Top to Bottom: Implementation of CAUTI Care Bundles in NHS Scotland: a Qualitative Exploration of Healthcare Professionals Perspectives Using Normalisation Process Theory

  • Debbie Waddell

Student thesis: Doctoral ThesisDoctor of Philosophy (PhD)


Background: Healthcare Associated Infections are a significant public health concern and a major cause of morbidity and mortality. Urinary Tract Infections (UTI) remain the most prevalent healthcare-associated infection globally and catheter-associated urinary tract infection (CAUTI) is one of the most common infections experienced in hospitals worldwide. The Scottish Patient Safety Programme (2008) developed a CAUTI care bundle to promote CAUTI reduction. Consequently, there is now an opportunity for Implementation Scientists, Policy Makers, Service Managers and Healthcare Professionals to reflect on and learn from the implementation, embedding and normalising of CAUTI care bundles in everyday clinical practice.

Aim: To apply Normalisation Process Theory to explore and explain the implementation of the CAUTI care bundle from the perspectives of participating NHS Scotland acute service staff.

Methods: The study commenced with a literature review of interventions designed to minimise CAUTI in acute care settings. Following this, a qualitative study was conducted accessing two National organisations, thirteen NHS Scotland Boards and thirty-eight local acute areas from four of the thirteen NHS Scotland Boards. A purposeful sample represented a variety of positions and staff groups from National, NHS Board and Local levels of NHS Scotland. Qualitative semi-structured interviews were conducted with 64 participants, 49 individual participants, 2 focus groups (n=7)and 4 joint interviews (n=8). Normalisation Process Theory (NPT) (May et al., 2009)was used to guide the development of data collection and analysis. Interviews were thematically analysed applying principles from Ritchie and Spencer’s (1994)Framework Analysis and subsequently mapped to the four constructs of NPT(Coherence, Cognitive Participation, Collective Action and Reflexive Monitoring) (May et al., 2009). NPT provided the theoretical framework to interpret the findings of the study.

Results: Expectations and understanding of the CAUTI care bundle between National, NHS Board and Local levels were disparate. There were four main themes identified in the thematic analysis: 1) ‘Making sense of CAUTI Care Bundle in Practice’,22) ‘Implementer Accountability’, 3) ‘Bundled Out’ and 4) ‘Maintaining Involvement’. Using the ‘lens’ of NPT, themes were further explored and a range of factors were found to either facilitate or present barriers to CAUTI care bundle implementation. Leadership was recognised as one of the most positive contributors for the implementation of the CAUTI care bundle, while having Local level ownership and dedicated facilitators to lead implementation were also deemed to be important. Overall, however, coherence within CAUTI and the CAUTI care bundle was lacking which affected engagement and the willingness to drive the implementation (cognitive participation). There was limited capacity within workloads to allow staff to be fully involved with the CAUTI care bundle (collective action) which resulted in a passive approach to implementation in many clinical areas. This produced a negative appraisal of the CAUTI care bundle initiative and implementation work (reflexive monitoring).Ultimately, this impacted the implementation, sustainability and embedding of the CAUTI care bundle.

Conclusions: This study contributes to the qualitative evidence regarding the experiences of macro, meso and micro healthcare professional implementers of the CAUTI care bundle in the acute sector of NHS Scotland. It has revealed the challenges and complexity of implementing a CAUTI care bundle into acute clinical practice. It adds to the body of literature by identifying the key drivers of implementation to guide healthcare professionals, particularly nurses and doctors, on the best strategies to adopt for CAUTI care bundle implementation. Recommendations for policy, education, practice and research have been provided which highlighted the need for a clearer understanding, across all implementer levels, of the rationale and benefit of implementing the CAUTI care bundle.
Date of Award2018
Original languageEnglish
Awarding Institution
  • Glasgow Caledonian University
SupervisorKay Currie (Supervisor), Jo Booth (Supervisor) & Jacqui Reilly (Supervisor)

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