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Journal of Hospital Infection
journal homepage: www.elsevierhealth.com/journals/jhin
Communication strategies in acute health care:
evaluation within the context of infection
prevention and control
R. Edwards a, N. Sevdalis b, C. Vincent b, A. Holmes a, b, *
a
Department of Infectious Diseases, and Centre for Infection Prevention and Management, Imperial College London and Imperial
Healthcare NHS Trust, London, UK
b
Department of Surgery and Cancer, and Centre for Patient Safety and Service Quality, Imperial College London, London, UK
A R T I C L E
I N F O
Article history:
Received 1 October 2011
Accepted 21 May 2012
Available online xxx
Keywords:
Communication
Infection prevention and
control
Behaviour
Behaviour change
Training
S U M M A R Y
Background: Communication in healthcare settings has recently received significant
attention in the literature. However, there continues to be a large gap in current understanding of the effectiveness of different communication channels used in acute healthcare
settings, particularly in the context of infection prevention and control (IPC).
Aim: To explore and evaluate the main communication channels used within hospitals to
communicate with healthcare workers (HCWs) and to propose practical recommendations.
Methods: Critical review of the main communication channels used within acute health
care to communicate information to HCWs, and analysis of their impact on practice.
Findings: The analysis covers verbal communications, standardization via guidelines,
education and training, electronic communications and marketing strategies. Traditional
communication channels have not been successful in changing and sustaining best practice
in IPC, but newer approaches (electronic messages and marketing) also have pitfalls.
Conclusion: A few simple recommendations are made in relation to the development,
implementation and evaluation of communications to HCWs; top-down vs bottom-up
communications; and the involvement of HCWs, particularly ward personnel.
ª 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Communication and the channels through which it occurs
within hospital settings are critical for effective clinical care.
However, there continues to be a large gap in current understanding of the effectiveness of different communication
channels used in acute healthcare settings. From the
perspective of infection prevention and control (IPC), there is
* Corresponding author. Address: Centre for Infection Prevention and
Management, Imperial College London, 2nd Floor, Hammersmith
House, Du Cane Road, London W12 0HS, UK. Tel.: þ44 (0) 203 31
33251; fax: þ44 (0) 208 38 33235.
E-mail address: [email protected] (A. Holmes).
often a need to disseminate information rapidly to healthcare
workers (HCWs), particularly in instances of infection
outbreaks, epidemics, and national or local emergencies. It is
therefore necessary to identify which communication channels
are (most) effective.
Systematic mapping and analysis of communication
processes in health care have highlighted both the complexity
and fragility of communication channels in acute care environments, and demonstrated that the communication process
is prone to error.1e5 At present, throughout developed
healthcare systems, substantial funding goes in to developing
and disseminating a range of communications throughout
hospitals (Table I). Unfortunately, these communications are
often undertaken without consideration of the appropriateness
0195-6701/$ e see front matter ª 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jhin.2012.05.016
Please cite this article in press as: Edwards R, et al., Communication strategies in acute health care: evaluation within the context of infection
prevention and control, Journal of Hospital Infection (2012), http://dx.doi.org/10.1016/j.jhin.2012.05.016
2
R. Edwards et al. / Journal of Hospital Infection xxx (2012) 1e5
Table I
Types and channels of communication used throughout acute
hospitals
Communication types
Direct communication
Practice regulations
Education
Electronic messaging
Mass media
Communication channel
e
e
e
e
e
e
e
e
e
e
e
e
e
e
e
e
e
e
e
e
e
e
Verbal information exchange
Telephone communication
Meetings
Non-verbal communication
Policy
Guidelines
Care pathways
Information packs
Handbooks
Formal education forums
Informal training
E-learning systems
Intranet/Internet
E-mail
Bleep
Personal digital assistant
Social networks
Newspaper/magazines/journals
Television
Internet
Radio
Banners/posters
known about how they relay the desired messages, or how they
impact on clinical practice or HCWs’ behaviour.
The numerous communication channels that regularly
disseminate large amounts of information from different
sources can contain conflicting or confusing messages. This can
contribute to disparities in attitudes and behaviours of HCWs.
The psychological theory of ‘cognitive dissonance’ offers a way
to understand such inconsistencies.10 Cognitive dissonance
occurs when a belief/opinion and a behaviour are not in
agreement. Such disagreements cause discomfort for the
individual, who then seeks to eliminate the dissonance.10 In the
context of IPC in hospitals, cognitive dissonance can result in
disempowering HCWs who are in conflict about which
communication to translate into practice. As more and more
communications get disseminated within hospitals on IPC
issues, the risk of dissonance increases, potentially resulting in
confused HCWs who lack clarity regarding professional roles,
behaviours and practices. As such, there needs to be awareness
of what and how to communicate with HCWs in order to ensure
clarity about what is expected of them, and where the hospital’s priorities lie, such that quality of care can be improved,
HCWs’ job satisfaction can be maintained and patient experience can be optimized. The key question, therefore, is how
information relating to IPC is best channelled throughout an
acute hospital, and how it can achieve positive behavioural
change (e.g. hand hygiene) and improve infection outcomes.
Infection prevention and control: how is it
communicated?
of the communication format, content or objective. Furthermore, assessment of the impact of these communications on
HCWs’ practice is often not performed.
The aim of this paper is to begin to fill this gap. Specifically,
the authors sought to explore and evaluate the main communication channels used within hospitals to communicate with
HCWs, and to understand the impact of these communications
on practice. An analysis of the traditional routes of communication used within IPC was undertaken (drawing on studies
relating to healthcare communications), their practical relevance to IPC was considered, and their efficacy in changing
HCWs’ behaviour was reviewed. The ultimate aim is to propose
practical recommendations for the development and quality/
impact assessment of communications within acute hospitals.
Infection prevention and control: a valuable
context for analysis
The social and economic burden of healthcare-associated
infections (HCAI),6 and public and media interest in hospital
infection rates7 have contributed to increasing the profile and
importance of infection prevention throughout hospitals. As
a result, there is now increased demand for communication
about IPC issues with HCWs within acute hospitals. In England,
hospitals are expected to have a communication strategy to
provide accurate information on HCAI to HCWs, patients and
the public.8 However, although hospitals have implemented
a range of initiatives to facilitate communications,9 the use of
multiple communication channels and messages means that
communications often lack consistency or direction. Moreover,
the lack of evaluation of their effectiveness means that little is
Verbal communications
HCWs prefer direct modes of communication (e.g. face-toface and telephone interaction) over more indirect modes of
communication (e.g. computer systems or policies).4,11e13 Up to
83% of HCWs’ communications are channelled through direct
interactions; as a result, HCWs can be interrupted by a new
communication event every 36 s.11 HCWs may feel justified in
interrupting colleagues in an effort to multi-task effectively and
care for large numbers of patients; however, constant disruptions can decrease patient safety, and increase staff stress and
workload.3,14 In IPC, an example of this culture of direct
communication may be reflected in the struggle of HCWs to
refer to notes or hospital policies for guidance on IPC procedures, preferring instead to contact the IPC team directly.
Reliability on verbal communication increases the likelihood of
variability in practices,4 whereas documented pathways or
policies can provide a more consistent means of communication.
Such over-reliance on verbal communications with the IPC
team, however, may be inadvertently encouraged by that
team. Sociological analyses show that direct communication
offers HCWs the opportunity to negotiate professional status,
roles and practice; in other words, it achieves much more than
information exchange.12,15 In healthcare settings, professional
identities are constructed primarily through comparisons
between groups of HCWs, often based on expertise or speciality.15 Groups seek to establish a positive identity of themselves and differentiate themselves from others, and
interprofessional interactions become the ‘arena’ of these
identity issues.16 The persistent involvement of IPC teams in
verbal communications regarding ward management of
Please cite this article in press as: Edwards R, et al., Communication strategies in acute health care: evaluation within the context of infection
prevention and control, Journal of Hospital Infection (2012), http://dx.doi.org/10.1016/j.jhin.2012.05.016
R. Edwards et al. / Journal of Hospital Infection xxx (2012) 1e5
infection offers a significant re-inforcement to the IPC team’s
professional identity and standing within the hospital. Such
sociological views of communication and its functions within
health care suggest that some self-reflection on communication practices may be useful, so that the strengths and weaknesses of verbal communications are appreciated by HCWs.
Standardization
Policies and guidelines are implemented throughout hospitals
as a means of providing all HCWs with the resources to carry out
effective IPC, whilst attempting to standardize practice.
However, there are barriers to the effectiveness of such standardized communications. Although there is increasing availability of evidence-based guidelines and care bundles, HCWs
struggle to adopt behaviours outlined in such documents.17
Adherence to guidelines can be variable depending on guideline format and content, resources available to staff, associated
training and perceived inconvenience to current practice.18e20
One study found that the largest barrier to the practical
implementation of guidelines for preventing ventilatorassociated pneumonia was HCWs’ disagreement with the interpretation of outcomes of evidence-based trials.21 Further to
this, the degree of non-adherence to guidelines did not reflect
the strength of evidence-based support, thus leading to the
conclusion that ‘published guidelines and clinical trials alone
cannot be expected to change practices at the bedside’.21
The increased use of policy and guidelines throughout
health care has not been successful in streamlining practice in
relation to IPC.19,20,22 Although guidelines form a repository for
information, they are not an effective relay of information to
HCWs who need to actively seek out and access the document,
usually during periods of direct patient care. Further, HCWs
who do reference guidelines need to overcome contextual and
cultural barriers (e.g. the concept that guidelines are detrimental to clinical judgement and autonomy). Guideline or
policy developers should, therefore, actively consider potential barriers to adopting these into practice.
Education
Traditionally, education has been a means through which
IPC teams have attempted to relay information and policy
contents across hospital staff. However, time pressures,
perceived lack of relevance, and diminished interest in the
topic of IPC are barriers to education reaching HCWs effectively. Poorly structured education and training events also
contribute to ‘trained’ HCWs having poor knowledge of IPC
measures even after education sessions.23,24 Even with
successful training, those who do acquire a sound understanding often have difficulty translating taught IPC measures
into daily clinical practice.23
As discussed in relation to direct, verbal communication,
professional identity issues across different professional groups
within a hospital often inform HCWs’ practice. This social aspect
of clinical practice and the status associated with a professional
group means that it may be difficult for HCWs to change their IPC
behaviours even following training. Peer support is a mechanism
that can reinforce a message imparted during training and the
relevant behaviour (e.g. in prescribing antibiotics or handwashing), or make it irrelevant within a professional group.16 It
is therefore crucial to consider the social and cultural context
3
within which educational interventions are implemented. A key
question for educators is to find the critical threshold of HCW
engagement at which education and training is reliably translated into everyday practice.
Electronic messaging: 21st century benefit or more
noise?
Technologically advanced means of communication have
become more widely used throughout health care.25 However,
there has been little evaluation of the usefulness or efficacy of
electronic messaging as a means of information relay to HCWs.
E-mail has replaced numerous verbal communications. Whereas
verbal means of information exchange involve interaction
between colleagues and ‘negotiation’ of messages, e-mail
provides less opportunity for interaction and relationship
building. In fact, there is often uncertainty in senders of electronic messages whether their e-mails are read or actioned. The
delayed and intermittent nature of e-mail may also contribute to
decreased productivity due to the increased time taken to
complete tasks and repetitions when using this communication
channel.
E-mails have also altered the reach of communications, with
mass audiences within hospitals reached easily via group
messages. However, large numbers of group e-mails often
result in large amounts of information being disseminated to
people to whom the content does not apply. The consequence
of this is that the audience ‘learns’ that the messages are not of
direct application or interest, and therefore e-mails go unread.
This means that important messages can get lost in the ‘noise’
generated by heavy e-mail traffic. Finally, there is often
a reduced sense of responsibility to action such communications; as large numbers of people are involved, personal
accountability is reduced significantly. IPC teams who need to
communicate with large numbers of staff, for example, in
instances of outbreaks, can find all these aspects of electronic
communication very problematic.
Another social aspect of electronic communications is that
they have been introduced into an already pressurized work
environment, in which care activities should be prioritized, yet
HCWs are expected to assimilate and respond to an everincreasing volume of often undifferentiated messages (a
point related to the point above). Moreover, in the medical and
nursing cultures, being engaged in direct patient care is greatly
valued, whereas whatever is perceived to be a desk-based or
‘form-filling’ task to be carried out at a desk is regarded
negatively. Desk-based activities may therefore not be valued
very highly.13,26 These are barriers to the effective use of
electronic communications, whether mobile or desk based, as
HCWs struggle to read e-mails and perform many computerbased tasks within the ward environment. It is worth considering whether mass electronic communications are a practical
form of communication relay to HCWs trying to perform tasks
at the bedside.
Marketing strategies
Within acute care, IPC teams have widely used commercial
marketing strategies as an approach to promoting effective IPC
behaviours relating to hand hygiene, influenza and norovirus.
Such marketing programmes often use imagery to attract
Please cite this article in press as: Edwards R, et al., Communication strategies in acute health care: evaluation within the context of infection
prevention and control, Journal of Hospital Infection (2012), http://dx.doi.org/10.1016/j.jhin.2012.05.016
4
R. Edwards et al. / Journal of Hospital Infection xxx (2012) 1e5
Table II
Critical evaluation of communication channels with healthcare
workers: key points
e Use of multiple communication channels and inconsistent
messages can create a dissonant workforce who are
uncertain about what information to prioritize or adopt,
and how to translate it into practice.
e Verbal communication relies heavily on interrupting
colleagues, which creates a culture of disruption,
contributing to a stressful work environment that can
compromise patient safety.
e Electronic communications have changed the way of
transferring information, with larger audiences reached
but less opportunity for social interaction between
healthcare workers.
e Education and training does not reliably change practice.
Social and cultural influences on behaviour and practice
need to be considered during development and implementation of education programmes.
e Marketing and imagery is often used to promote compliance with infection control practices, although there is
little research on how imagery can change a behaviour.
Some evidence suggests that images may be more
successful than words or numbers at getting into
healthcare workers’ consciousness.
attention, and to bring habit into the conscious mind whilst
seeking to change a behaviour.27 However, the selection of
imagery is often based on intuition as opposed to empiricallybased evidence on imagery processes that may work within
the IPC context.28 There has been relatively little research on
the role of imagery in motivating desirable behaviours, and
even less on how imagery used via a marketing approach within
a hospital can actually change HCWs’ behaviour and practice.
There is evidence to suggest that images are more successful in
reaching the consciousness and adhering to memory (compared
with words or numerical information), and as such may
outperform words and numbers when used in behavioural
change initiatives.27,28 As marketing initiatives and campaigns
throughout acute care settings are increasing, there needs to
be further consideration of the content and format of these
communications. Clear, measurable behavioural change
objectives linked to infection outcomes should be put in place
and evaluated prospectively.
Conclusions and future directions
Using IPC as a case study, this paper has offered an appraisal
of communication with HCWs within acute hospitals. The key
points of this analysis are summarized in Table II. The authors
consider that there is currently a strong drive to release everincreasing communications, in numerous formats and at
significant cost, without true consideration of their aims or
measurement of their impact on practice. Traditional
communication channels, however, have often been unsuccessful in changing and sustaining best practice in IPC.
Table III provides some practical recommendations that aim
to improve communication with HCWs throughout acute
hospitals. All means of communication (written, electronic or
other) need to be used responsibly and systematically (i.e. in
a planned and strategic manner). There may even be an
argument for a shift in focus from institution-wide to more
localized communications, which, for example, could allow
wards to manage local communications that more closely
reflect the needs and practices of their own staff. There have
recently been interesting approaches, based on network
analysis and ‘systems’ thinking, to ‘bottom-up’ and ‘top-down’
communications within hospital settings. Such approaches
stress that the two types of communication can co-exist, and
can promote successful organizational learning and improvement in the context of IPC.29,30 Such a successful marriage of
the two assumes that the top-down communications disseminate clear, explicit knowledge and direction throughout the
hospital, whereas the bottom-up communications take place at
local level (i.e. within a ward) and offer tacit knowledge and
understanding within the local context (i.e. within a department or ward).
The key premise of such organizational learning and
improvement approaches is that the communications should be
targeted, clear and have actionable elements for implementation by HCWs (not just generic advice). Recent
Table III
Recommendations to improve the efficacy of information relay to healthcare workers within acute hospitals
‘Verbal economy’
Ward-based assessments
Target initiatives
Measurable objectives
Healthcare worker engagement
e Consider the fragility of verbal communication networks
e Interventions aimed at economizing verbal communication may impact on
patient safety and institutional productivity
e Perform ward-based assessments prior to education initiatives
e Identify cultural and social barriers to translating new information into practice
e Address these in the development and implementation of education programmes
e Limit the ‘one size fits all’ approach
e Develop communications with an increased understanding of target audiences and their
communication preferences (ideally based on primary research)
e Develop communications with actionable messages
e Develop communications with clear, measurable objectives
e Assess the impact of communications against set objectives
e Evolve communication strategies in line with measured outcomes to increase efficacy
e Involve healthcare workers in the development and dissemination of information
e Engage ward staff in communicating hospital priorities
e Limit the top-down approach to information dissemination
Please cite this article in press as: Edwards R, et al., Communication strategies in acute health care: evaluation within the context of infection
prevention and control, Journal of Hospital Infection (2012), http://dx.doi.org/10.1016/j.jhin.2012.05.016
R. Edwards et al. / Journal of Hospital Infection xxx (2012) 1e5
application of such an approach did result in significant
improvements in IPC outcomes.31 It is important that the
balance between hospital-wide and local communications is
taken into account and evaluated when a communication
strategy is developed and when new communications are
designed. In addition, appropriate research is certainly
required to further understand the process and efficacy of
communications, and how these contribute to the success and
limitations of interventions aimed at changing HCWs’ behaviour. An increased understanding of how best to disseminate
information throughout a hospital will enhance emergency
preparedness and response, facilitate clearer perception of
institution priorities, and reduce unnecessary communications
that cost time and money.
Acknowledgements
The authors wish to thank Dr Tammy Boyce for her valuable
contribution to this study.
Conflict of interest statement
None declared.
Funding sources
National Institute for Health Research Biomedical Research
Centre Funding Scheme at Imperial College, and National
Centre for Infection Prevention and Management funded by
the UKCRC. Holmes, Sevdalis and Vincent are also affiliated
with the Imperial Centre for Patient Safety and Service
Quality, which is funded by the National Institute for Health
Research, UK.
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Please cite this article in press as: Edwards R, et al., Communication strategies in acute health care: evaluation within the context of infection
prevention and control, Journal of Hospital Infection (2012), http://dx.doi.org/10.1016/j.jhin.2012.05.016