Introduction
Leaders providing oversight for infection prevention or antimicrobial stewardship programs develop deep expertise in outbreak investigation, antimicrobial management, and healthcare-associated infection (HAI) prevention, yet rarely have direct managerial control of resources such as full-time equivalents (FTEs) and budgets. Much of what we do involves driving quality improvement and behavior change, both of which require persuasion of others. Most IP/ASP leaders have had no formal training in persuasion and influence and may perceive it as a domain reserved for sales or deal-making or as a form of manipulation. Reference Conger1
Effective persuasion is not manipulation; it is a process through which a persuader leads colleagues to a shared solution. Reference Conger1 As used here, power refers to the capacity to affect others’ decisions; influence is the exercise of that capacity without coercion; and persuasion is one mechanism of influence: the use of communication to change beliefs or behavior. Cialdini’s core principles of ethical influence (reciprocity, commitment and consistency, social proof, authority, liking, and scarcity) have been validated across disciplines and contexts. Reference Cialdini2 This review adapts these and other evidence-based strategies for the IP/ASP leader, providing concrete examples and actionable recommendations.
Building and leveraging power
French and Raven’s taxonomy describes several bases of social power relevant to IP/ASP leaders. Reference French, Raven and Cartwright3 Positional power derives from formal titles and resource authority, which most IP and stewardship leaders hold only nominally. Personal power reflects charisma, approachability, and emotional intelligence. Expert power rests on knowledge and credentials; it is a natural strength for IP/ASP leaders but can backfire when over-relied upon. Most important is relational power, which emerges from one’s ability to create cooperation through empathy and active listening and to gain support through likeability and trustworthiness. Relational power grows with the breadth of one’s professional network, particularly when one serves as a broker bridging unconnected groups.
IP/ASP leaders are uniquely positioned to strengthen their relational power. Our cross-departmental reach and ability to interpret and communicate complex data such as National Healthcare Safety Network (NHSN) definitions, standardized infection ratios (SIRs), and antibiogram data are powerful assets. Building diverse networks of allies is essential, and this often means seeking partners beyond traditional colleagues, including nursing leaders, quality directors, environmental services directors, and hospital administrators.
The power of reciprocity
Proactively helping others builds relationships through the principle of reciprocity. Reference Cialdini2 It may not sound surprising that performing professional courtesies for others leads them to reciprocate, but far less intuitive is the finding that asking others for assistance can lead to greater influence as well. Help seekers frequently overestimate the likelihood that their request will be refused; in reality, others are far more willing to assist than predicted. Reference Flynn and Lake4
The Autobiography of Benjamin Franklin illustrates this principle elegantly. Reference Franklin5 Franklin turned a political adversary into a lifelong friend not by confronting him but by asking to borrow a rare book. The adversary obliged, Franklin returned it with a gracious note, and the relationship transformed – a phenomenon now known as the “Benjamin Franklin effect.” For the stewardship leader facing resistance from a surgical department regarding perioperative antibiotic duration, a similar approach might involve approaching the department chair for advice on a complex clinical case. This signals respect for the surgeon’s expertise and opens the door for subsequent conversations in a collaborative context.
Reciprocity is best understood through the lens of social capital, the accumulated goodwill that builds through repeated positive interactions. Like a bank account, it must be built before it can be drawn upon. Equally powerful is spending our own capital on behalf of other leaders. If a nursing director is struggling to get buy-in for a new hand hygiene monitoring program, the IP leader who volunteers to present the rationale at a staff meeting, absorbing the potential pushback personally, saves that director from expending her own political capital. She becomes a natural ally when nursing leadership’s support is needed for the next initiative.
Practical tips: building power
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• Consistently offer professional assistance such as sharing data, interpreting results, and providing guidance, both when requested and proactively. Do not hesitate to make professional requests in return.
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• Build informal coalitions with allies outside traditional ranks. Leverage dyadic partnerships with IP managers and stewardship pharmacy leaders, whose existing relationships with frontline staff can extend the reach of physician-led initiatives.
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• Enlist adversaries by asking them for advice. This signals respect and invites collaboration.
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• Use analytical skills to provide actionable information, not just raw data. Interpret SIRs, antibiograms, and outbreak data in plain language.
Framing through perceptual contrast
A key persuasion skill is perceptual contrast: the evaluation of a request changes relative to the alternatives presented alongside it. Reference Cialdini2 The “Door in the Face” technique illustrates this principle: make a large request first, and have a smaller backup ready when the other party declines. Reference Cialdini, Vincent, Lewis, Catalan, Wheeler and Darby6
Suppose the stewardship team identifies a colorectal surgeon routinely using piperacillin-tazobactam for perioperative prophylaxis when guidelines support cefazolin plus metronidazole. We recommend the guideline-concordant regimen, which the surgeon declines. We then propose ceftriaxone plus metronidazole, still eliminating unnecessary antipseudomonal coverage, which was our primary goal, and the surgeon accepts the suggestion. Had we opened with the compromise, we would have had no room to negotiate.
When presenting proposals to leadership, bracket the preferred choice between alternatives. Present low-, medium-, and high-cost options; the medium choice will typically prevail through both perceptual contrast and “extremeness aversion.” Reference Simonson7 If we need a new infection preventionist, present three scenarios: (1) maintain the status quo with re-allocation of existing duties resulting in gaps; (2) hire one new IP (our actual goal); (3) hire two IPs and a data analyst to match peer institutions’ staffing. The medium choice typically prevails. Additionally, make the deliberation visible: “Other peer hospitals have two to three IPs in this role, and I seriously considered requesting two. But given our budget, even one IP would let us cover the surgical units, where most of our preventable surgical site infections (SSIs) are occurring.”
Practical tips: framing and contrast
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• Make the ideal request first and have a smaller fallback ready.
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• Present low, medium, and high-cost options, with the preferred option as the middle choice.
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• Show your work: mention alternatives considered and rejected.
Establishing trust and credibility
Credibility is the sine qua non of persuasion, comprising expertise and trustworthiness. Reference Conger1 In most healthcare settings, our audience already knows we are experts. But expertise alone is insufficient; we must also demonstrate transparency and act in the interest of patients and the institution.
Expertise can be reinforced through underutilized cues. Write your own introduction for lectures rather than letting the host read off your CV. Introduce team members with genuine specificity: “This is Sarah Chen, one of our most experienced infection preventionists, who led our successful methicillin-resistant Staphylococcus aureus (MRSA) reduction initiative.” This credibility is bidirectional: the established trust that infection preventionists and clinical pharmacists hold with frontline staff can strengthen our own influence, just as our physician authority can amplify theirs.
Trustworthiness is where many well-intentioned persuaders falter. Two-sided arguments – those that acknowledge limitations before presenting strengths – are more persuasive than one-sided arguments, particularly with sophisticated audiences. Reference Allen8 The key is to mention a small weakness immediately before your strongest point. Compare: “We’ve made a lot of progress with our central line-associated bloodstream infection (CLABSI) rate, but we still have a way to go” [the “but” erases the progress] with “While we didn’t quite reach our target, our CLABSI rate has dropped 34% over the past two quarters, putting us ahead of the national benchmark” [weakness first, then the strongest evidence].
The Dialogue Around Respiratory Illness Treatment (DART) program demonstrated the same principle in clinical communication: combining a negative treatment recommendation (“antibiotics won’t help”) with a positive one (“here is what you can do”) reduced inappropriate prescribing by 85% and improved visit satisfaction. Reference Mangione-Smith, Zhou, Robinson, Taylor, Elliott and Heritage9 Whether the audience is a parent, an administrator, or a surgical colleague, the lesson is the same: pair what we cannot offer with a concrete, constructive alternative.
Transparency also means admitting uncertainty. An IP leader who says, “The evidence for chlorhexidine (CHG) bathing beyond the intensive care unit (ICU) is mixed, but the intervention is low-cost and our surgical unit has the highest MRSA transmission rates, so the risk-benefit calculus favors a pilot” is more credible than one who presents only favorable data.
Concreteness, storytelling, and emotional appeal
The power of specificity
People pay more attention to, remember, and are more persuaded by information that is specific, detailed, and vivid. Reference Heath and Heath10 Goals should be specific, time-bound, measurable, and realistic. “Better” is not a goal. “Improve” is not specific. Compare a corporate mission statement like “Our mission is to become the international leader in the space industry through maximum team-centered innovation” with President Kennedy’s declaration: “I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the Earth.” Reference Heath and Heath10 The first is abstract; the second is concrete and galvanizing.
In IP and stewardship, specificity transforms aspirations into action. Don’t commit to “improving” hand hygiene rates – set a target: “We will achieve 90% hand hygiene compliance in the medical ICU by December 31.” Don’t propose to “reduce” unnecessary antibiotic use, state: “We will decrease fluoroquinolone prescriptions by 25% in the ICU over the next 12 months, using peer comparison feedback and a clinical decision support alert.”
Analogies can be especially powerful when paired with loss avoidance. For example, “A single CLABSI costs the hospital approximately $46,000 and adds an average of seven inpatient days. Last quarter, our seven preventable CLABSIs consumed roughly $320,000 and 49 bed-days – the equivalent of keeping an entire med-surg unit offline for nearly two weeks. For that same cost, we could fund a full-time infection preventionist for three years.” 11 Loss-avoidance framing resonates particularly with administrative leadership. For clinical audiences, direct patient impact is more powerful: clinicians are more likely to be moved by “49 excess hospital days that our patients spent away from their families” than by the dollar figure alone.
Dr. Donald Berwick demonstrated this principle at scale. In 2004, facing a rate of clinical process failures (the rate at which patients did not receive evidence-based care) of 1 in 10, Berwick, with no direct authority over any hospital, declared a specific goal: save 100,000 lives within 18 months. Reference Berwick, Calkins, McCannon and Hackbarth12 He emphasized, “Some is not a number; soon is not a time.” Over 3,000 hospitals enrolled, and an estimated 122,300 lives were saved.
Storytelling and emotional appeal
A powerful complement to concrete data is storytelling: facts wrapped in emotion. Reference McKee13 PowerPoint slides and SIR graphs may persuade intellectually, but people are not always inspired to act by reason alone. Stories work best when they arouse high-energy emotions such as awe, excitement, humor, or even anger and feature a protagonist struggling against a recognizable obstacle. Reference Berger and Milkman14
Both the Infectious Diseases Society of America (IDSA) and the Centers for Disease Control and Prevention (CDC) maintain patient narratives illustrating the tragedies of HAIs and multidrug-resistant organisms. 15,16 Stories from our own institutions are even more compelling. Consider beginning a committee presentation not with quarterly SIR data but with a 60-second narrative: “Last month, a 68-year-old woman was admitted for elective hip replacement. She developed an SSI with MRSA, required two additional surgeries, spent three weeks in the ICU, and was discharged to a skilled nursing facility instead of going home to her grandchildren.” Then present the data. The combination of narrative and numbers is far more persuasive than either alone.
Social proof and the power of norms
People look to the behavior of others to determine the correct course of action, particularly in situations of uncertainty. Reference Cialdini2 This principle, social proof, is one of the most potent and underutilized tools available to the IP/ASP leader. When individuals are unsure how to behave, they default to what they perceive as normal.
Peer comparison, or “normative feedback,” has been demonstrated to change physician prescribing behavior. In a landmark randomized trial, letters sent to the highest-prescribing primary care physicians in England informing them that their prescribing rate was higher than 80% of their peers reduced antibiotic prescribing by 3.3%, averting tens of thousands of unnecessary prescriptions. Reference Hallsworth, Chadborn and Sallis17 Similar results have been replicated in US health systems using peer comparison dashboards. Reference Meeker, Linder and Fox18
The framing of normative messages is critical. Messages that describe what most people are doing (descriptive norms) tend to be more effective than messages about what people should do (injunctive norms). Reference Cialdini2 For example, “92% of physicians on this unit document their central line necessity daily” is more motivating than “All physicians should document central line necessity daily.” External benchmarking works similarly: “We are currently in the fourth quartile among academic medical centers for CLABSI rates” leverages social proof by implying the desired behavior is the norm elsewhere.
A word of caution: social proof can backfire when the undesirable behavior is framed as widespread. Telling physicians that “60% of antibiotic prescriptions in the ED are inappropriate” may inadvertently normalize inappropriate prescribing. When the negative behavior is prevalent, lead with the aspirational norm or use injunctive norms that emphasize institutional expectations.
Scarcity and urgency
People assign greater value to opportunities that are scarce or diminishing. Reference Cialdini2 Emphasizing what stands to be lost, rather than what might be gained, is consistently more persuasive, rooted in loss aversion. Reference Kahneman and Tversky19 Compare: Gain frame: “Implementing prospective audit and feedback could save up to $500,000 annually.” Loss frame: “Without prospective audit and feedback, we are currently losing an estimated $500,000 per year, and every month of delay costs approximately $42,000.” The second is more compelling because it emphasizes ongoing loss and creates a cost of inaction.
Urgency can also be created through time-limited windows of opportunity. When CMS announces a new quality reporting requirement, when accreditation surveyors are expected, or when an outbreak is unfolding, these moments of heightened institutional attention are opportunities to advance proposals that might otherwise languish. Framing a request as time-sensitive (“We have six months before this reporting requirement takes effect; if we begin implementation now, we can use the first quarter as a pilot”) prevents the default response of inaction.
Consistency and commitment
People value consistency in themselves and others, and they generally desire to act in accordance with their prior statements, values, and behaviors. Reference Cialdini2 The IP/ASP leader can leverage this principle by encouraging others to make commitments and then helping them follow through.
Foot-in-the-door
The “Foot-in-the-Door” technique is the counterpart to “Door in the Face”: start with a small, easily agreed-upon request and build incrementally. Reference Cialdini, Vincent, Lewis, Catalan, Wheeler and Darby6 Rather than asking a reluctant surgical department to adopt an entire SSI prevention bundle, ask them to pilot just the preoperative CHG bathing component on one service for one month. Having committed to and succeeded with that step, they are far more likely to adopt the next element.
Public commitments and voluntary agreement
Commitments are most powerful when they are public, active, and voluntary. Reference Cialdini2 Ask for declarations of agreement in group settings: “Who is willing to champion this initiative on their unit?” Follow up with a summary email naming individuals who agreed to specific action items. In a notable example, publicly displayed commitment posters signed by clinicians in examination rooms significantly reduced inappropriate antibiotic prescribing. Reference Meeker, Linder and Fox18 Counterintuitively, affirming autonomy (“feel free to decline”) paradoxically increases the likelihood of agreement. Reference Guéguen, Pascual and Dagot20
Labeling
Labeling is the practice of explicitly attributing positive traits to someone that align with our goal, creating a standard they feel compelled to uphold. Reference Cialdini2 Phrases such as “I know you’re deeply committed to patient safety,” if authentic, set the stage for an aligned request. Labeling is especially useful with resistant colleagues: “You supported this hand hygiene program when we launched it, so I’m hopeful you’ll support this next phase.” If someone is entrenched in a prior position, present new evidence while validating their earlier judgment: “Your decision last year was the right call based on what we knew then. New data from three large trials have changed the landscape.” This allows the person to evolve without losing face.
Summary of key persuasion principles
The Table 1 summarizes the major persuasion principles discussed in this review and their applications to infection prevention and antimicrobial stewardship.
Summary of key persuasion principles
Table 1. Long description
A table with three columns and seven rows. The columns are labeled Principle, Core concept, and Healthcare application. The rows are labeled with different persuasion principles and their descriptions. Row 1: Principle, Reciprocity; Core concept, People feel obligated to return favors and concessions; Healthcare application, Offer unsolicited data analysis or advice; ask resistant colleagues for their expert input. Row 2: Principle, Perceptual contrast; Core concept, Evaluation of a request changes relative to anchoring alternatives; Healthcare application, Present low/medium/high options when requesting resources; use Door in the Face for negotiations. Row 3: Principle, Credibility; Core concept, Expertise plus trustworthiness; enhanced by transparency; Healthcare application, Lead with a small weakness before the strongest point; disclose uncertainty in data. Row 4: Principle, Concreteness; Core concept, Specific, vivid information is more memorable and persuasive; Healthcare application, Set measurable targets; translate costs into vivid analogies; use patient stories. Row 5: Principle, Social proof; Core concept, People follow the behavior of others, especially peers; Healthcare application, Use peer comparison dashboards; benchmark against peer hospitals; frame desired behavior as the norm. Row 6: Principle, Scarcity/urgency; Core concept, Opportunities seem more valuable when limited or fleeting; Healthcare application, Frame proposals around regulatory deadlines; emphasize costs of inaction; share exclusive data. Row 7: Principle, Consistency; Core concept, People strive to act in accordance with prior commitments; Healthcare application, Start with small requests and build; secure public commitments; label allies with desired traits.
Conclusion
Whether convincing physicians to improve hand hygiene, securing funding for a new stewardship pharmacist, or building alliances to address an emerging pathogen, effective persuasion is a force multiplier for the IP/ASP leader. The principles outlined here are not manipulative tricks; they are evidence-based communication strategies that align stakeholders around shared goals.
A note of caution: these techniques carry ethical responsibility. Persuasion applied without genuine commitment to patient welfare such as to advance a career, protect a department’s HAI metrics, or avoid accountability, erodes the very credibility on which influence depends. The line between ethical persuasion and manipulation is intent and transparency: ethical persuasion uses truthful information to align stakeholders; manipulation exploits cognitive biases for self-serving ends. Leaders should regularly ask whether their persuasion efforts would withstand scrutiny if their reasoning and motives were fully transparent.
These skills are learnable. Like any clinical competency, they improve with deliberate practice. The stakes are high: antimicrobial resistance is accelerating, and HAIs continue to cause preventable morbidity and mortality. Implementing solutions requires changing behavior at every level of the organization, from the bedside nurse to the chief medical officer (CMO). That is, fundamentally, a persuasion challenge, and one within our reach.
Acknowledgements
The author would like to acknowledge the contributions of Noah J. Goldstein, PhD, and Thomas R. Talbot, MD, MPH.
Competing interests
No conflicts of interest.
AI disclosure
Assistive AI tools (Claude, 2026, Anthropic) were used for grammar, spelling, syntax review, and editing.
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