which were then discussed at future PD sessions. Our primary outcome was success in completing 4 joint arthroplasties in a day. We recorded time from the patient being in the OR to anesthesia-ready (anesthesia prep time), time from the patient being anesthesia-ready to surgery start (surgery prep time), procedure length, time from surgery finish to the patient leaving the room (anesthesia finish time), and room turnover time. We collected data before PD sessions (baseline), 1 to 5 months post-PD sessions (short-term follow-up), and 9 to 13 months post-PD sessions (long-term follow-up).Results:Before PD sessions, 48.7% of joint arthroplasty days were completed on time. At short- and long-term follow-up, 87.5% and 80.0% were completed on time. The average time to complete 4 cases decreased. Notable changes were made in anesthesia prep time (21 min at baseline, 17 min at both short- and long-term follow-up), and turnover time (30 min at baseline, 25 min at short-term follow-up, 23 min at long-term follow-up).Conclusion:Overall, PD sessions in a rural hospital increased success in completing 4 joint arthroplasties in a day with minimal costs, stimulating local strategies for efficiency. Long-term sustainability and applicability to other surgical procedures or specialties is yet to be determined.

Health care organization leaders are charged with patient safety, evidence-based practice, financial sustainability, capacity, and staff supervision in systems that are challenged by bureaucracy, fragmentation, mistrust, and limited interdisciplinary engagement. It is not known how leaders effectively address specific challenges of staff supervision, policies/mandates, difficult conversations, and staff burnout. This study collected strategies from high-performing leaders in the Veterans Health Administration to understand how they approach these challenges. Applying a positive deviance approach to examine organizational survey data across the entire administration, we first statistically identified Veterans Health Administration sites that, based on employee feedback, showed the greatest organizational health improvements from 2022. These sites' chiefs of staff (N = 24) were then interviewed about how they approached four specific challenges. Findings indicate commonalities across these leaders' best practices, including creating opportunities for dialogue, building a culture of learning and psychological safety, proactively addressing process improvements, supporting work-life balance, leading with grace and courage, and maximizing and protecting resources. Public sector health care leaders may benefit from this approach to learning from these highest performers. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

The quality of symptom management directly influencesthequality of life and survivalof patients, a and influenceshealth service outcomes. There is an evidence practice gap between the known benefits of a structured approach to symptom management and how to operationalize high-quality symptom management as a part of routine oncology care. To understand practices and processes that influence the quality of symptom management, particularly the characteristics associated with high-quality symptom management. This work included two qualitative datasets: (i) qualitative focus groups with oncology nurses and (ii) qualitative interviews with specialist health professionals. Positive Deviance Theory informed the methods. This study took place in an oncology outpatient department providing care to patients within a major hospital health service in Australia during June 2022 until August 2022. Oncology nurses and specialist health professionals were purposively recruited via email distribution lists and at general staff meetings. High-quality symptom management practices included early screening and assessment, interprofessional knowledge sharing, referral pathways to specialist teams, and flexible delivery of information to patients and carers. Quality symptom management may be optimized by drawing on the knowledge of healthcare teams providing symptom management.

ABSTRACT Purpose Working with livestock farmers in Kenya, Uganda, and Ethiopia, we explored how extension can better support actor-oriented, collaborative learning. We focused on locally-led adaptation solutions already working for livestock farmers affected by climate change, using positive deviance (PD). Our main research question was whether PD theory can be adapted to identify positive deviants whose uncommon solutions are a response to climate change. Design/Methodology/Approach Using qualitative research methods, we identified PD livestock farmers who were more successful in adapting to climate change and securing their livelihoods. From an initial sample of 112 local innovators, we selected 27 positive deviants across the three countries. Findings The PD approach effectively identified farmers with high potential for scaling locally-led adaptation practices and farmer-led innovations. However, we observed that climate change is not always the primary concern for these farmers, as other factors can sometimes take precedence. Practical Implications Our locally-led adaptation focused approach to PD has strong potential to support research, farmers, and extension services in building climate resilience in East African livestock farming. Originality/Value Positive Deviants succeed not just because of external project support but due to their own ingenuity and drive for change. Their ability to innovate – shaped by life histories and unique experiences – offers valuable learning opportunities for others in similar situations. A holistic AR4D approach is needed to better reflect the realities of East African farmers and promote adaptive, collaborative learning.

Background: Bullying is a critical school issue rooted in low self-esteem, which serves as a major vulnerability factor for children. This study aims to analyze the role of Positive Deviance (PD) education in improving children’s self-esteem as a bullying prevention strategy. Methods: A quantitative quasi-experimental pretest–posttest control group design was employed. The population consisted of grade VI students at SD Negeri 101893 Bangun Rejo, with a total sample of 58 students, divided into an experimental (n=29) and a control (n=29) group. Sampling involved identifying "positive deviants"—children who successfully overcame bullying risks—to develop the PD education module. Variables measured included knowledge, self-esteem (SE), and Positive Deviance Bullying behavior (PB) as dependent variables, collected via validated instruments. Ethical clearance was ensured throughout the procedure, and data were analyzed using Paired and Independent t-tests. Results: Most respondents were aged 11–12 years, and the experimental group had a higher proportion of females (65.5%). The experimental group showed significant improvements in knowledge (p=0.0001), self-esteem (p=0.043), and behavior (p=0.034). Independent t-test results confirmed significant differences between the experimental and control groups for knowledge (p=0.013), self-esteem (p=0.037), and behavior (p=0.024), indicating the intervention's effectiveness. Conclusion: Positive Deviance education effectively enhances children’s self-esteem, providing a vital psychological foundation for bullying prevention. It is recommended that future programs adopt a whole-school approach involving teachers and parents to support long-term behavioral change and sustainability.

Knowledge mobilisation concerns translating knowledge into action and bridging the gap between knowledge production and its apt utilisation in practice. Scholars have called for more interactive models that integrate different forms of knowledge through iterative collaboration among diverse actors. However, insights on how such interactive models function in practice are scarce. This article addresses this gap by examining how knowledge is mobilised during implementation of the positive deviance (PD) approach, a problem-solving approach involving diverse actors. The article draws on an in-depth qualitative case study of a cross-sectoral project in six Norwegian municipalities, where PD was applied to address youth marginalisation. Data were generated through iterative PD processes involving practitioners, managers and stakeholders across sectors. Insights were gleaned on PD as an interactive strategy for knowledge mobilisation. The findings show that PD enabled the identification and amplification of locally embedded practices, facilitated cross-sector collaboration, and contributed to shifts in participants' understandings of problems and solutions. Rather than relying on external expert knowledge, PD supported practice-driven learning and adaptive responses, resulting in interventions being perceived as more context-sensitive and sustainable. The article argues that PD represents a promising strategy for interactive knowledge mobilisation by reconfiguring the relationship between evidence, policy and practice. It contributes to debates on co-creation and knowledge use by demonstrating how practice-based knowledge can act as a driver of change. Certain limitations related to institutional scalability are discussed. The findings have implications for research, policy and practice addressing complex social challenges.

This article presents 'Becoming a Rotterdammer' (BaR), a social innovation project aimed at supporting the integration of status holders (refugees with a residence permit) in Rotterdam, the Netherlands. We applied the Positive Deviance (PD) strategy to identify and amplify successful, community-driven practices and inform grassroots support and local policy innovation. Collaborating with three communities of status holders, we identified individuals thriving despite similar systemic constraints. Through surveys and interviews, we assessed their sense of belonging as a key indicator of integration and well-being. We used a Random Forest model, a machine-learning approach estimating outcomes from interacting factors, to identify individuals whose sense of belonging exceeded predictions based on contextual factors like time in the Netherlands, employment, education, and social support. Follow-up interviews and card-sorting sessions uncovered uncommon practices fostering belonging, including easily adoptable ones (e.g., language buddy programs) and more challenging practices (e.g., affording sports club memberships), which highlighted structural barriers for NGOs and policymakers. This study demonstrates how PD can adapt to super-diverse contexts by integrating Random Forest analysis. Sorting practices by ease of adoption expanded their applicability, complementing top-down integration strategies. Our insights contextualize belonging as a dynamic process shaped by both agency and structural conditions.

Kenya experiences the triple burden of malnutrition, and despite a notable decline in stunting over the last decade, Bomet County continues to report very high stunting levels. This study sought to assess the effect of the PD-Hearth model on the weight of children 6–24 months and explore contextual determinants of malnutrition in Konoin, Bomet County. An exploratory sequential design was used, comprising a qualitative Positive Deviance Inquiry and a quantitative quasi-experimental non-randomized study with a non-equivalent control group. Phase one targeted adults aged ≥ 18 years, and phase two targeted underweight children aged 6–24 months and their caregivers. Phase two sample size was determined using G*Power software. Data was analyzed using SPSS version 22. Differences in weight, MUAC, and nutritional status between baseline and endline, and between study groups, were assessed using t-tests, chi-square tests, and difference-in-differences analysis, with p < 0.05 at the 95% confidence interval considered significant. Phase 1 showed that 85% of respondents had post-primary education, with 67.1% being farmers. In Phase 2, out of 110 children sampled, 53.6% were male. Caregivers demonstrated awareness of childcare practices, though these were limited by poverty, workload, and cultural beliefs. At baseline, the study groups showed no significant differences in age, weight, height, or MUAC, with p-values > 0.05 and a 95% confidence interval. The difference-in-difference analysis indicated that the proportion of well-nourished children increased by 7.3% in the intervention group compared to 1.8% in the control group (DiD = + 5.5%) for the weight-for-age z-score. For the weight-for-height z-score, the proportion of well-nourished children increased by 20.0% in the intervention group versus 3.6% in controls (DiD = + 16.4%). This analysis confirmed better outcomes regarding underweight and wasting in the intervention group, suggesting a meaningful positive impact of the intervention on these outcomes. Additionally, the mean weight gain was higher in the intervention group (0.15 kg, SD 0.32) than in the control group (0.10 kg, SD 0.14) over the study period. The PD-Hearth model demonstrated a positive short-term effect on weight and nutritional status among children aged 6–24 months, highlighting its potential as an effective community-based approach for addressing underweight in high-burden settings such as Konoin.

Tanzania launched the nationwide Star Rating Assessment in 2015 and has implemented it as a cornerstone of its national quality improvement program. We use variation in assessment results to explore mechanisms through which facilities improve quality. A mixed-methods positive deviance approach was applied by ranking all primary care facilities included in the Star Rating Assessment (n = 5,595) by their change in score between 2015/16 and 2017/18. The least- and most-improved facilities (n = 27) were selected for qualitative interviews with the highest-ranking provider at the facility on the day of data collection. The dataset was thematically analyzed first as a full-set and then divided by most and least improved to develop a local theory of improvement. Interviews were conducted with 27 facility leaders in 27 primary care facilities. Analysis showed that the SRA helped providers and staff find meaning in their clinical work which served as a core mechanism for improvement. This meaning-making was supported by stronger relationships and connections between health system actors. Connection to leaders came through the creation of a shared national mission to improve quality and an accountability system that allowed respondents to advocate for change. Connections to colleagues came through greater collaboration within facilities and competition between facilities. Connection to patients came through improved knowledge about clinical and interpersonal quality and self-checking against this new knowledge. Inputs to care were important, but not sufficient to drive improvement. Distilling SRA into a replicable improvement model carries with it the risk of losing contextual and programmatic factors which appear to be key to the success of the program in Tanzania. Implementation and ownership by the government of Tanzania was one of these critical elements.

Purpose This study investigates the role of employee positive deviance (PD) defined as voluntary behaviors that deviate from the standard norms but intends to achieve favorable outcomes in corporate social responsibility (CSR) outcomes. The study addresses a gap in literature by modeling bottom-up, employee driven initiatives to CSR. Design/methodology/approach The study uses Interpretive Structural Modeling (ISM) to identify and hierarchically structure twelve key variables. The variables were then applied through Matrice d‘Impacts Croisés-Multiplication Appliquée á un Classment or Cross-Impact Matrix Multiplication Applied to Classification (MICMAC) analysis and classified into four quadrants (driving, linkage, dependence and autonomous). Findings ISM produced a five-level hierarchy with organizational culture and leadership support as foundations (level 5), six PD behaviors as intermediate levels (level 2–4) and three CSR outcomes (corporate transparency, community engagement and sustainable resource management) as top level outcomes. Establishing that employee PD behaviors collectively influence CSR outcomes. Further, the mapping in MICMAC shows how foundational enables propagate through PD behaviors to achieve organizational CSR aspirations. Practical implications Our study offers valuable insights for the top management, policymakers, and HR practitioners. The study encourages organizations to foster a conducive environment to reinforce employee PD behaviors through leadership training, flexible role structures, and technology-enabled platforms for idea sharing. Originality/value This study integrates PD and CSR literature to model their micro-to-macro linkage through ISM-MICMAC. The findings also offer practical and actionable recommendations for organizations seeking better employee engagement toward CSR initiatives.

The positive deviance approach (PDA) to behavior and social change has been used to tackle child malnutrition in low-resource settings and has yielded positive health outcomes. Yet, not much is known about its application in noncommunicable disease (NCD) prevention and promotion. We did a scoping review by searching three electronic databases; PubMed (MEDLINE), Scopus (ScienceDirect), and Google Scholar and gray literature websites for primary research studies published in any language, country, and on any date, reporting on the application of the positive deviance (PD) approach to NCDs. A total of 2802 records were retrieved and 26 articles were included in the final analysis. The majority of studies were related to the application of the PDA on physical activity, obesity, weight-loss, and healthy eating, and the majority did not cover all steps of the PD approach and focused mainly on the identification of positive deviants and the identification of underlying PD behaviors and strategies, using a variety of quantitative and qualitative methods. All studies where PD behavior strategies were disseminated to nonpositively deviant communities and organizations yielded positive outcomes, such as clinically significant weight loss, and increased blood pressure control. The results of these studies suggest that positive deviants exhibiting exceptional performance exist in high-risk NCD settings, and therefore researchers and public health practitioners in the field of NCD prevention and promotion can learn from their success.

BackgroundCross-border postgraduate education is reshaping the public health workforce, yet little is known about what “return” looks like in aid-reliant health systems where authority, resources, and evidence are co-produced across government, research institutes, and international organizations. In Nepal, internationally trained public health scholars re-enter a mixed institutional landscape shaped by global higher-education markets, donor accountability regimes, and transnational procurement and supply chains. This study examines how Nepali returnees translate overseas training into system-facing work upon returning home, and how the timing of key milestones shapes what becomes actionable.MethodsSemi-structured interviews were conducted with 12 Nepali public health scholars who returned after postgraduate study abroad (five doctoral graduates; seven master’s graduates) and were working in Nepal at two research institutes and two international non-governmental organizations. Positive deviance purposive sampling targeted returnees with identifiable system impact. Data were analyzed using applied thematic analysis, guided by Bronfenbrenner’s bioecological model (micro-, meso-, exo-, and macrosystems), with the chronosystem examined as a cross-cutting influence.ResultsFour interconnected themes described patterned engagement across ecological levels. (1) Microsystem—reconstituting role and voice at home: return decisions were anchored in close relationships and early workplace recognition, with a time-sensitive shift from “credentialed outsider” to trusted colleague. (2) Mesosystem—boundary navigation: participants described convening and translating across institutions, with coordination accelerating after early probation and crystallizing around budget cycles, grant windows, and emergencies. (3) Exosystem—rules, resources, and distant decision-makers: procurement timelines, ethics review procedures, donor reporting templates, and customs/banking processes frequently determined the feasibility and tempo of reforms. (4) Macrosystem—national imaginaries, credential politics, and moral horizons of work: participants described credentials as opening initial doors, but sustained legitimacy depended on visible delivery amid shifting political and administrative cycles; some trained in regional Asian hubs emphasized the practical transferability of methods and policy argumentation. Across themes, timing mattered: family events, contract endings, fiscal quarters, monsoon disruptions, and crisis periods re-shaped constraints and opportunities.ConclusionsIn this cohort, returnee contribution was bioecological and time-sensitive: agency was not simply “brought home,” but assembled through relationships, cross-organizational brokerage, arm’s-length governance, and national legitimacy contests, all modulated by temporal milestones. Treating return as a time-sequenced ecology of action—rather than skill transfer—can better inform how governments, funders, and academic institutions design re-entry supports, procurement and reporting architectures, and evidence-use processes so that international learning more reliably translates into public value.Clinical trial numberNot applicable.

The positive deviance approach identifies uncommon yet successful practices within communities to address malnutrition through context-specific solutions. While it identifies locally effective practices, a critical gap remains in understanding how these practices are translated into structured interventions for broader dissemination. This scoping review aimed to identify key enablers in positive deviance nutrition interventions that support the transition from identifying positive deviant practices to their active dissemination through structured interventions. We conducted a systematic search across five electronic databases (PubMed, Web of Science, PsycINFO, Science Direct, CINAHL) and grey literature. We included original research of all study designs published in English from January 1st, 1990, to December 2, 2024. Then, we conducted a narrative synthesis to account for heterogeneity among the studies. Out of 259 positive deviance studies, 13 identified and then disseminated uncommon but successful practices. Among these, twelve studies included comparison groups and demonstrated improved nutrition outcomes. We identified six overarching themes that capture the key enablers of effective dissemination: integration with existing programs, ongoing capacity and skill building, active participant engagement, adaptable and modifiable practices and activities, cost-effective strategies, and cross-sectoral collaboration and partnership. This scoping review identified six themes that summarize enablers for effectively disseminating uncommon yet successful practices. These enablers not only align with successful criteria for scaling up conventional interventions but also reflect the principles of positive deviance. They highlight the value of integrating local knowledge and resources with external efforts to design tailored approaches to tackling malnutrition. Cross-sectoral collaboration and partnerships emerged as particularly important for scaling interventions. However, these enablers alone may not guarantee success, highlighting the need for future research to explore additional facilitators and barriers to optimize long-term implementation of positive deviance interventions in nutrition. CRD42020180396.

The US is experiencing an unprecedented sexually transmitted infections (STIs) epidemic. Although recent provisional data show some stabilization or minor declines in case rates for chlamydia, gonorrhea and syphilis, overall rates remain significantly higher than a decade ago. Local health departments (LHDs) play a crucial role in preventing and treating STIs, but some LHDs are demonstrably more effective than others. This study utilized a positive deviance (PD) approach to identify and analyze US counties with unexpectedly low STI rates. We used a cross-sectional study design, analyzing data from 981 counties across the US, using a two-step approach: (1) multivariate linear regression to identify PD counties, and (2) multivariate logistic regression to examine predictors of PD status. We identified 187 (19.06%) high-performing counties, considering internal and external factors, and investigated predictors that affect the identification of these high-performing counties. These counties were more likely to have the smallest population category (<25,000), which had 6.47times odds of being identified as PD counties compared with counties of ≥1million, counties with high social vulnerability in specific subcategories (racial and ethnic subgroup, housing, and transportation), and counties with LHDs that provided STI-related treatment services directly and through community partnerships. Our findings demonstrate the potential of using a PD approach for identifying and learning from high-performing LHDs. The identification of high-performing counties provides a foundation for future research to explore the nuanced interventions contributing to their success, ultimately informing targeted public health strategies and resource allocation.

Minimizing overtime and improving operating room (OR) throughput are a constant challenge in our publicly funded healthcare system. Previous experience with Positive deviance sessions (PDS) identifying excelling individuals and disseminating their strategies leads to significant improvements in a tertiary care level institution. The purpose of this study is to utilize PDS to increase the chance of success for 4 joint-day completion in a smaller rural community hospital. PDS seminars were conducted for 13 OR nurses, 4 anesthetists and 2 arthroplasty orthopedic surgeons. Best performing staff shared strategies to enhance performance at PDS. Efficiency and agreement following use of these strategies was measured and discussed at future PDS. Success of 4 joint days is the primary outcome. Time from the patient in the room to anesthesia ready (anesthesia prep time = APT), from anesthesia ready to surgery start (surgery prep time = SPT), procedure length, from surgical finish to patient leaving the room (anesthesia finish time = AFT) and room turnover were recorded to determine best performers and effect of intervention. Data points were obtained prior to PDS, 1–5 months post PDS, and 9–13 months post PDS to represent sustainability of the intervention. Prior to PDS, 49% of total joint arthroplasty days were completed on time. At the two different time points post PDS, 81% and 80% were being completed on time respectively. Average time to complete 4 cases was reduced. Notable changes were made in anesthesia prep time (baseline 21 minutes, 17 minutes at the different time points), and turnover (baseline 30 minutes, 25 minutes at short term, 23 minutes at long term). Positive deviance sessions in the rural setting can result in increased success in completing 4 joint arthroplasty days with minimal associated costs identifying positive performers as well as stimulating local strategies for efficiency. Long term sustainability data involving an analysis of complications will determine any adverse events associated with this intervention.

Despite the international popularity of Indonesian batik and the recognition of traditional batik-making as a specifically Indonesian cultural practice, fewer Indonesians choose batik makers as their profession. This study explores the motivations for becoming and remaining the producers of traditional Indonesian batik, an aspect that has been understudied. We use the positive deviance method, Ryan and Deci’s self-determination theory, and Bourdieu’s notion of doxa and habitus, to deepen our explanations. Using the life-story approach, we interviewed thirty traditional batik producers, both entrepreneurs, and workers, in-depth about their motivations. We found that in terms of motivation, there are two distinguishable groups: descendants and newcomers. Bourdieu’s notions of doxa and habitus provide insights into the motivations of descendants. They were often driven by family traditions and ties. All producers were driven by the core motivations of the SDT: (1) the desire for autonomy, (2) competence, and (3) the need for belonging. However, the first two motivations were particularly powerful among newcomers. Our study not only sheds light on the motivations of existing producers of traditional batik but also provides valuable insights for securing the future of batik as a traditional textile from Indonesia.