Communication and Messaging Strategies in Infection Prevention

Louise-Marie Dembry

Ann Freeland Fisher

The successful healthcare epidemiologist requires core competencies across a wide range of skills including epidemiology, subject matter expertise, quality and performance improvement, healthcare administration, regulatory and public health liaison, and clinician educator/teacher. Strong communication skills are needed in order to demonstrate to others the hospital epidemiologist’s knowledge and skills, to share information, to implement and disseminate interventions, and to convince the C-suite of the importance of the infection prevention program and garner the support of everyone within the healthcare organization. The Society for Healthcare Epidemiology of America (SHEA) white paper: “Guidance for Infection Prevention and Healthcare Epidemiology Programs: Healthcare Epidemiologist Skills and Competencies”¹ provides an overview of the multiple roles a hospital epidemiologist must fulfill as the leader of a successful healthcare epidemiology/infection prevention (HEIP) program. Areas where strong communication skills are required include the following:

“Ensuring the infection prevention program is part of an institution’s strategic plan through advocacy and communication”
“Knowing the basics of effective communication with various populations including internal and external stakeholders, media and the general population”
“Being able to discuss cases and processes with stakeholders and patients”
“Communicating with public health agencies”
“Facilitating communication to prevent harm”
“Teaching through personal communication”

In the past, hospital epidemiologists entered leadership roles with little to no communication skills training. They need to be able to communicate to individuals and groups and tailor their communications to be effective in order to support their program’s success as well as their own.² Communication is a skill of extreme importance as communication failures are a leading root cause of adverse patient safety outcomes.³ Though there are no distinct training programs specifically for hospital epidemiologists to enhance communication skills, professional development through participation in leadership development courses or online training programs is available.⁴

This chapter is intended to give a broad overview of the opportunities and methods of communication that a hospital epidemiologist will encounter and utilize.

Effective leadership is a critical component of a hospital epidemiologist’s success.⁵ Each hospital epidemiologist needs to assess his or her style of leadership, which may also be tied to his or her style of communication. Commonly identified styles of leadership are autocratic, laissez faire, transactional, and transformational.⁶

Autocratic leaders lead by intimidation and punishment, which creates a negative work environment.⁷ This type of leader tends to make unilateral decisions and has no tolerance for mistakes. Others may be intimidated by this approach and will not attempt to participate in decisionmaking or express creativity for fear of being reprimanded. Rigid organizations such as the military require leaders to make unchallenged decisions; this is contrary to the team approach preferred in the healthcare sphere. Though there are many downsides to the autocratic style of leadership, one scenario in hospital epidemiology for which this style of leadership can be of benefit is during a crisis or situations where there is an urgent need to complete a task.⁸

Laissez-faire leaders are detached from their workgroup and rely on the group to make independent decisions. It is a style of leadership that is best suited to an environment with highly motivated staff. The drawback is that individuals may suffer from confusion as to their expected roles and responsibilities. When individuals receive little or no feedback, they are not cued to attempt or develop further learning or behavior correction.⁷^,⁸

Transactional leadership, the most pervasive style of healthcare leadership, is based on a reward and punishment model. Transactional leaders set goals and standards for the group, and if these expectations are not met, the group members face negative consequences.⁶ This type of leader focuses on efficiency, control, and generally does not seek change.⁹ This leadership style prevents group members from developing a sense of organizational mission and inhibits creativity.

Transformational leadership requires role modeling to garner respect and inspire individuals or teams to exceed expectations. This approach promotes acceptance of the mission and purpose of the group or organization.¹⁰^,¹¹
A transformational leadership style is strongly linked to improved process quality, improved patient outcomes, and the development of a high-reliability organization (HRO).⁵

Though many will identify strongly with one style, successful leaders utilize multiple styles as is situationally appropriate. Leaders need to be able to effectively communicate not only within managerial circles but also with clinical professionals, frontline staff, and support services within the organization.¹² The manner in which leaders choose to communicate with others determines the type of relationship established with members of the healthcare organization and impacts their satisfaction, commitment, and performance.¹³

COMMUNICATION WITHIN THE HEALTHCARE EPIDEMIOLOGY/INFECTION PREVENTION TEAM

Interprofessional communication is key to effective teamwork within a healthcare organization. A successful HEIP program also requires effective intradepartmental communication. Hospital epidemiologists are among the leaders of process improvement within healthcare organizations, and their success requires strong communication skills to effectively share knowledge and drive engagement.¹⁴ To successfully lead an infection prevention team, one must state and articulate goals clearly, including outlining targets for improvement. This helps create a shared understanding of the departmental mission and aligns messaging for stakeholders outside the department.¹⁵

TABLE 11-1 Infection Prevention Staff Meeting Agenda

*HEIP team meeting agenda*
Staffing	Provide clarification of the workforce available within the team for the upcoming week and need for coverage of meetings and other tasks.
Review of clusters, outbreaks, investigations	Report out epidemiologically significant organisms/syndromes from the past week’s surveillance and discuss affected areas and affected individuals (patients and healthcare personnel). Clarify planned follow-up, and assign responsibility to a team member.
Review of meetings	Team members are expected to deliver succinct summaries of meetings they attended during the prior week and the issues discussed for the team’s awareness. This situational awareness permits tracking of current issues in the healthcare organization that may require infection prevention input. It also makes covering meetings by others more seamless as everyone is aware of the issues and ongoing discussions.
Infection prevention rounds and problem-solving	By reviewing findings of rounds and problems encountered, the team is provided updated information of daily activities and challenges faced by other team members. This creates opportunities for team collaboration and problem-solving. The shared information assists in focusing efforts on high-risk issues and new initiatives.
Review of ongoing projects	This review provides team members with updates on projects other team members are working on and informs departmental planning and timelines for completion.
Policy and procedure review	It is important for the HEIP team to have clarity on content and status of documents being developed by various team members. The entire team needs to be aware when policies or guidance that HEIP provides to the healthcare organization will be changing and the rationale for such changes. The hospital epidemiologist can use these reviews to confirm that the team has a clear understanding of the policies and procedures to allow for consistent and accurate messaging by HEIP to stakeholders outside the department.
Infection Prevention Committee preparation	Given that the Infection Prevention Committee meeting and the minutes produced are two important HEIP communication venues, thoughtful and detailed preparation is vital. Agendas must be developed and finalized early so proper preparation can occur. Consider having team members script their presentations and comments ahead of time to assure accurate and concise presentations. Minutes must be carefully written and edited, approved by the committee, and signed by the appropriate individuals according to your organization’s policy. These documents are heavily scrutinized by accrediting agencies such as The Joint Commission and regulators.
Review of The Joint Commission or healthcare organization regulations and directives, Centers for Disease Control and Prevention (CDC), or professional society guidelines	An essential function of HEIP is to monitor the outside landscape for best practices, new guidance, and requirements and determine how these will be implemented in the healthcare organization.

To establish team cohesiveness and a sense of shared mission, formalized staff meetings should be held on a regular basis.¹⁶ Consider utilizing a standardized worksheet to guide staff members’ preparation and keep the meeting focused and efficient. The worksheet can then be used for follow-up messaging to the team highlighting agreed-upon plans and responsibilities for the workweek and provide an overview of important decisions for team members who were not present (Table 11-1).

Staff meetings should have a designated individual to lead the meeting on a regular basis. That role can rotate among HEIP team members to promote engagement and active involvement as well as provide an opportunity for developing leadership skills.

Aside from structured staff meetings, team huddles are a common and effective communication tool and can be utilized daily in the HEIP department to discuss hot-topic issues and strategize workflow in real time. This establishes expectations of what information needs to be communicated, where the communication will be directed, and when communication should occur. Clarify which team member will perform needed communication and the expected format for delivery (eg, in person, phone call, e-mail). Team huddles have been demonstrated to improve team function and cohesion.¹⁷ They create frequent opportunities for members to engage in daily learning, discuss daily challenges, and participate in group problem-solving. The huddles provide HEIP with a safe space to openly discuss issues and support each other through challenges that further leads to an environment of trust and increases team resilience.¹⁸

COMMUNICATION WITHIN THE HEALTHCARE ORGANIZATION

There are multiple communication types available for HEIP to utilize.¹⁹ Communication can occur in a synchronous manner where individuals exchange information in real time, or by an asynchronous route where information is exchanged over time in an indirect fashion. One of the most effective modalities is direct communication. Direct, personal and synchronous communication is perceived by many as a more acceptable and effective mode of communication than an asynchronous mode (eg, e-mail, electronic health record [EHR] note).²⁰ For example, when performing antimicrobial stewardship interventions, face-to-face communication has been demonstrated to be a more effective mechanism for transfer of information, improving acceptance of interventions and changing practice.²¹ Consider participating in ward huddles or work shift meetings to obtain face time with relevant stakeholders. This is an opportunity to disseminate infection prevention information and to gain information regarding issues that the HEIP team may not be aware of (eg, a water leak that has yet to be addressed). This is an effective way to establish relationships, show support, and enhance collaboration.²² Other avenues of verbal communication are by phone or through virtual meetings using FaceTime or Skype. When performing direct communication, one also needs to consider concurrent nonverbal communication. Body language, eye contact, volume of voice, or idiomatic expressions can greatly affect communication effectiveness.²³ Tightly crossed arms and eye rolling create a perception of resistance or disrespect. Acts such as nodding one’s head and maintaining eye contact and verbal affirmations demonstrate engagement and respect.¹²

Depending on the healthcare organization, various opportunities to communicate electronically can be provided through e-mail/instant messaging, screensavers and Internet/intranet. Consider the use of an organization-wide, monthly newsletter to highlight new HEIP policies and procedures, projects, and reminders such as the tenets of respiratory etiquette/cough hygiene and the importance of vaccination during influenza season.

At times, the HEIP team may utilize mass media. Advertisements, interviews, commentaries, or editorials can be distributed through printed media, radio, and the Internet when the goal is to communicate with large numbers of individuals whether it be healthcare personnel (HCP) or the general public. For these modes of communication, consider tapping into the expertise of a communication specialist if one is available. These individuals will know best the communication opportunities available to you and can partner to creatively enhance communication potential and avoid missteps when utilizing newer platforms such as social media.²⁴

HEIP also communicates expectations and guidance through documents such as policies, procedures, and guidelines. These documents should be standardized, clearly presented, and easy to access to be beneficial. All policies should be evidence based citing recommendations from organizations such as the Centers for Disease Control and Prevention (CDC) or professional societies as well as any regulations (eg, Occupational Safety and Health Administration [OSHA]). Each policy should explain its purpose, provide concise guidance, and outline responsibilities and accountability.²⁵ There should be a plan for how new or updated guidance will be communicated and disseminated. One should consider using appropriate Infection Prevention Committee (IPC) members to assist including involving them in a prereview to get their support prior to implementing a new or revised policy.

HEIP provides and oversees formal and informal teaching of infection prevention content. The messages and education delivered should be based on an assessment of the targeted learners’ needs. One should strive to provide a variety of learning opportunities and venues such as lectures, small group meetings, handouts, and posters.²⁶ Web-based learning can be utilized as an efficient method for providing up-to-date and accessible infection prevention knowledge.²⁷ Consider using interactive educational programs with hands-on training for such topics as hand hygiene and personal protective equipment donning and doffing. Additionally, interactive educational programs may be case based to engage and empower learners in problem-solving. Interactive modalities have demonstrated improved HCP knowledge of infection prevention topics.²⁸ Consider train-the-trainer approaches to expand opportunities to disseminate infection prevention education. This technique, when applied to a worldwide hand hygiene simulation-based educational program, demonstrated a significant increase in HCP knowledge.²⁹ It is also important to assess educational programs for effectiveness by assessing learner outcomes such as increased knowledge through postprogram testing or surveys.

When utilizing the various communication methods outside of the HEIP department, HEIP can best communicate to a healthcare group or system following the basic communication tenets of complete, clear, brief, and timely messaging.³⁰ One needs to communicate all the information required for a receiver to fully understand what is being conveyed and how he or she should respond to this communication. To provide clear communication, avoid the use of jargon and clearly define concepts as the listener may lose the meaning of your message if the terminology is confusing. One can consider interchanging “germs” for “bacteria,” “gather information” for “surveillance,” and
“spread” for “transmit” when addressing a nonexpert audience.³¹ Use the correct terminology when speaking to HCP as it transmits a message that you pay attention to detail and meaning. The term infection prevention should be used instead of infection control as prevention is superior to control. Hand hygiene is a better descriptor than hand washing as it references use of either alcohol hand rub or soap. “Healthcare personnel” is preferred over “healthcare worker” as it is inclusive of trainees and volunteers and aligns with terminology found in CDC and other professional guidance. Focus on making communications brief and avoid extraneous commentary to prevent dilution of your message. Timeliness of messaging is also important, as prompt communication by HEIP demonstrates awareness of issues and engagement in problem-solving. Even with tight crisis-driven time pressures, it is paramount to first verify the information to be transmitted. This information will be widely shared with others and needs to be truthful (eg, acknowledge what is known and what is not known), clear, and correct.

Information not only is communicated through manner and modality but also has a component of directionality. The four basic types of communication directionality are internal (upward), internal (downward), internal (lateral), and external. Upward communication moves from lower level to higher levels within an organization. Rigid forms of upward communication can include required presentations to leaders such as formal reports or presentations. Less formal upward interactions include being visible and approachable for face-face encounters and “open door policies” inviting others to reach out to leaders.³² Encouragement of this less formal upward flow of communication lends to a culture of safety and cooperation. Downward communication originates from higher levels within an organization. The general elements of downward communication include job instruction (expectation); rationale of an instruction such as a duty or assignment; ideology, which is the expression of the organization’s philosophy; information dissemination; and feedback in response to organizational behaviors.³³ Proactive top-down communications from leadership can increase knowledge across many professional subgroups leading to increased learning and acceptance of change.³⁴ This is best demonstrated when healthcare leaders visibly support HEIP policies and procedures and clearly define them as organizational goals. Downward communication can also be delivered from HEIP. This direction of communication has been demonstrated to improve infection prevention practices and outcomes such as those related to the prevention of central line-associated bloodstream infections (CLABSIs) at the unit level. Providing process data feedback and supplementing this with education on best practices has been shown to increase the knowledge level and engagement of HCP through this method and results in practice change.³⁴

Lateral or horizontal communication occurs across service lines, among staff, or others considered to be on the same organizational level. It is a method often used for coordination and provides an opportunity for change.³⁵ Lateral communication might occur during a morning huddle on a patient care unit or in a time-out situation where all participants have equal responsibility for compliance with an intervention or a process. Collaborative rounding between nurses and physicians can elevate cohesiveness and improve communications leading to opportunities to address barriers and create solutions to prevent future healthcare-associated infections (HAIs).³⁶ External or extramural communication refers to communication that occurs outside the healthcare organization. For a hospital epidemiologist, this may occur during interactions with the media.³⁷ Engagement with external stakeholders occurs when reporting information and data to a public health agency or when transferring a patient requiring transmission-based precautions to another facility. Communication ideally flows in all directions in a culture of safety. Infection prevention intramural communication occurs daily within the healthcare organization at the time of patient movement. It is well documented that during transitions of care, the transfer of a patient colonized or infected with an epidemiologically significant organism can lead to the risk of ongoing transmission if crucial information is not communicated and precautions are not maintained. This also holds true for transfers of care out of the healthcare organization. Many states have regulations requiring extramural communication to the receiving facility on a patient’s colonization or infection status with a multidrug-resistant organism or other pathogens requiring transmission-based precautions.³⁸ One barrier to sharing of information can be the lack of standardized forms and procedures. The CDC and other organizations have created interfacility infection prevention transfer tools that can be utilized for this purpose.³⁹^,⁴⁰ Another potential barrier to transparent information transfer can be concerns within a healthcare organization where sharing information could affect public perception of the healthcare organization (eg, reporting of an emerging pathogen such as a cluster of Candida auris infections). Facility leadership in conjunction with the hospital epidemiologist should collaborate with external stakeholders such as public health agencies to facilitate data sharing as required and needed to support public health (Table 11-2).⁴¹

COMMUNICATION AS A PERFORMANCE IMPROVEMENT TOOL

HEIP uses communication to support a culture of improvement to promote infection prevention and patient safety.²⁴ Communication is necessary to enlist staff engagement and engender understanding of the mission. Knowledge sharing is crucial to support the implementation of process improvement measures.²⁷ To advocate for the implementation of infection prevention projects or interventions it is essential to identify and engage stakeholders. Communication to stakeholders allows them to gain knowledge on how a change will affect them while improving care. By developing these relationships, it permits the HEIP program to message around shared values.⁴² Transparency in communications is required when seeking engagement by others. If there is a need to change direction or correct course regarding an infection prevention intervention, clearly explain to stakeholders the reason for redirection or reassessment of actions. A successful communicator is present, focused and engaged, available for communication, and approachable. Communications can be unplanned as in a face-toface encounter in the hallway or in more structured forums such as a committee meeting. Wherever the communication occurs, strong leaders demonstrate active listening
by being present in the moment and listening in a mindful, nonjudgmental, and undistracted manner.¹³ The listener must be aware of body language and avoid multitasking, which can make one appear disengaged and rude.²⁴ To support a culture of improvement, one should practice inclusive behaviors such as actively soliciting input from others, inviting alternative views, and providing constructive responses.⁴³ Initiation of communications proactively can increase a hospital epidemiologist’s awareness of organizational issues. It is known that HCP often will not initiate communication regarding infection prevention challenges and may wait until a crisis to reach out.⁴⁴ Creating an environment of open communication is an important component of building a culture of safety where everyone feels safe speaking up with concerns. To reach all audiences, one needs to be creative. Choose many channels for communication as not all HCP have the same level of health literacy or easy access to common communication avenues such as the Internet.⁴⁵ Communications need to be tailored to the workflow of various areas, and one must be sensitive to time constraints. Lack of physical proximity and challenging working conditions can hinder effective communication and team building.⁴⁶ Within healthcare organizations, personnel are spread across multiple units and buildings, which hinders effective and efficient communication and increases a reliance on “opportunistic meetings.”⁴⁷ To overcome physical barriers, HEIP can provide opportunities for virtual meetings or scheduled interprofessional infection prevention rounds.

TABLE 11-2 External Stakeholders

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