Practitioner Feedback Research Articles

Towards Sustainability of AI – Identifying Design Patterns for Sustainable Machine Learning Development

AbstractAs artificial intelligence (AI) and machine learning (ML) advance, concerns about their sustainability impact grow. The emerging field "Sustainability of AI" addresses this issue, with papers exploring distinct aspects of ML’s sustainability. However, it lacks a comprehensive approach that considers all ML development phases, treats sustainability holistically, and incorporates practitioner feedback. In response, we developed the sustainable ML design pattern matrix (SML-DPM) consisting of 35 design patterns grounded in justificatory knowledge from research, refined with naturalistic insights from expert interviews and validated in three real-world case studies using a web-based instantiation. The design patterns are structured along a four-phased ML development process, the sustainability dimensions of environmental, social, and governance (ESG), and allocated to five ML stakeholder groups. It represents the first artifact to enhance each ML development phase along each ESG dimension. The SML-DPM fuels advancement by aggregating distinct research, laying the groundwork for future investigations, and providing a roadmap for sustainable ML development.

Municipal Geothermal Systems: Evaluation of Three Hungarian Cases

Geothermal energy holds great potential for a sustainable future, as it is a clean and weather-independent form of energy. In addition to energy production, it can also serve the population of a region through direct use. In this paper, three municipal geothermal systems (Szarvas, Nagyszénás, Békéscsaba) in the same Hungarian region which have been recently installed or expanded are presented and analysed. Here, the direct usage of geothermal energy for heating purposes is a very important issue. The three systems show several differences and to some extent face different challenges in the various phases of the projects. Particular attention has been paid to engineering solutions to the problems that arise. The challenges, such as technical difficulties during installation, maintenance difficulties, or problems arising during operation are introduced. The strengths, weaknesses, opportunities, and threats of similar geothermal systems were summarized, based on the relevant literature. These points were evaluated by their appearance and characteristics in the examined systems. This study aims to provide insights, based on recently gained experiences, into geothermal projects, thus providing feedback and practical information for researchers and practitioners.

DEVELOPMENT OF STUDENT NEEDS ASSESSMENT GUIDELINES IN PLANNING GUIDANCE AND COUNSELING PROGRAMS

The Coronavirus Disease 2019 (Covid-19) pandemic has necessitated the adaptation of daily life, including education, to coexist with the virus, commonly termed the "new normal." This study investigates the implementation of needs assessment activities for counseling programs in Palangka Raya City Public High School during the Covid-19 pandemic era. Interviews with key personnel reveal that while there is recognition of the importance of needs assessment, practical challenges hinder its effective execution. Guidance counselors often resort to using previous years' programs due to difficulties in data collection and analysis, resulting in counseling services that may not align with student needs. To address this, operational guidelines are proposed, emphasizing the utilization of technology for needs analysis activities. Expert and practitioner feedback underscores the importance of adapting assessment models to counselor capabilities and school contexts. Enhancing student-centered needs assessment practices is crucial for improving counseling program efficacy and supporting holistic student development.

Participatory and Place-Based Socioeconomic Knowledge Generation: An Experience in Community-Based Research Pedagogy

This article uses fieldnotes along with student and practitioner feedback to recount the challenges, benefits, and broader learnings of engaging master’s students in a participatory research seminar. The students developed research proposals about a real-world socioeconomic challenge with and for local practitioners. Proposals were consistent with the principles and practices of participatory action research (PAR). The planning, implementation, and assessment of this course was informed by feminist scientific philosophies of collaboration, situatedness, partiality, accountability, and a sensitivity to power dynamics. In line with both PAR and SoTL principles, there was an explicit emphasis on partnership, reflexivity, and broad forms of learning in both the classroom and practitioner meetings. The students were challenged by the unfamiliarity of the research approach, the need to navigate a new way of working directly with stakeholders, as well as the responsibility to the community that participatory approaches espouse. Despite the challenges, the students were eager to soak up local knowledges, reflect on their role as researchers, and contribute constructively if they could.

Design, fabrication, and evaluation of 3-D-printed cystotomy spoons as a retrieval method in dogs.

Current cystotomy methods often implement the use of off-label devices, resulting in urocystolith extraction difficulty and potentially leading to postoperative complications and discomfort for the patient. The objective of this study was to create 3 novel 3-D printed cystotomy spoons that offer a dedicated solution for removing urocystoliths from a patient's urinary bladder. Clinical use of the 3 novel 3-D printed cystotomy spoons were ultimately evaluated in 4 dogs and 1 cat that presented for urocystotlith removal at 3 different veterinary hospitals in northwest Arkansas. The novel cystotomy spoons were designed using SolidWorks, 3-D printed with a Dental Surgical Guide resin, and underwent prototype testing that included chlorhexidine soaking, autoclave sterilization, 3-point bend testing, and Finite Element Analysis. The efficiency of the spoons was then evaluated through a limited proof-of-concept study utilizing a postoperative questionnaire for the participating clinicians. Practitioner feedback indicated positive experiences using 1 or more of the novel 3-D printed cystotomy spoons while performing a cystotomy surgery. However, successful use of the spoons was ultimately limited to dogs in the 23 to 34 kg weight range. Novel 3-D printed cystotomy spoons have the potential to mediate urocystolith extraction difficulty and reduce postoperative complications. Additionally, this research demonstrates how veterinarians might develop custom 3-D models and prints to meet patient-specific needs. As such, further development could impact the standard of healthcare and the veterinary industry by promoting the use of additive manufacturing in veterinary medicine.

Using the VERA-2R, professional and organisational aspects.

Violent extremism risk assessments of individuals suspected or convicted of terrorism are relevant for legal decisions, in prison and probation settings, and in inter-professional risk collaboration. These risk assessment reports by professionals should be applicable to and usable for the different judicial contexts. Informal and formal clinical practice evaluations, in the form of practitioners feedback and standardised evaluation of professional violent extremism risk reports are needed to gain insight in the use and quality of violent extremism risk assessments. In this study we examined how forensic professionals from three different countries (Sweden, Belgium and the Netherlands) use the VERA-2R in different judicial contexts. We also investigated which organizational aspects are important for the use of the VERA-2R. We focused on the perspective of the forensic professionals and their judicial organisations. We did a standardised survey among 86 VERA-2R trained professionals and a standardised interview with 20 executives and managers of organizations working with the VERA-2R. This study showed that professionals find the VERA-2R useful for structuring information and speaking a common risk language. However, using the VERA-2R comes with a variety of challenges, both on the professional and organisational level. VERA-2R trained professionals had few opportunities to use the instrument and when they did, they were not always offered regular supervision, intervision and booster training. Also, organisational issues in collaboration between judicial partner organisations and the lack of risk transfer information to professionals came to light. More research on the topic of risk transfer is needed. Policy implications are advised, for example the development of booster trainings, more organizational support, regulations on re-assessments, providing expertise and knowledge to indirect stakeholders and clear writing guidelines.

Incorporating a REIT Module to an Undergraduate Capstone Course: An Experiential Education Approach

This paper describes the pedagogical approach of incorporating a Real Estate Investment Trust (REIT) module in an undergraduate finance major capstone course at Florida Gulf Coast University, a regional comprehensive 4-year university. The module consists of two class periods and requires research of publicly-traded REITs using industry accepted sources of data, empirical and qualitative data analysis, and preparation of written and oral presentations that receive academic and practitioner feedback. The assignment aligns with experiential learning theory and the constructivism learning theory found in research in that it incorporates experiencing, reflecting, thinking, and active learning combined with the participation of guest speakers and judges who serve as external validators enhancing the student classroom experience.

Large scale medical image online three-dimensional reconstruction based on WebGL using four tier client server architecture

The development of medical device technology has led to the rapid growth of medical imaging data. The reconstruction from two-dimensional images to three-dimensional volume visualization not only shows the location and shape of lesions from multiple views but also provides intuitive simulation for surgical treatment. However, the three-dimensional reconstruction process requires the high performance execution of image data acquisition and reconstruction algorithms, which limits the application to equipments with limited resources. Therefore, it is difficult to apply on many online scenarios, and mobile devices cannot meet high-performance hardware and software requirements. This paper proposes an online medical image rendering and real-time three-dimensional (3D) visualization method based on Web Graphics Library (WebGL). This method is based on a four-tier client-server architecture and uses the method of medical image data synchronization to reconstruct at both sides of the client and the server. The reconstruction method is designed to achieve the dual requirements of reconstruction speed and quality. The real-time 3D reconstruction visualization of large-scale medical images is tested in real environments. During the interaction with the reconstruction model, users can obtain the reconstructed results in real-time and observe and analyze it from all angles. The proposed four-tier client-server architecture will provide instant visual feedback and interactive information for many medical practitioners in collaborative therapy and tele-medicine applications. The experiments also show that the method of online 3D image reconstruction is applied in clinical practice on large scale image data while maintaining high reconstruction speed and quality.

Core functions and forms of Bright IDEAS: A multi-methods evaluation of the adoption of an evidence-based psychosocial training program through iterative adaptation.

Despite efforts to widely disseminate interventions designed to increase access to quality supportive care to pediatric cancer patients and their families, many of these interventions fail to meet expectations once deployed in real-life clinical settings. This study identifies the functions and forms of Bright IDEAS: Problem-Solving Skills Training, an evidence based psychosocial intervention for caregivers of children recently diagnosed with cancer, to identify pragmatic program adaptations in its real-world clinical implementation. We compare intervention adoption before and after adaptations to the Bright IDEAS training program as part of a national training program designed to disseminate the intervention. 209 pediatric psychosocial oncology practitioners representing 134 unique institutions were trained during 10 in-person 8-hour workshops (2015-2019). Functions and forms of Bright IDEAS were identified, and adaptations made to the training agenda and curriculum based on practitioner feedback following implementation in local institutions. Mixed method evaluation included longitudinal surveys at 6- and 12-months post training; and qualitative interviews among a subgroup of practitioners (N = 47) to understand and compare perspectives on intervention adoption and barriers to implementation before and after adaptations to the Bright IDEAS training program. The RE-AIM framework was used to guide dissemination evaluation. A total of four adaptations were tailored to the identified forms of the intervention: case studies; pre-training reading materials; training videos; and letters of institutional support from primary supervisor. Pre- and post-training adaptations to the Bright IDEAS training program were mapped to RE-AIM constructs. Quantitative findings demonstrate that adaptations appeared to improve adoption and usage overall. This study provides insight into how contextual factors influence psychosocial practitioners' capacity to adopt, implement, and maintain Bright IDEAS in the clinical setting. This study demonstrates the use of real-time stakeholder feedback to guide intervention translation from research to practice settings.

Presyndromic surveillance for improved detection of emerging public health threats.

Existing public health surveillance systems that rely on predefined symptom categories, or syndromes, are effective at monitoring known illnesses, but there is a critical need for innovation in "presyndromic" surveillance that detects biothreats with rare or previously unseen symptomology. We introduce a data-driven, automated machine learning approach for presyndromic surveillance that learns newly emerging syndromes from free-text emergency department chief complaints, identifies localized case clusters among subpopulations, and incorporates practitioner feedback to automatically distinguish between relevant and irrelevant clusters, thus providing personalized, actionable decision support. Blinded evaluations by New York City's Department of Health and Mental Hygiene demonstrate that our approach identifies more events of public health interest and achieves a lower false-positive rate compared to a state-of-the-art baseline.

Visual Analytics to Leverage Anesthesia Electronic Health Record.

Visual analytics is the science of analytical reasoning supported by interactive visual interfaces called dashboards. In this report, we describe our experience addressing the challenges in visual analytics of anesthesia electronic health record (EHR) data using a commercially available business intelligence (BI) platform. As a primary outcome, we discuss some performance metrics of the dashboards, and as a secondary outcome, we outline some operational enhancements and financial savings associated with deploying the dashboards. Data were transferred from the EHR to our departmental servers using several parallel processes. A custom structured query language (SQL) query was written to extract the relevant data fields and to clean the data. Tableau was used to design multiple dashboards for clinical operation, performance improvement, and business management. Before deployment of the dashboards, detailed case counts and attributions were available for the operating rooms (ORs) from perioperative services; however, the same level of detail was not available for non-OR locations. Deployment of the yearly case count dashboards provided near-real-time case count information from both central and non-OR locations among multiple campuses, which was not previously available. The visual presentation of monthly data for each year allowed us to recognize seasonality in case volumes and adjust our supply chain to prevent shortages. The dashboards highlighted the systemwide volume of cases in our endoscopy suites, which allowed us to target these supplies for pricing negotiations, with an estimated annual cost savings of $250,000. Our central venous pressure (CVP) dashboard enabled us to provide individual practitioner feedback, thus increasing our monthly CVP checklist compliance from approximately 92% to 99%. The customization and visualization of EHR data are both possible and worthwhile for the leveraging of information into easily comprehensible and actionable data for the improvement of health care provision and practice management. Limitations inherent to EHR data presentation make this customization necessary, and continued open access to the underlying data set is essential.

The Questionnaire on Teacher Support Adaptivity (QTSA): Reliability and Validity of Student Perceptions

Adaptive teacher support (i.e., support that is tailored to students’ understanding) is considered crucial for students’ learning. Previous research examined support adaptivity mostly in small-scale, observational studies without distinguishing between theory-based facets of support adaptivity. Yet, students’ perceptions of different aspects of teachers’ support adaptivity may be important for students’ academic functioning. We investigated to what extent students perceive theory-based support adaptivity facets. We developed the Questionnaire on Teacher Support Adaptivity (QTSA) measuring students’ perceptions of teacher support adaptivity and examined its reliability and validity in two samples of secondary school students (N study1 = 1682; N study2 = 1048). Overall, the QTSA provided reliable and valid scores of students’ perceptions of teacher support adaptivity at the student and teacher level. One facet (non-adaptive support with much regulation upon high student understanding) should be used with some caution and needs further research. The QTSA scores converged with but also added to other constructs tapping into teachers’ support adaptivity. Students’ support adaptivity perceptions were distinguishable from students’ perceptions of other teaching indicators (agency and autonomy support). The QTSA can provide both individual and class level feedback for practitioners and help researchers to gain more insight into possible differential effectiveness of different adaptivity facets.

Kampo Formula-Pattern Models: The Development of 13 New Clinically Useful Standard Abdominal Pattern Models in the Fukushin Simulator.

Aim: In Kampo medicine, there exists an important system of diagnosis called Fukushin, or abdominal diagnosis or palpation. By applying pressure to the abdomen of the patient, the physician can gain important information on the patient’s physical state and use those indications to choose a suitable Kampo formulation. We have previously developed a Fukushin simulator, a teaching tool that reproduces the important abdominal patterns that doctors will encounter in clinical practice and that has received favourable feedback for students and practitioners. In order to make diagnosis and prescription easier, it is desirable to have matched formula–pattern pairings. The present study aims to develop such pairings. Methods: With the previously developed models as a foundation, in the present study the production team (two members) used materials such as urethane foam and silicone rubber to build an additional 13 standard abdominal pattern models matched to Kampo herbal formulas commonly used by practitioners in Japan. Subsequently, the evaluation team (the remaining 10 authors) investigated the viability of these models. Results: The evaluation team determined that abdominal pattern models matched to the following typical Kampo formulas were created successfully: Dai-saiko-To (大柴胡湯), Dai-joki-To (大承気湯), Shigyaku-San (四逆散), Saiko-ka-ryukotsu-borei-To (柴胡加竜骨牡蛎湯), Keishi-bukuryo-Gan (桂枝茯苓丸), Hachimi-jio-Gan (八味地黄丸), Hange-shashin-To (半夏瀉心湯), Sho-saiko-To (小柴胡湯), Hochu-ekki-To (補中益気湯), Sho-kenchu-To (小建中湯), Toki-shakuyaku-San (当帰芍薬散), Ninjin-To (人参湯), and Dai-kenchu-To (大建中湯). Conclusion: We suggest that these new formula-pattern models can make an important contribution to the standardization of abdominal diagnosis and prescription and to Kampo education.

“By educators for educators” – an introduction to a GDR education television project for teachers (1970–1982)

ABSTRACTThe GDR series “Von Pädagogen für Pädagogen” (“By Educators for Educators”), which addressed GDR educators, was established in 1970 and then broadcast in this form for 13 years at approximately monthly intervals. The article presented here locates the programme within the GDR’s continuing education landscape and endeavours to reconstruct the origins and further development of the programme. It offers a valuable insight into the GDR’s education and training system, as the production of the programme took place in a spirit of cooperation, but also against a background of tension between the Ministry of National Education, the Academy of Pedagogical Sciences (APW), the Central Institute for Continuing Education (ZIW), and the GDR schools (in their function as both co-producers and recipients). It illustrates that the format was strongly influenced by ministerial guidelines but at the same time had to face the judgement of the teachers regarding its practical relevance in order to fulfil the intended function: a continuing education beyond the organised events. It is furthermore shown that the two institutions entrusted with the organisation (first the APW, then the ZIW) contributed their own perspectives and thus cannot be reduced to the role of executors of ministry wishes. The result of the cooperation was a series of broadcasts that presented a – scientifically based – ideal image of GDR education, but at the same time also used the feedback of practitioners for optimisation and can thus be classified as documentation of educational ideals that were accepted (but not necessarily implemented) through practice.

Systematic analysis of driverless technologies

Purpose The advent of Industry 4.0 has engendered opportunities for a coalescence of digital technologies that collectively enable driverless vehicles to operate during the construction and use of a highway. Yet, hitherto scant research has been conducted to review these collective developments and/or sample construction practitioner opinion on them. This study aims to present a systematic review of extant literature on the application of driverless technologies in civil engineering and in particular, the highways infrastructure sector and offers insight into the limitations of associated barriers to full adoption, namely, current technological development processes, legal deficiencies and societal concerns. In so doing, this work presents a vignette of contemporary developments augmented by a critical analysis from practitioners’ perceptions. Design/methodology/approach A mixed philosophical methodological approach is adopted for this inductive research study. Interpretivism is used to critically analyse the literature and post-positivism to perform content analysis of the literature and synthesis of the discourse with practitioners. A total of 44 related papers published between 1998 and 2019 have been included in this study. Emergent themes identified from literature are then discussed in some further detail, namely, 1) automation and robotics; 2) case studies and simulations; and 3) safety and ergonomics). A focus group is then held with leading industrialists to discuss their experiences of advanced driverless technology applications in practice. Based upon a culmination of emergent evidence, a conceptual model of prevailing barriers is then developed to further elucidate upon the challenges facing the highways infrastructure sector. Findings Research into driverless technologies within the highways infrastructure sector has received relatively scant academic attention. Hitherto, most advancements made have stemmed from multidisciplinary teams consisting of engineering, information technology and social scientist researchers. There is insufficient supporting evidence of civil engineering and construction academics input into developments made – suggesting that prototype products often fail to adequately consider practical applications in the highways infrastructure sector at the design and use case stage. This view is substantiated by feedback from leading industry experts who participated in unstructured telephone interviews. Their feedback suggests that practical applications of products have been beset with problems, thus creating a perception that advanced technologies are largely “unusable” within the highways infrastructure sector and so are unsuitable for large-scale (and particularly bespoke) industrial applications. Originality/value This research critically synthesises the prevailing scientific discourse within extant literature on driverless technologies implemented but also garners practitioner feedback from leading UK industrialists on their applications in practice. Hitherto, this combined analysis approach has been rarely used in spite of it having significant advantages of tacit knowledge reflection on technologies used, where such can be used as a basis for further informed discourse and/or development. Moreover, this work culminates in a conceptual model that acts as a catalyst for future research investigations.

Validity and Reliability of StriveTM Sense3 for Muscle Activity Monitoring During the Squat Exercise

Background: Recent innovations in surface electromyographic (sEMG) technology have enabled the measurement of muscle activity using smart textiles. Objective: In this study, the StriveTM Sense3 performance monitoring system is evaluated against a research-grade system, NoraxonTM, in measuring activity during the back squat exercise. Method: Seventeen participants performed three total trials of the squat exercise with a progressive load for individual trials equal to 30%, 60%, and 80% of their estimated maximum 1RM (one-repetition maximum). sEMG measurements from the rectus femoris were captured for the left and right leg by both systems. Pearson product-moment correlation coefficient (r) and intraclass correlation coefficient (ICC) values were computed for each trial to assess concurrent validity and interrater reliability of the StriveTM Sense3 device. Additionally, five coaches at the collegiate- and professional-level of Men’s Basketball speak from an autoethnographic frame to the findings from this study. Results: Results ranged from “Poor” to “Excellent” validity and “Poor to Moderate” to “Excellent” reliability, with a majority of trials achieving “Good” or better results across all loads [93% trials: r >= 0.7; 87% trials: lower ICC 95% CI bound >= 0.75 (absolute sEMG); 98% trials: lower ICC 95% CI bound >= 0.75 (normalized sEMG)]. Higher validity and reliability for medium and heavy loads were observed in comparison to the light load, and several outliers indicate the need for coaches to lubricate sensors and ensure proper fit to collect accurate data. Conclusion: Examining results alongside practitioner feedback indicate the StriveTM Sense3 system is capable of tracking sEMG activity in comparison to a research-grade system.

Practical Training Strategies to Apply Neuro-Mechanistic Motor Learning Principles to Facilitate Adaptations Towards Injury-Resistant Movement in Youth

Youth may be particularly responsive to motor learning training strategies that support injury-resistant movement mechanics in youth for prevention programs that reduce injury risk, injury rehabilitation, exercise performance, and play more generally (Optimizing Performance Through Intrinsic Motivation and Attention for Learning Prevention Rehabilitation Exercise Play; OPTIMAL PREP) One purpose of the present manuscript was to provide clinical applications and tangible examples of how to implement the proposed techniques derived from OPTIMAL theory into PREP strategies for youth. A secondary purpose was to review recent advances in technology that support the clinical application of OPTIMAL PREP strategies without extensive resources/programming knowledge to promote evidence-driven tools that will support practitioner feedback delivery. The majority of examples provided are within the context of anterior cruciate ligament (ACL) injury rehabilitation, but we emphasize the potential for OPTIMAL PREP strategies to be applied to a range of populations and training scenarios that will promote injury resistance and keep youth active and healthy.

Exploring alternative solid waste management strategies for achieving policy goals

The authors previously analysed a real-world solid waste management (SWM) system using the solid waste optimization life-cycle framework (SWOLF) to identify optimal SWM strategies that meet modelled objectives (e.g. cost, environmental impacts, landfill diversion). While mathematically optimal strategies can support SWM decision making, they may not be readily implementable because of unmodelled objectives (e.g. practical limitations, social preferences, political and management considerations). A mathematical programming technique extending SWOLF is used to systematically identify, for several scenarios, different ‘optimal’ SWM strategies that are maximally different from each other in terms of waste flows, while meeting modelled objectives and constraints. The performance with respect to unmodelled issues was analysed to demonstrate the flexibility in potential strategies. Practitioner feedback highlighted implementation challenges due to existing practices; however, insights gained from this exercise led to more plausible and acceptable strategies by incrementally modifying the initial SWM alternatives generated.

Audit and feedback for individual practitioners in the emergency department: an evidence-based and practical approach.

Audit and feedback for individual practitioners in the emergency department: an evidence-based and practical approach.

Using patient-reported measures to drive change in healthcare: the experience of the digital, continuous and systematic PREMs observatory in Italy

BackgroundThe use of Patient Reported Experience Measures (PREMs) has great potential in healthcare service improvement, but a limited use. This paper presents an empirical case of PREMs innovation in Italy, to foster patient data use up to the ward level, by keeping strengths and addressing weaknesses of previous PREMs survey experiences. The paper reports key lessons learned in this ongoing experience of action research, directly involving practitioners.MethodsThe aim of this paper is to present the results of an ongoing action research, encompassing the innovation of PREMs collection, reporting and use, currently adopted by 21 hospitals of two Italian regions. The continuous and systematic PREMs collection has been implemented between 2017 and 2019 and includes: a continuous web-based administration, using web-services; an augmented and positive questionnaire matching standard closed-ended questions with narrative sections; the inclusion and benchmarking of patient data within a shared performance evaluation system; public disclosure of aggregated anonymized data; a multi-level and real-time web-platform for reporting PREMs to professionals. The action research was carried out with practitioners in a real-life and complex context. The authors used multiple data sources and methods: observations, feedback of practitioners, collected during several workshops and meetings, and analysis of preliminary data on the survey implementation.ResultsA continuous and systematic PREMs observatory was developed and adopted in two Italian regions. PREMs participation and response rates tend to increase over time, reaching stable percentages after the first months. Narrative feedback provide a ‘positive narration’ of episodes and behaviours that made the difference to patients and can inform quality improvement actions. Real-time reporting of quantitative and qualitative data is enabling a gratifying process of service improvement and people management at all the hospitals’ levels.ConclusionsThe PREMs presented in this paper has been recognized by healthcare professionals and managers as a strategic and positive tool for improving an actual use of PREMs at system and ward levels, by measuring and highlighting positive deviances, such as compassionate behaviours.