Non-Adherence to Patient Safety Guidelines: an Evolutionary, Ecological Hypothesis

Non-adherence to patient safety guidelines

Non-adherence to patient safety guidelines: an evolutionary, ecological hypothesis

[*]Abilio Cesar de Almeida Neto,

B.Sc. (Psychology) Hons, Ph.D.

Faculty of Pharmacy, The University of Sydney

Abstract

Often well meaning health care workers do not adhere to patient safety guidelines or recommendations, with serious consequences; patient injuries and mortality. Non-adherence has been attributed to external limitations, such as heavy workload, the non-availability of resources or how health care workers perceive the expectation of their superiors towards their performance. This paper presents new thoughts and ideas on such non-adherence. It presents a theoretical argument for how current policies for promoting patient safety in health care delivery might be hindered by a particular evolved mechanism that has not been considered.Non-adherence is argued to be an adaptation, or, more specifically, it is argued to be structured in such a way to generate adaptive outcomes when elicited by those in positions of power in dominance hierarchies wherein it is an efficient strategy.The core explanatory dynamics of non-adherence to patient safety guidelines are presented in terms of the social dominance hierarchy within which physicians function and that accounts for these evolved adaptations that enable maintenance of dominant status and cohesive (cooperative) group living and social rank-related mate selection behavior. Applied approaches to minimizing non-adherence to patent safety guidelines among health care workers (primarily physicians) are also presented.

Keywords:Evolutionary Psychology, Patient safety, Hand hygiene, Psychological reactance, Team work, Inter-professional collaboration.

Introduction

In 1999 the Institute of Medicine released the landmark report ‘To Err is Human: Building a Safer Health System’ (Kohn et al., 2000) that exposed the magnitude of health care errors in the United States, which was then estimated to result in up to 98,000 deaths and more than 1 million injuries each year. Soon after the release of the report we learned that health care errors is a global phenomenon affecting 1 in every 10 patients around the world (WHO, 2004). Over a decade later research has validated concerns raised in the United States (Leape and Berwick, 2005) and in the United Kingdom (Vincent et al., 2008) that the rate of patient harm resulting from health care remains high. Despite a decade of quality-improvement initiatives and discussion and research on how to remedy causes of adverse events, Landrigan et al. (2010) demonstrate that harms remain common, with little evidence of widespread improvement, with “compliance with even simple interventions such as hand washing being poor in many centers” (p.2130). This begs the question: why are we still unable to deliver safer health care?

This recognition by the Institute of Medicine in the United States that as human beings health care providers are prone to make mistakes (Kohn et al., 2000) has led to a decade of efforts being predominantly directed at counteracting the human factor in health care. This has been done by improving system design, organization and operation in the health care system. While health care scientists would agree that such improvements are an important and necessary facet of the progress towards achieving safer health care, this new direction in quality improvement has come at a price: we have to a significant extent lost sight of the fact that if we are to deliver safer patient care, we must also understand what it is about being a human that contributes to preventable adverse events. We need to gain a better understanding of the behavior patterns that generate preventable adverse events and their regulating mechanisms. By identifying, describing, and examining these behavior patterns and their regulating mechanisms we become closer to being able to remedy the causes of preventable adverse events and to deliver safer patient care.

This paper argues that some behaviors that facilitate preventable adverse events in the health care setting do not happen in isolation but as critical parts of behavior patterns that are adaptively significant. It draws on evolutionary and social psychology to argue that mechanisms shaped by biological evolution that evolved to facilitate group living can generate behavior patterns that were adaptive in the human ancestral environment but dysfunctional in the modern health care setting causing non-adherence to simple patient safety recommendations and guidelines; that is, a mismatch outcome. Non-adherence to hand hygiene recommendations is used as the model framework for arguing how this mismatch between our genetic makeup and the demands of the modern health care system adversely impacts on patient safety. A theoretical framework is presented not only for further understanding the genesis of non-adherence to rightful guidelines and recommendations but also for suggesting how to remedy non-adherence. In so doing, the work of evolutionary, social, clinical, physiological, and personality psychologists, and medical researchers, in the last five decades is pieced together to formulate a theoretical argument of:

• how acting contrary to communication from others (non-adherence) may have served an adaptive purpose in the human ancestral environment;
• how it is possible that non-adherence to rightful recommendations is biologically determined;
• what biological mechanisms are likely to generate non-adherent behavior;
• how mechanisms generating non-adherence may impact specifically on physicians’ behavior;
• which circumstances and under what conditions biologically determined non-adherence is more likely to occur; and
• how principles currently used in clinical psychology to extinguish maladaptive activation of behavior patterns of deep evolutionary origin could guide efforts to avert non-adherence to rightful recommendations in the health care setting.

Finally, directions for future research are discussed.

The mismatch hypothesis

The central tenet of evolutionary psychology holds that the brain is an adapted organ designed by evolution to produce behavioral responses. Much of human behavior is believed to be the output of psychological adaptations that evolved to solve recurrent survival problems in the human ancestral past (Tooby and Cosmides,1990). That is, rather than being organized as general purpose mechanisms, behavior is believed to be organized into relatively independent modules (Tooby and Cosmides, 1992 cited in Öhman and Mineka, 2001: 484). Just as our body is composed of organs serving different survival purposes, behaviors or psychological systems can be approached as organs or independent modules serving different survival and procreation purposes (Fodor, 1983 cited in Öhman and Mineka, 2001: 484).

Eaton et al. (2002 cited in Dickins, 2006) advocate what is known as the ‘mismatch hypothesis’: the human phenotype has emerged during a long evolutionary history and anatomically modern humans (Homo sapiens) have only been in existence for the past 100,000 years, which is too short a period of time for significant evolutionary change to occur, hence our adaptations were selected to solve problems in our evolutionary past. Consequently, in the modern world there is the potential for mismatch between modern problems and our adapted solutions. Therefore, it is possible that the human brain will produce behavioral responses to health care problems that were adaptive in the human ancestral environment but dysfunctional in the modern health care setting.

Non-adherence to rightful guidelines: a mismatch outcome?

Pathogen transmission has been a real concern for humans since the time of the great chemist Justus von Liebig (1803-1873)who most actively supported the spontaneous generation of disease within the blood and the pathologist Friedrich Henle (1809-85) who well formulated the theory that infection was caused by a living organism (Brock, 1997).

We now know that health-care-associated infections are considered the most frequent adverse event threatening patients’ safety worldwide (Allegranzi et al., 2011) affecting one in 11 patients, with a mortality rate of 13% (Grol and Grimshaw, 2003). Although 15% to 30% of health-care-associated infections are considered preventable - eg, by improved hand hygiene (Grol and Grimshaw, 2003) - the application of hand hygiene measures by health care workers has been deemed by researchers to be a complex phenomenon that is not easily explained or changed despite its simplicity (Pittet and Boyce, 2001; Larson and Killien, 1982 cited in Pittet et al., 2004: 4-5). Adherence to hand hygiene recommendations is unacceptably low; typically well below 50% (Pittet et al., 2004), with research showing that in health care settings where resources are limited adherence is even lower; below 20% (Allegranzi, et al. 2011).

The medical literature shows that hand hygiene behavior is the product of a complex interaction of multiple factors (Pittet, 2004), with common determinants of hand hygiene performance being: workload of health care workders (O’Boyle, Henly, & Larson, 2001; Pettit et al., 2000); attitude towards hand hygiene, perceived ease of complying with hand hygiene guidelines, subjective norms, and behavioral norms (Sax et al., 2007; Whitby et al., 2007; Pessoa-Silva et al., 2005); how health care workers perceive the expectation of their superiors towards hand hygiene (Lankford et al., 2003; Saloojee & Steenhoff , 2001; Muto, Sistrom, & Farr, 2000). Interestingly, researchers have pointed out that hand hygiene performance is more likely to be influenced by external limitations, such as workload or the availability of hand cleansing agents (Pittet et al., 2000; Hugonnet, Perneger, & Pittet, 2002; Pettit et al., 2004; Pessoa-Silva, et al., 2005; Traore et al., 2007) and how staff perceive the expectation of their superiors towards their performance (Saloojee & Steenhoff, 2001; Muto, Sistrom, & Farr, 2000; Lankford et al., 2003) but not by internal factors, such as knowledge, skill, and attitudes (Tai et al., 2009).

The current paper attempts to complement current thinking by arguing that non-adherence to rightful patient safety guidelines can also be understood as a result of a naturally selected behavior system that evolved to facilitate group cohesiveness and functioning. It argues that acting contrary to communication from a conspecific has a function: it is a signal that conveys social dominance information to social opponents. Implicit in obeying orders, in having no choice, is social submissiveness whereas having the option of whether or not to adhere to communications from others signals social dominance. Indeed, a behavioral response in the form of ignoring or acting contrary to communication from a conspecific must have played an important role in conveying signals of dominance to social opponents, and prospective mating partners, throughout human evolution thereby assisting individuals to define and maintain optimal rank in dominance hierarchies within a group, as well as assisting them to gauge how dominant social opponents would be in the particular situation by analyzing their reactions to the defiant behavior. We know that once differentiation in terms of dominance is established within a group, stable hierarchies can then be formed, decreasing antagonistic interactions among group members; this is beneficial for group cohesiveness and the group’s functioning as a social unit (Öhman, 1986). Therefore, behaviors such as acting contrary to communication from others assisted our evolutionary ancestors to form stable hierarchies, which enabled them to exploit the environment in tightly knit bands increasing their chances of survival and reproductive success. Thus, although social dominant behavior is not generally adaptive in the modern health care setting, it is possible that behaviors that prevent us from improving patient safety outcomes, such as acting contrary to simple patient safety guidelines (non-adherence), reflect naturally occurring evolutionary influenced reactions that can be adaptive in the context of establishing and maintaining social dominance hierarchical conditions favorable to one’s survival. Although the literature on non-adherence to patient safety guidelines is a vast one, an argument for such non-adherence being evolutionarily adaptive has yet to be made.

Biological basis of non-adherence

We display and detect dominance related signals because group living pressure has been a primary force shaping our gene pool throughout human evolution. Selective pressures have operated so that an individual’s chance of survival and reproductive success are greater when operating as part of an integrated group compared to when the individual operates alone. The risk of predation and the competitively induced need to forage efficiently are believed to have been the prime forces responsible for the formation and maintenance of groups (Rubenstein, 1978). But this greater chance of survival and procreation brought about by group living came at a price: humans and their ancestors have had to contend with aggressive behaviors from conspecifics. Among humans, threatening or physically attacking a conspecific has been a common form of instrumental aggression persisting throughout human history, which suggests that aggressive, dominant behavior has adaptive significance (Van der Dennen, 1995).

To be able to respond to signals of submissiveness or aggression in interpersonal interactions and form interpersonal hierarchies favorable to their survival, humans and their evolutionary ancestors must have relied on mechanisms capable of detecting dominance related signals in social opponents automatically rather than relying solely on recently evolved time-costly higher order cognitive processes involving language and conscious thought. Had our ancestors relied solely on rational thinking and decision making, they would have risked being harmed before they knew whether or not the social opponent posed a threat in the particular situation. In addition, the continuous conscious decoding and conscious displaying of social signals would have placed too much strain on higher order cognitive processing leaving very little resources for survival tasks that actually require reasoning and conscious decision making. Therefore, evolution must have designed cost-effective mechanisms that allowed group living animals to establish and maintain social order skillfully, allowing them to reach optimal dominance rank in group hierarchies, and, consequently, optimal access to resources and mating opportunities, whilst minimizing aggressive behavior from dominant conspecifics that could threaten the transport of genes between generations. Where there was potential danger in interactions with conspecifics, there was by survival necessity mechanisms that allowed for successful navigation of interpersonal interactions.

The brains of our evolutionary ancestors not only must have been able to detect dominance related signals in conspecifics but also to assess whether or not the signals detected constituted potential threats, and to initiate dominant or submissive responses, including behaviors, aimed at creating hierarchical conditions conducive to their survival, independent of time-costly conscious cognition. Indeed, we know that subcortical neural circuitry located in the amygdala in the human primitive brain continuously and non-consciously monitors potential social opponents for signals of threats in facial expressions, verbalization, and posture (Davidson et al., 2000; Davis and Whalen, 2001), which are quickly and non-consciously processed and appropriate response reflexively elicited assisting to establish and maintain interpersonal hierarchies. Animal research supports a role for the amygdala in the formation and maintenance of interpersonal hierarchies: following amygdala lesions monkeys have been reported to present profound change in social behavior losing their capacity to maintain social hierarchical conditions favorable to their survival and rapidly falling in rank within dominance hierarchies in their colonies (Kling & Brothers, 1992).

It is possible that in group living animals, including humans, critical signals of dominance can be automatically detected and also displayed, with no need for conscious awareness of such signals before a response is elicited. For example, in experiments conducted by Esteves and Ohman (1993) and Momura et al. (2004), subliminal presentation of images of facial expressions of fear and anger (too brief to be visually perceived by humans), were sufficient to activate the amygdala despite the absence of any conscious awareness of these images in experimental subjects. In turn, the amygdala reflexively activates facial motoneurons leading to facial expressions (Lang, 2010; Davis and Whalen, 2001) and also reflexively orients gaze (Gamer and Büchel, 2009).

Similarly, a body of research (discussed below) supports the notion that it is possible that a behavior pattern such as acting contrary to communication from others (eg. non-adherence to patient safety guidelines) can be the output of non-conscious biological mechanisms that send dominance related signals to the environment not only reflexively but also proactively to assist in the establishment and maintenance of interpersonal hierarchies.

Psychological reactance: an interpersonal dominance regulatory adaptation?

It has been known for five decades that humans have an “inherent” tendency to act contrary to recommendations from others. This is the case even in circumstances where we agree, in essence, to the value of the recommendation, a phenomenon known as “psychological reactance” (Brehm, 1966). When we perceive the actions of others as restricting our freedom to behave the way we want, a motivational state compels us to react in a way that affirms our freedom to choose how to behave. For the last five decades, research has consistently shown that recommending that an individual takes a certain course of action often leads to the opposite effect (Mazis et al., 1973; Brehm and Weintraub, 1977; Clee and Wicklund, 1980; Engs and Hanson, 1989; Moore et al., 2000; Fitzsimons and Lehmann, 2004; Miller et al. 2007; and Potts, 2007). The long history of successful support for the theory of psychological reactance in diverse settings and areas of behavior may have implications for the phenomenon of non-adherence to rightful guidelines in the health care setting, as health care workers may not be immune to the phenomenon of psychological reactance.

Consistent with a biological evolutionary origin, in humans psychological reactance manifests itself at a very young age. For example, Brehm and Weintraub (1977) demonstrated that two-year-old boys present oppositional behavior consistent with the phenomenon of psychological reactance. When placed in a room with two toys, two-year-old boys tend to ignore a toy that is easily accessible and go after an apparently “forbidden” toy that is not easily accessible (eg, behind a Plexiglas wall). As a biological tendency, a logical question would be: what problem in human ancestral environment did psychological reactance evolve to solve? Although not incompatible with current view of psychological reactance as a response to threats to one’s own freedom to choose, psychological reactance is more easily understandable from a functional evolutionary perspective with its origin in biological mechanisms controlling intraspecific dominance in group-living animals.