We applied our codes to the four ways staff orient to risk framework and found that this framework provided an in-depth means of understanding how risk and use of a device are related. We also used contrary data to expand and build upon this framework to include other variables we found that might influence perceptions of and responses to risk. These additions resulted in some expansions and redefinitions of the risk orientations which are explained below.
Dixon-Woods et al. [9
] state that staff deal with competing priorities about matters that are inherently contestable. Our data suggests that what might be contestable are other patient safety initiatives. When health care providers related risk to the initiative being implemented, they would prioritize their work because of other, numerous, patient safety initiatives that were often implemented concurrently. On one unit, we heard that they were participating in four separate patient safety initiatives (pressure ulcer, falls, delirium, and medication error prevention). As one participant stated:
… it’s complicated to try to keep that patient safe (Hospital 5- Medical/Surgical Charge Nurse).
In many of the hospitals interviewed, falls were classified as “never-events” and, therefore, were often the primary focus for nurses. In relation to falls, urinary catheters were seen as both a preventive strategy against falls and a potential cause of falls.
Example of urinary catheters preventing falls:
It’s that nurses are worried, “Well do I really want this person hopping out of bed and can I really be sure that they’re going to call me to help them?” We don’t want there to be any falls. That’s considered a never-event in a hospital and we don’t want them to have a [urinary] catheter and, we’re not sure because they just had anesthesia, are they really going to remember to put on their call light or will they try to get up and go to the bathroom? (Hospital 5- Infection Preventionist)
Example of urinary catheters causing falls:
… a lot of times it [catheter] agitates them [patients] more and then they’re trying to climb out of bed because they don’t know the catheter’s there. They keep forgetting and then they feel like they still have to pee, so we had said, you know, ‘Can we pull this catheter, otherwise the catheter’s either going to get pulled out by the patient or they’re trying to get out of bed and they’re going to injure themselves,’ (Hospital 7- Staff Nurse).
The quotes above illustrate how the use of the urinary catheter was perceived differently between two hospitals. In the first case, use of the urinary catheter was seen as a strategy to prevent falls. Thus, urinary catheter use was viewed as compatible with other patient safety initiatives. In the second case, the urinary catheter was seen as a potential cause of falls and, therefore, use of the urinary catheter posed a risk, not necessarily to infection, but to the “never-event” falls.
In addition to prioritizing patient safety initiatives, health care providers were also prioritizing their day-to-day patient care workload. Because nurses were caring for multiple patients, they had to choose which patient care activities were most important and then decide how these activities were going to get done. Many of our interviewees stated that nurses view the urinary catheter as a means to lighten their workload. So, in their opinion, nurses would either ask physicians to order a urinary catheter or they would not ask for an early discontinuation order.
It is hard for a nurse when she’s got five patients, two of which are critical, a patient wants to get up and use the toilet or wants to get on a bedpan and she’s doing six other things, it’s hard for her to break the habit of just going to put in a [urinary catheter] so she can get to the rest of her work. That is a legitimate impediment… (Hospital 11- Infection Preventionist)
However, it should be noted that our findings about nurses not removing catheters or inserting them as a convenience is largely based on the perceptions of those we interviewed (most of whom were management and senior level practitioners) and not based on staff nurses themselves speaking to this issue. What we did find was that when the whole work context was taken into account, it became clear that use of the urinary catheter was possibly in response to other organizational issues, such as insufficient staffing, that increased nurse workload.
In addition to hearing about use of the catheter for “nurse convenience” we also heard that some physicians, mainly those in the Emergency Department (ED), will also insert a catheter for “convenience.”
Dr. XXX went to the physician services meetings, talked to the docs about how important it is not to just do it for convenience because in the [ED] it sometimes is for convenience and in our [ED], typically we could have 25 people waiting for a bed, full with 25. It’s crazy (Hospital 12- Infection Preventionist).
As with the nurse convenience finding, the quote above demonstrates that other issues, such as being too busy to be able to assist a patient to the bathroom, may be contributing to health care providers’ decisions to insert a catheter and only peripherally-related to convenience. The perception that catheters are being inserted for “convenience” may hinder the implementation success of patient safety initiatives because it does not speak to the underlying organizational issues, such as lack of staffing or lack of medical alternatives, (e.g., a bladder scanner that could help determine the need for a catheter) that may be contributing to these decisions.
Many patient safety initiatives, including the Bladder Bundle, were seen by health care providers as competing with one another rather than complementary. Like Dixon-Woods et al. , our findings also suggest that health care providers engage in certain work activities based on how they prioritize patient safety initiatives in relation to patient and work outcomes. The “worse” the outcome, (not necessarily to the patient) the higher the priority. Additionally, we found that some patient safety initiatives were seen as “threatening” to other initiatives so health care providers often had to decide which initiative they would focus on.
Tightly coupled errors (or loosely coupled errors?)
Tightly coupled errors are when the link is made between the error and negative outcomes. The link happens when there is a, “significant lapse in patient safety that [can] be directly attributed to someone doing something incorrectly” [9
]. In contrast, we found a lack of tightly coupled errors; what we re-defined as loosely
coupled errors. Although most participants acknowledged that urinary catheters could cause CAUTI, the issue for some was that this link was not very compelling because the outcome was often not immediate or life-threatening. For example, one interviewee stated:
… so it’s just making them [nurses] understand that there is a relationship between bladder infections and urinary tract infections and [urinary] catheter days… (Hospital 8- Director of Nursing)
One hospital even made it a point to collect urinary tract infection (UTI) data on patients seven days post-discharge to use as evidence for their staff that urinary catheters (and hence their actions related to the use of urinary catheters) do cause infections.
We even track UTI associated with a [urinary] catheter post hospital… We’re trying to get some [infections] to show people, “See? There it is, a UTI occurring. It just didn’t happen quick enough for you to see it in the hospital.” (Hospital 5- Infection Preventionist).
We found that, although increased risk for infection related to urinary catheter use resonated with some health care providers’, other factors also influenced how they viewed this device. For example, some of our participants stated that the urinary catheter is a “low tech” or basic nursing procedure and, consequently, does not pose much risk to the patient. In addition, some nurses and physicians did not see CAUTI as a significant risk to their patients’ health compared to other infections, such ventilator-associated pneumonia (VAP) and CLABSI, which were seen as more risky and, therefore, prioritized above CAUTI.
… it’s difficult to find people that are excited about getting Foleys out of patients; other things take higher priority like central lines and VAP (Hospital 11- Director of Nursing).
The link between urinary catheter use and whether CAUTI represents a significant lapse in patient safety also appears to be influenced by personal experience. For example, we heard that many nurses themselves had experienced UTI’s and, therefore, considered it an easily curable condition. It was basically seen as an “innocuous” infection.
Let’s think about it, the majority of our RNs are still female and they’ve all had hundreds of urinary tract infections in their life time. They did not die (Hospital 2- Infection Preventionist).
Unlike tightly coupled errors, we did not find a link between a lapse in patient safety and someone doing something wrong. In fact, if someone did do something wrong, such as improper insertion that resulted in a CAUTI, health care providers felt that it was easily treatable and, therefore, did not pose much risk. In addition, we found that perceived risk associated with the urinary catheter and the specific outcome of CAUTI was relatively low; what we re-defined as loosely coupled errors. The urinary catheter was considered a basic or “routine” procedure and for some health care providers, a part of standard care. The Bladder Bundle tries to clearly link use of the urinary catheter with increased risk for infection to the patient. However, this link was sometimes minimized based on whether providers viewed the severity of CAUTI as a significant patient safety problem and if the risk of catheter use was associated with developing a negative outcome.
According to Dixon-Woods et al.  process weaknesses are organizational processes that health care providers’ believe could pose more of a risk when used. They found that when a process did fail, it was unclear who had the authority to change the process and, therefore, the suboptimal process usually continued causing health care providers’ to work in “reactionary” mode.
However, our data led us to reconceptualize the notion of process weaknesses to include the initiative being implemented. Where Dixon-Woods et al.  concept focuses on how organizational processes can pose a risk if used, we found that problems can also arise if the initiative is not context appropriate. We found that, when implementing this initiative, hospitals experienced difficulties due to the disparity between the Bladder Bundle’s processes for use and the pre-existing organizational processes. Hospitals in our study often experienced two process weaknesses that were difficult to overcome; (1) the context in which they were trying to implement the Bladder Bundle (organizational process weakness) and; (2) the indications for urinary catheter use (Bladder Bundle process weakness).
The first process weakness was how hospitals were trying to apply the Bladder Bundle indications in organizational settings and populations for which the program was not designed. For example, more specialized units, such as obstetrics (OB), had difficulty with the Bladder Bundle indications because what they used the urinary catheter for was either not listed or did not seem to apply to their patients. In one hospital, it was organizational policy that if an OB patient had an epidural they automatically received a urinary catheter which is not a Bladder Bundle indication. Therefore, to not insert a catheter would go against hospital policy.
… one of our challenges is what to do with epidurals and our culture is that if you have an epidural in place, you have a [urinary catheter] in place and [health system] as a whole has decided not to tackle that too much yet (Hospital 6- Clinical Nurse Specialist).
What was also interesting was that there was recognition, by the hospitals, that the indications did not seem to be developed for specialized units, but they went ahead with trying to implement the initiative anyway.
. . . I looked at the criteria set forward indications for [urinary] catheter use. I think my gut reaction was that perhaps some of those were not as applicable in the ED setting, that maybe they were more devised for the inpatient setting (Hospital 12- Infection Preventionist).
The second process weakness, indications for urinary catheter use, as defined by the Bladder Bundle initiative, created difficulty when hospitals tried to rigidly apply these indications. The Bladder Bundle has a list of indications, based on expert opinion, that are meant to guide health care providers in deciding whether or not a urinary catheter is necessary and appropriate. However, we found that health care providers continued to use the urinary catheter for non-indicated reasons.
One of the most cited reasons for use of the urinary catheter was to determine Intake’s and Output’s (I’s and O’s) and this measurement was seen, by some health care providers, as “common” practice. A patient’s fluid balance is monitored carefully through I’s and O’s. This measurement is considered a management tool that provides information on a patient’s hydration level, and renal and cardiovascular function. However, within the Bladder Bundle program, I’s and O’s are not an indication for urinary catheter use except for critically ill patients. Also, there is a lot of debate both as to the usefulness of this measurement for monitoring a patient’s condition and for acceptable alternatives. For example, one participant stated that she could not get consensus among the physicians on an alternative measurement. Weight was suggested by the Bladder Bundle but many physicians felt that this measurement was not accurate:
I think it’s [I’s and O’s] still an issue . . . it’s hard to define. The (Bladder Bundle) Project, said you’re supposed to be using the weight really more than the measure, etcetera. But that is a hard thing to actually get everybody to agree upon and to practice (Hospital 12- Infection Preventionist).
Physicians felt that the alternative measurement for I’s and O’s, weight, was not accurate enough and, therefore, continued to use the catheter. We cannot conclude, by virtue of our findings, that physicians viewed not using the catheter as more of a risk. The relationship between risk and not using a device is an area that needs further exploration.
One hospital thought the Bladder Bundle indications were so ambiguous and inapplicable to their patient population, they developed their own indications:
To be honest with you, the reasons [indications] why the catheters were in, that was very confusing, that needs to be tightened up… I asked for a little more clarification, didn’t really get it, so we kind of developed our own… (Hospital 3- Project Manager, Quality and Research)
In addition, no matter how explicitly the Bladder Bundle indications were stated, interpretations of these indications occasionally differed from what was intended. For example,
This is kind of a weird thing that happened but one of the appropriate indications is prolonged immobilization and I think the intent of it was a patient who had a thoracic or lumbar spine fracture that was unstable. However, I think many people are selecting that indication just because patient’s going to be on bed rest (Hospital 6- Trauma nurse specialist).
Although more work in this area is warranted, by reconceptualizing Dixon-Woods et al. construct , we found that process weaknesses may have to do with both the pre-existing organizational processes and the initiative being implemented. Some units were able to directly relate urinary catheter use to the Bladder Bundle indications whereas other units found it difficult to apply these indications to both their patient populations and the units existing context. Ultimately, staff were trying to implement the Bladder Bundle’s processes into contexts that were a poor fit due to pre-existing organizational processes. In fact, in one hospital, non-use of the catheter went against their policy. In addition, the Bladder Bundle’s indications were based on “expert opinion” but these indications did not address the existing behaviors as to why the catheter was being used in the first place. We also found that when the Bladder Bundle tried to restrict the use of the urinary catheter through “appropriate indications,” health care providers developed workarounds to continue to use the urinary catheter in ways they deemed appropriate.
Cutting corners (or workarounds?)
As described in the Dixon-Woods et al. framework , when staff were involved in managing risks, they would often “cut corners,” meaning not follow the standardized procedures, and then justify the reasons for such noncompliance. Justifications included not relating the behavior or activity to infection, questioning the standards, and viewing such behavior as the “norm” because they were following what co-workers were doing.
However, our findings suggested that health care providers were more likely to engage in workarounds then cut corners. Workarounds and related patient safety incidents have been studied in various health care settings [18–21]. The concept of workarounds is generally thought of as, “work procedures that are undertaken to bypass perceived or real barriers in work flow,” . We found workarounds involved several of the strategies implemented to limit use of the urinary catheter, including those related to the use of technology, assessment for catheter need, and ongoing monitoring of catheter use.
We found that the electronic medical record (EMR) offered health care providers several opportunities to by-pass organizational processes (based on Bladder Bundle recommendations), to continue to use the urinary catheter. Documentation, technological or written, often did not reflect why urinary catheters were being used. For example, use of an “other” category in the EMR ordering system as the indicated reason for urinary catheter use was common at one site but this made it difficult to both understand the reasons for insertion and to change the resulting behavior.
I think some of the challenges are related to our electronic medical record, the way it’s set up because when a physician goes in to order a catheter, they put in the order and then they have to select one of those, I think there are 7 indications and it’s all the approved indications. But the way our rules are with our electronic record, we always have to give physicians something of an out, that if it doesn’t fit in those categories, they can select “other” or they can bypass it (Hospital 6- Trauma Nurse Specialist).
Some hospitals were implementing electronic orders to standardize the various uses of the urinary catheter indications and assessments. However, this solution presented its own set of workarounds. For example, one hospital’s EMR allowed physicians to set up their “favorites” in their order sets where indications were preselected. Therefore, the urinary catheter was deemed “appropriate” even if it might not reflect the actual reason for use.
Another workaround we found had to do with urinary catheter assessments. Once the urinary catheter is inserted, the Bladder Bundle requires “necessity” assessments to be done to determine the on-going need for the urinary catheter. The purpose of these assessments is to ensure that unnecessary urinary catheters are removed promptly thus decreasing the likelihood of CAUTI. We found, however, that these assessments were used as workarounds because health care providers had developed variations in how they interpreted and applied these assessments. For example, at one site that had developed an automated system and scoring algorithm to indicate whether the urinary catheter was still necessary, one participant stated:
I wouldn’t say it’s [needs assessment] been as helpful as we had hoped it would be because I find that sometimes they forget to do it and sometimes they’ll just mark something that gets the patient a 5, [5 indicates that a urinary catheter is needed] unfortunately . . . we still have some nurses who don’t want to deal with it so they’ll just put “reevaluate in one week” or whatever (Hospital 2- Clinical Nurse Specialist).
Like the documentation issues, this scaled necessity assessment, which was intended to aid health care providers’ in their decision making process, was being used to justify keeping a urinary catheter in, thus it did not change the underlying behavior.
An additional workaround was the use of “catheter patrols.” Catheter patrols consisted of health care providers checking each inpatient for a urinary catheter, if appropriate indications were documented, and whether or not the urinary catheter was still necessary. Use of the catheter patrols was meant to prompt the physician or nurse for a removal order if the urinary catheter was found to be unnecessary. Catheter patrols were often headed by someone other than the bedside nurse such as the infection preventionist or the unit manager. Catheter patrols were successful in decreasing extended urinary catheter use but, when these catheter patrols ceased, urinary catheter use often increased indicating that health care providers were responding to the catheter patrol and not the patient safety argument.
… now you can tell why that catheter patrol was so essential though because they took the catheter patrol away briefly. And our rates went up… I think they took it away for 2–3 months thinking that things were going to be on autopilot and they were not. I think we’ll need a permanent catheter patrol (Hospital 3- Family Practice Physician).
The catheter patrol was used as a workaround on the nursing side of care because, instead of the bedside nurse taking responsibility for the daily assessment and follow-up with physicians, this activity was taken on by someone else who, perhaps, was not directly involved in patient care. Therefore, the bedside nurses were not prompted to change their behaviors and integrate this initiative into their everyday work.
In comparison to Dixon-Woods et al.  cutting corners, we found that health care providers were more likely to develop workarounds to complete their work tasks. Even with the use of the EMR, health care providers were still able to find ways to work around its structure and continue to use potentially unnecessary urinary catheters. The Bladder Bundle “necessity” assessment was pliable enough it would actually support behavior it was meant to change. The catheter patrols, even though designed to get health care providers to think differently about catheters, only managed to control their behavior when it was patrolling.