Proposing a Positive Deviance Model to Improve Management of Cancer-Related Psychosocial Distress

Article excerpt


Psychosocial distress resulting from cancer diagnosis and treatment is common, occurring in up to 50% of patients. Mental distress (e.g. depression, anxiety) as well as social distress (e.g. job loss, family discord, economic compromise, lack of transportation) affect many aspects of cancer patients' and survivors' lives. Positive deviance identifies those clinical settings that are able to provide for patient needs within resource poor environments. The organizational strategies of positive deviant clinicians can be captured, modeled, and transferred to a wide range of settings and patients. Positive deviance is based on the belief that solutions to optimize resources already exist in practice and can be broadly applied, in this case to enhance organizations that currently do not provide comprehensive psychosocial distress screening or services. Discovering organizational practices which deviate from the current practice norm, yet benefit a wide range of cancer patients is an ongoing challenge. We propose positive deviance as an appropriate theoretical approach to research which addresses the propagation of effective psychosocial intervention to a variety of cancer treatment settings.

Key words: Psychosocial distress, cancer, positive deviance

Cancer related psychosocial distress can influence many aspects of a patient or survivor's life, including treatment decisions, compliance with treatment, family coping, and overall quality-of-life (Ellis, Lin, Walsh, Lo, Shepard, Moore et al., 2009; Moandel, Morgan & Dutcher, 2007). Psychosocial distress is complex and includes emotional, spiritual, relational, economic, and practical challenges occurring during the navigation of cancer treatment, survivorship or end-of-Iife care. Although common, psychosocial distress is frequendy under-diagnosed and poorly managed in the current US healthcare system (Clark, 2001; Jacobsen, 2007). We suggest ^positive deviance approach to guide future innovation in the management of cancer-related psychosocial distress.

What is Positive Deviance?

Positive deviance is an approach to organizational change that adopts the unique practices of those organizations which have the same resources and conditions as others, but whose unique attitudes, practices or strategies enable them to provide excellence in psychosocial screening and care (Marsh & Schroeder, 2002; Marsh, Schroeder, Dearden, Sternin & Sternin, 2004). Identification of those positive deviant organizations which are atypically successful in their ability to implement best practice guidelines provides the basis for future research focused upon the implementation of identified positive deviant behaviors. Modeling these environments gives practitioners cost effective organizational strategies which are transferable to a wide variety of settings and patients, and can lead to significant performance improvements or psychosocial care (Marsh & Schroeder, 2002; Walker, Sterling, Hoke & Dearden, 2007).

The National Comprehensive Cancer Network (NCCN, 2008) selected distress as the overarching term to describe widely varied types of psychosocial problems, ranging from such debilitating mental illnesses as major depressive disorder, to societal and functional impediments that cancer brings to daily living (e.g. loss of driving ability, role function, sexuality, and family relationships). Although we use the rubric 'distress' throughout this article, we will be more specific with regard to the nature of distress where warranted.

Review of the Literature

Overview of Distress

The NCCN (2008) defines cancer related distress as "an emotional experience of a psychological, social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and treatment." Psychosocial distress ranges from normal feelings of vulnerability, sadness, and fears regarding the cancer experience to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis. …