Editorial: Patients: passive subjects or active participants in reducing the spread of infection?


Each year hundreds of millions of patients worldwide are affected by potentially preventable healthcare-associated infections (HAIs), causing patients needless pain and suffering, prolonged hospital stays, financial burden and even death (World Health Organization 2011). The overuse and misuse of antibiotics has resulted in multidrug-resistant organisms (MDROs) that further increase the morbidity and mortality associated with infections (World Health Organization 2012). Despite the increasing standardisation and implementation of infection prevention and control strategies such as hand hygiene, environmental cleaning and surveillance, HAIs remain the most frequent adverse event experienced by patients (World Health Organization 2011). Current strategies for reducing HAIs have largely concentrated on what healthcare professionals can do to prevent spread of infection. However, little consideration has been given to the role of patients in preventing infection transmission. Clearly, patients can and should have a role, but are patients aware of the role and who determines the nature of this role?

Several studies identify organisational and management characteristics that present risk factors for infection transmission. These studies are unanimous in recommending a combination of strong leadership, strictly defined hand washing routines and use of personal protective equipment, restrictions placed on antibiotics use and improved nurse–patient ratios (Griffiths et al. 2008). Recently, after developing and testing a multimodal hand hygiene improvement strategy, the World Health Organization (2009) has recommended initiatives that also include patient involvement in infection control. Studies that have embraced this approach often aim to educate patients about the importance of hand hygiene and/or invite them to remind clinicians to wash their hands (McGuckin et al. 2011). Findings generally show improvement in clinician hand hygiene compliance; however, the sustainability of these improvements and their impact on infection rates remain unknown (Landers et al. 2012). Furthermore, critics suggest that it is inappropriate to expect sick, vulnerable patients to be responsible for their own safety around infection control (Hill 2011).

More importantly, however, these strategies and recommendations fail to attend to the complexity of how infection control plays out in the everyday ‘here and now’ of patients, carers and clinicians in busy clinical settings such as hospitals (Iedema et al. 2013). Instead, we argue that the strategies put into place to tame the complexity of infection transmission will only work when staff are intelligent about infection control, meaning that they, researchers and policy makers, must deal with the everyday complexity of care processes (Iedema et al. 2013). This includes acknowledging, exploring, accepting and engaging with the many roles that patients, their friends and families may play (and may already be playing) in identifying infection risk and preventing cross-contamination (Hor et al. 2013).

All too often, patients are represented as passive subjects upon whom the rituals of the health professional are played out. Let us consider the WHO ‘5 moments for hand hygiene’ poster (http://www.who.int/gpsc/tools/Five_moments/en/), which features a patient lying in bed – a body upon which infection control strategies are practised. Patient involvement in hand hygiene studies attempt to make this passive body more active by asking patients to remind clinicians to clean their hands. We know that some patients may, due to profound illness or incapacity, be unable to act; however, most patients are not passive. Patients are not simply bodies lying in bed, and clinicians rarely travel in straight lines to and from the bed to execute isolated, singular actions. Patients (and their visitors) get up and move about; they visit other patients, use communal patient facilities and attend other areas of the hospital for therapies and diagnostic tests. They interact with multiple people and environments. Likewise, clinicians engage in complex activities, many of which cut across one another, and which therefore raise delicate questions about how specific infection control rules [such as when to put on gloves] are to be followed.

It is important to note in this context that studies of patient experiences of being isolated for MDROs commonly describe patients as feeling lonely, imprisoned or violated (Mutsonziwa & Green 2012). Mobile infectious patients, however, are not always confined to their rooms. In ethnographic research currently underway in a surgical ward, we have found that mobile infectious patients often leave their isolation rooms and that nurses are concerned about, but uncertain as to how to address this infection risk (Wyer 2013). We have also found that brochures are available for patients and visitors, explaining the importance of hand hygiene, but in this site at least, they are not commonly available, nor discussed. Furthermore, adherence to hand hygiene protocols can vary (or be absent) outside of ward areas, such as at the patient gym where infectious and noninfectious patients exercise on the same equipment and outdoor areas where patients socialise (Wyer 2013).

Infection transmission and control is complex.

When we observe practice in situ, we find that conversations between patients and clinicians about infection control are noteworthy for their absence. And yet patients are the people who have the most at stake here. With this in mind, Hor et al. (2013) recently emphasised the importance of attending to moment-to-moment clinician – patient interactions as ‘sites of safety production’. By attending to patients' experiences, understandings and actions around these moments, Hor and colleagues provide evidence that patients actively and successfully contribute to the safety of their own care. So how can we attend to these moments when researching infection control?

We agree that evaluating patient-centred hand hygiene programmes is a start, but keeping in mind that such strategies draw on clinician or researcher viewpoints on what a patient might do to ensure safety. They do not explore the creative safety contributions made by patients that clinicians may not even be able to imagine (Hor et al. 2013). Other studies have explored patient experiences of HAIs and subsequent infection control measures (Mutsonziwa & Green 2012). Most of this research, however, has been conducted through quantitative survey and the use of standardised measurement tools or single interviews that capture the thoughts and feelings of people at only one point in time. One study on patients' experiences of source isolation involved conducting interviews up to 3 years after discharge (Skyman et al. 2010). Unlike Hor et al.'s (2013) study, what these latter studies have in common is that they distance the researcher from the complexity of in situ interactions (Iedema et al. 2013). Consequently we lack insight into the way in which infection control unfolds as part of everyday practice. This means that we are denied understanding of how everyday practices shape patients' and clinicians' attention, reactions and precautions around infection risk. We also lack understanding of how then to change or extend these everyday practices to improve infection prevention.

Given the growing emphasis on patient-centredness and consumer engagement Australian Commission on Safety and Quality in Health Care (ACSQHC, 2011), it is now time that patients and their families are given a real voice about how infection control is played out in the immediate and meaningful contexts of their healthcare experiences. We must embrace new ways of researching alongside and with patients and their families if we want to better understand the full complexity of infection transmission and to incorporate these findings into more inclusive and patient-centred redesign of infection control services. Get up close, watch and listen, have conversations, build relationships and involve patients as much as possible. After all, it is patients who have the most at stake here.