Signs of the times - Infection prevention messaging

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Cathryn Murphy explains how signage plays a pivotal role in preventing infection disease.

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Walk into any modern Australian inpatient facility and you will be immediately confronted by multiple signs. More than ever, we are seeing the integration of commercial operations in the entrances and high public traffic areas of our newest healthcare facilities and with them come multiple efforts to grab our attention.
“Get the best/ hottest/ freshest coffee now”. “Need cash? Try this ATM”. “Looking for a gift/ flowers/ toiletries? – we have them right here”.
This attempt to involuntarily capture our eyeballs, gain our attention and engage us in desired behaviour is not new to healthcare. There are many fine examples of signage used to promote specific public health actions and to offer urgent and compelling warnings against unhealthy or dangerous behaviours.
The prevention of infectious disease has relied heavily on signage for at least a century. Conditions and issues addressed in those early signs continue to be at the heart of messages depicted in modern infection prevention and control (IPC) signage. These include recommendations for immunisation, isolation and disease-specific announcements including influenza. More recently, hospitals have used signs to simultaneously provide clinical messages, convey expectations and provide feedback to employees, patients and visitors.¹ Accreditation, human resource, risk management or statutory obligations may drive such signage. Bright, fast-moving and rapidly changing, evocative graphic images shooting across liquid crystal display screens strategically placed at hospital or ward entrances are steadily replacing traditional short messages characterised by their easy-to-read language and font. IPC messages are becoming more frequent and as IPC become increasingly complex, its reliance on messages becomes more urgent.
 
 
Designing, framing and delivering IPC messages through signs is difficult, even for skilled and experienced health promotion staff and marketing teams. For IPC staff, most of whom come from clinical rather than creative backgrounds, the challenge can be daunting. Regardless, some of the most engaging healthcare signs have addressed and positively impacted complex IPC challenges such as non-compliance with recommended practices or rapid education about new, highly transmissible and deadly conditions. Behind each successful sign, consideration of some simple but very important questions, like those below, has likely guided its originator and designer. To illustrate the usefulness of these questions it’s worth referring to examples of recently encountered hand hygiene signs. They include a reminder currently located at the entrance to a bank of elevators in a large private Australian hospital (see Figure 1), a button reminder from the US Centers For Disease Control and Prevention (CDC) (see Figure 2)² and a World Health Organization (WHO) educational poster (see Figure 3)³.
Who is the intended audience for your sign and how well do they already understand the issue the sign is addressing?
Defining your intended audience sets the scope of your sign in terms of its language, tone and message complexity. If clinicians are your only target, your sign may convey a message consistent with their level of health literacy. Non-clinicians will most likely poorly understand or ignore the same message. If you are targeting clinical and non-clinical hospital employees, the language and simplicity of the sign should be more generic so that the sign engages all staff equally. In this case, graphic images rather than words may reduce ambiguity and convey a clear, specific message. If the sign must resonate equally with hospital employees and members of the public the sign will most definitely benefit from using more imagery and less complex wording. However, simple, carefully selected specific words may offer a unique opportunity for the hospital to convey its genuine intent about hand hygiene being a means to keep all staff, patients and visitors safe. This appears to be the intent of the sign at Figure 1.
What is the sign’s key message?
The way humans read and interpret signs depends on their beliefs, experiences, knowledge and values. Simple signs avoid ambiguity and maximise intent. A few carefully selected words or even no words may make a powerful statement with greater impact than a busy, distracting sign where crowded words or excess images can confuse the message, lead to ambiguity and even detract from the visual impact of one single compelling image or the clever placement of a few carefully chosen but powerful words. Compare the messaging on the CDC’s button at Figure 2 to the WHO’s poster at Figure 3. CDC’s key message is simple; hand hygiene can save lives whereas WHO’s message, a complex instructional one about correct technique, is both audience-specific, highly technical and comparatively complex.
SIGNAGE HINTS
Including a Quick Response (QR) code on IPC signs automatically directs viewers with QR reader enabled technologies to web, blog and social media sites. These are useful repositories and access points for additional IPC messages, information and materials beyond that which can be easily and effectively included in a sign.
How can the sign best convey that message?
IPC signs most often combine language and images. The chosen word(s) and image(s) are important but so too is their tone, size and placement. Infection control sign designers need to consider whether they want their message to appeal to emotion, logic or values as this will guide whether they include compelling stories or confronting images to capture attention, data or reference to standards or guidelines to illustrate their message. Figure 1 appeals to the values of all who will pass or enter the elevators. It assumes they all equally care for and can see value in hand hygiene as an IPC measure.
Where is the best place for the sign to be displayed?
Healthcare ‘real-estate’ for sign placement is under increasing pressure especially as organisations recognise the commercial potential for their limited highly prominent spaces. As well, existing building and safety codes may preclude placement of signs in certain areas and in those remaining areas, it is common to find multiple speciality groups vying for prime space. The options for placing and securely fixing infection control messages are limited. As a basic guide, place IPC signs only in high traffic areas. They must be easily seen for periods long enough for their message(s) to be read and received. They should not directly compete with either more critical, more compelling or more appealing signs. Studying and understanding hospital traffic and workflows provides valuable insight into the best locations for sign display.
Some innovative hand hygiene signage includes:

• screen savers,


• as part of portable hand hygiene promotion stations,


• in conjunction with audible cues activated on entry to intensive care units;


• on LCD screens in individual wards; and


• in basic materials distributed to patients and their families.

Including a Quick Response (QR) code on IPC signs automatically directs viewers with QR reader enabled technologies to web, blog and social media sites. These are useful repositories and access points for additional IPC messages, information and materials beyond that which can be easily and effectively included in a sign. The QR code will take up a small proportion of any sign’s available space. Although QR code use in IPC is in its infancy this and similar applications will likely revolutionise IPC signage and messaging.
How will we know whether the sign is working?
Measuring the direct impact of an IPC sign is difficult and no published research specifically addresses this issue. Signs as reminders and prompts for desired IP&C behaviours have been favourably reported in large campaigns using multiple targeted interventions to improve compliance.^4,5 Perhaps rather than attributing change to signs it is more prudent to consider what are the risks an organisation faces if in fact the sign is counterproductive or misleading?
Ironically, despite multiple reminders and signs similar to Figure 1 our national hand hygiene compliance remains a dismal 76%. Is non-compliance in fact the greatest sign that signs themselves do little to positively impact IPC behaviours or is it simply that few designers of IPC signs have seriously considered and addressed the important issues?
SIGNAGE HINT
Bright, fast-moving and rapidly changing, evocative graphic images shooting across liquid crystal display screens strategically placed at hospital or ward entrances are steadily replacing traditional short messages characterised by their easy-to-read language and font.

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REFERENCES

1.  Murphy C. Signs To Improve Infection Prevention. In. Gold Coast: Infection Control Plus; 2013.


2.  Hand Hygiene in Healthcare Settings. 2011. (Accessed 27th January, 2014, at http://www.cdc.gov/handhygiene/Resources.html#HCP.)


3.  How To Hand Rub Poster. World Health Organization, 2009. (Accessed 27th January, 2014, at http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf?ua=1.)


4.  Grayson ML, Jarvie LJ, Martin R, et al. Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out. The Medical journal of Australia 2008;188:633-40.


5.  Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307-12.

As Executive Director of Infection Control Plus Pty Ltd, Cathryn Murphy PhD provides independent consulting services to a range of clinical, public policy and commercial clients throughout the world. In more than 25 years working in Infection Control and Prevention Cath’s career has covered senior positions within the clinical, government, non-government and professional associations within Australia and internationally.
For more than twenty years Cath helped shape infection control domestically as an Executive member and then President of both her state and national Infection Control Associations. She was a foundation member of the Asia Pacific Society of infection Control (APSIC) and an invited member of the World Health Organisation’s Expert Technical Infection Control Group. Since 2004 she has been a senior partner in Infection Control Plus.