Top to bottom: implementation of CAUTI care bundles in NHS Scotland

Introduction
Urinary tract infections remain the most prevalent healthcare-associated infection in NHS Scotland (Health Protection Scotland, 2017). Catheter-associated urinary tract infection (CAUTI) is one of the most prevalent healthcare-associated infections globally and is the most common experienced in hospitals (Saint et al, 2016). The Scottish Patient Safety Programme developed a CAUTI care bundle to promote CAUTI reduction. Following this recent innovation in patient safety, there is an opportunity for healthcare professionals to learn from the implementation, embedding and normalising of CAUTI care bundles in everyday practice.

Methods
Normalisation Process Theory (NPT) (May et al, 2009) has been used to study the implementation of complex healthcare interventions in various areas of health care. Using qualitative methodology, semi-structured interviews were adopted to explore participants’ (n=68) perceptions of the implementation process. Participants were recruited from national strategic organisations, NHS board-level implementers and local ward level nursing staff to determine the barriers and facilitators of CAUTI care bundle implementation. Framework analysis methods were applied to explore how these participants made sense of the work of implementing the CAUTI care bundle (coherence); how they engaged with it (cognitive participation); enacted it (collective action); and appraised its effects (reflexive monitoring).

Results
Overall there was a view that CAUTI care bundles met the needs of patients, staff and the organisation. A common challenge to implementation was the perception of disconnection and hierarchical influence from both board and local participants. There was a further feeling that CAUTI care bundles could be a ‘tick-box exercise’. Data illustrated that organisational support, leadership, staff education and stakeholder ‘buy-in’ were most influential in achieving successful mplementation.

Conclusions
Despite participants’ initial expectations that the implementation of the CAUTI care bundle would have numerous advantages, its implementation exposed several barriers. This study highlights the complexity of implementing and embedding complex interventions into clinical practice.