Part of patient empowerment involves the ability to ask healthcare workers to wash their hands. While this task may seem easy, data from studies conducted both in the United States and Europe suggests that acting on this instruction is not universal. To best understand this issue, one needs to take a step away from infection control environment and into the archives of psychology.
Back in 1955, the great psychiatrist, Dr. Thomas Szasz, who is partly credited for having started the patient advocacy movement with the publication of his 1961 book, The Myth of Mental Illness, co-authored a paper examining the doctor-patient relationship and postulated three basic models.
• Activity-Passivity: In this model, the patient is an unaware recipient, such as in surgery in which the doctor is essentially performing a task to help the recipient without any interaction.
• Guidance-Cooperation: In this model, the patient is akin to a student who is learning from a teacher on what is necessary to achieve the best possible health outcome. In this particular model, the patient is viewed to be desperate for answers and the physician has the power and the patient is required to ‘obey’ unconditionally.
• Mutual Participation: In this model, both parties have equal amount of power and engage in an activity that will be satisfying to both. This model is considered to be a highly developed one and rarely achieved although often desired by those who wish to have a more robust relationship.
The paper concluded mutual participation was ultimately the best option but that it would be hard to achieve without some type of intervention to overcome guidance-cooperation. Over the next forty-five years, there were several attempts using question-asking as a measure yet as Szasz predicted, there were few successes.
In 1999, infection control took the reins with the first evidence that educating patients led them to ask for hand hygiene compliance. Unfortunately, the euphoria didn’t last as the results of numerous subsequent studies were disappointing. The factors causing this barrier were numerous, ranging from age to socioeconomic status to gender to literacy. There appeared – and perhaps still does appear – to be no concrete solution.
Yet these problems may have less to do with asking the question and more with how the question is asked. Back in 1976, Greg P. Kearsley published a review breaking down the process of question asking. The results were congruent across all individuals: the most popular questions started with “How are” and “What is”; the most eschewed were those requiring an obligatory yes or no. Looking further, Kearsley found the tone and flow of obligation detracted from the rest of the conversation and created a barrier that altered the discussion and left both feeling disconnected.
It should be no surprise then that when we advocate that patients ask a question outside of normal discourse that they are less likely to take on the role. Yet turning hand hygiene into a matter of discourse may appear to be unachievable. Still, there are ways to improve the potential of including the topic into discussion using a few easy, inexpensive and proven ideas.
The results from historical analysis of patient psychology suggest the potential for improvement is present although requires a different mindset. Rather than enforcers, patients should be collaborators in hand hygiene. The tactics for education should be based on social marketing rather than regulation. But most importantly, promotion should be based on fostering the conversation and the relationship, not diverging from it lest as Szasz pointed out, the relationship is doomed to be dissolved.
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