The Joint Commission Journal on Quality and Patient Safety 2020; 46:691–698

An Examination of the Barriers to and Facilitators of

Implementing Nurse-Driven Protocols to Remove
Indwelling Urinary Catheters in Acute Care Hospitals
Matthew J. DePuccio, PhD, MS; Alice A. Gaughan, MS; Lindsey N. Sova, MPH; Sarah R. MacEwan, PhD;
Daniel M. Walker, PhD, MPH; Megan E. Gregory, PhD; John Oliver DeLancey, MD, MPH;
Ann Scheck McAlearney, ScD, MS

Background: Urinary catheter nurse-driven protocols (UCNDPs) for removal of indwelling urinary catheters (IUCs)
can potentially prevent catheter-associated urinary tract infections (CAUTIs). However, they are used inconsistently. The
objective of this study was to examine the barriers to and facilitators of implementation of UCNDPs in acute care hospitals.
Methods: Between September 2017 and January 2019, researchers interviewed 449 frontline staff (nurses, physicians),
managers, and executives from 17 US hospitals to better understand their experiences implementing, using, and overseeing
use of UCNDPs. Our semistructured interview guide included questions about management practices and policies regarding
enactment of a UCNDP.
Results: Although the features of UCNDPs differed across hospitals, the analysis revealed that hospitals experienced com-
mon issues related to implementing and consistently using UCNDPs as a result of three major barriers: (1) nurse deference
to physicians, (2) physician push-back, and (3) miscommunication about IUC removal. Interviewees also described several
important facilitators to help overcome these barriers: (1) training care team members to use the UCNDP, (2) discussing
IUC necessity and UCNDP use during rounds, (3) reminding care team members to follow UCNDPs, and (4) developing
buy-in for UCNDP use across the hospital.
Conclusion: Although UCNDPs are fundamental in efforts to reduce and prevent CAUTIs, hospitals can proactively
support their implementation and use by developing the skills that care team members need to enact UCNDPs when patients
meet the clinical indications for removal, and increasing awareness about the value and importance of such protocols for
reducing CAUTIs and improving patient safety.

A catheter-associated urinary tract infection (CAUTI) is

one of the most common health care–associated infec-
tions (HAIs).1 Approximately 12% to 16% of hospitalized
adults will have an indwelling urinary catheter (IUC) (com-
monly referred to as a Foley catheter) inserted during their
stay, and the risk of acquiring an infection increases each day
it remains in place.1–3 These infections can result in longer
hospital stays and higher costs of care.4 , 5 Reducing CAUTIs
has become an area of focus of the Centers for Medicare &
Medicaid Services Hospital-Acquired Condition Reduction
Program, which reduces payments to hospitals in the worst-
performing quartiles for HAI measures, including CAUTI
incidence.6
Evidence-based guidelines give health care providers
a framework to maintain, monitor, and properly re-
move IUCs3 , 7–11 ; however, preventing CAUTIs has proved
difficult.12–15 Urinary catheter nurse-driven protocols
1553-7250/$-see front matter
© 2020 The Joint Commission. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jcjq.2020.08.015
(UCNDPs) for removal of IUCs are clinical directives
aimed at reducing CAUTIs. They allow nurses to remove
these catheters from patients who meet prespecified clinical
indications, with little or no physician consultation.15–19
A growing body of evidence suggests that UCNDPs can
decrease average catheterization time and improve quality
of care.20 , 21 Yet despite the potential benefits of UCNDPs
to reduce CAUTIs, UCNDPs are not used consistently in
acute care settings.22 , 23 Reported challenges to UCNDP
use include patient and family requests to maintain IUC
placement, cultural norms related to leaving catheters in
place, clinical convenience, and the discomfort of nurses
who have to enact the UCNDPs.23–25
Improving our understanding of how hospitals imple-
ment UCNDPs is important in the context of HAI preven-
tion and may help identify opportunities to address barriers
to protocol use23 , 24 , 26 as well as minimize CAUTIs.27 Using
data from a multiyear research project focused on identify-
ing management practices to reduce HAIs,28 we conducted
a secondary analysis to examine barriers to and facilitators
of UCNDP implementation and use across the 17 hospitals
that participated in that study.
692 Matthew J. DePuccio, PhD, MS, et al. Nurse-Driven Protocol Implementation

Table 1. Characteristics of Hospitals Participating in

centage of interviews by site and interviewee role. The
Study (N = 17)∗ Institutional Review Board of The Ohio State University
approved this study, and informed consent was obtained.
Hospital Characteristic n (%)
Interviews were conducted using a semistructured in-
Hospital size terview guide that included questions about management
< 300 beds 6 (35.3)
300–499 beds 3 (17.6) practices on infection prevention, policies related to enact-
500–899 beds 5 (29.4) ment of UCNDPs, and perceptions of best practices for in-
≥ 900 beds 3 (17.6) fection prevention in that hospital (see Appendix 1, avail-
Region able in online article). We conducted most interviews in
East 5 (29.4)
West 2 (11.8) person, with some executive leaders interviewed by phone
Midwest 6 (35.3) when necessary. Interviews were held during normal work
South 4 (23.5) hours in hospital conference rooms and unit break rooms
Ownership status and were either one-on-one or group interviews, depending
Nonprofit 14 (82.4)
Government 2 (11.8) on participants’ availability. Interview length ranged from
Proprietary 1 (5.9) 15 to 60 minutes with an average of 28 minutes. All inter-
Membership in COTH views were audio recorded, transcribed verbatim, and de-
Yes 10 (58.8) identified.
No 7 (41.2)
Safety-net hospital†
Yes 5 (29.4)
Data Analysis
No 12 (70.6) Consistent with rigorous qualitative research methods, we
∗ Data sources: American Hospital Association Annual Survey; first developed a preliminary coding dictionary based on
Centers for Medicare & Medicaid Services Hospital Compare. questions in the semistructured interview guide. Then, us-
† Defined as hospitals in the highest quartile of the dispropor-
ing this preliminary dictionary, three members of the cod-
tionate share hospital index.
ing team [A.A.G., S.R.M., M.E.G.] coded the same five
COTH, Council of Teaching Hospitals and Health Systems.
transcripts, noting new codes that emerged from the data.
These new codes were incorporated into a revised coding
dictionary, and the coding team then coded all of the in-
METHODS terviews from the first five site visits. The coding team was
Study Setting and Participants overseen by the lead investigator [A.S.M.] and met regularly
throughout this preliminary coding process to ensure con-
Using a purposive sampling approach, we invited 35 acute sistency in coding. As new themes emerged from the data,
care hospitals from across the United States to participate in new iterations of the coding dictionary were developed, and
a study that aimed to improve our understanding of man- coders recoded transcripts to incorporate the new codes.
agement practices that support HAI prevention efforts.28 Then, after coding and recoding of transcripts from the first
To ensure variability among participating hospitals, we at- five sites was completed, the remaining 12 sites were coded
tempted to recruit both higher- and lower-performing hos- by a single coder [A.A.G.], thus ensuring a consistent and
pitals and included hospitals from different regions and accurate coding process. We used ATLAS.ti version 8.3.1
with a variety of organizational characteristics (for exam- (Scientific Software Development GmBH, Berlin) to sup-
ple, hospital size, teaching status). We used standardized port the coding and analysis process.
infection ratios (SIRs) to define hospital performance on Our overall approach to coding was a deductive domi-
infection prevention. The SIR is a summary statistic that nant thematic analysis,29 , 30 but our identification of emer-
compares the number of observed HAIs in a hospital to the gent codes and themes enabled a thorough exploration of
number of predicted HAIs based on a national benchmark. our data. This approach allowed for comparison of themes
Seventeen hospitals agreed to participate. Table 1 presents a across sites to characterize management practices important
general overview of the characteristics of participating hos- in infection prevention. Our approach allowed us to iden-
pitals. tify key management practices in CAUTI prevention and
led to our focus on the implementation of UCNDPs as we
Data Collection describe in this paper. For these secondary analyses, using
Our research team conducted site visits to the 17 partic- the complete coded data set, we specifically focused on ex-
ipating hospitals from September 2017 to January 2019. tracting data that described UCNDP implementation in a
As part of these site visits, we conducted 449 interviews round of secondary coding led by a single coder [M.J.D.].
with a variety of key informants, including executive lead- This analytic approach enabled us to identify and charac-
ers, managers (including both nonclinical and nurse man- terize the policies and practices that hospitals used to suc-
agers), infection preventionists, and frontline staff (nurses, cessfully implement UCNDPs as well as the challenges hos-
physicians). Table 2 summarizes the total number and per- pitals faced during the implementation process. Through-
Volume 46, No. 12, December 2020 693

Table 2. Numbers and Percentages of Interviewees Participating in Study, by Site and by Role
Site Number Executives Managers∗ Infection Preventionists Frontline Staff Site Total (%)
1 3 21 10 12 46 (10.2)
2 1 4 2 9 16 (3.6)
3 3 6 11 10 30 (6.7)
4 2 4 4 5 15 (3.3)
5 1 10 7 11 29 (6.5)
6 4 10 1 11 26 (5.8)
7 1 12 2 26 41 (9.1)
8 2 8 5 11 26 (5.8)
9 7 4 6 10 27 (6.0)
10 2 3 4 11 20 (4.5)
11 1 5 4 9 19 (4.2)
12 2 11 8 11 32 (7.1)
13 3 7 9 11 30 (6.7)
14 3 4 5 7 19 (4.2)
15 7 5 5 10 27 (6.0)
16 1 5 4 6 16 (3.6)
17 3 12 9 6 30 (6.7)
Role Total (%) 46 (10.2) 131 (29.2) 96 (21.4) 176 (39.2) 449 (100)
∗ Includes nurse educators and specialists.

out this secondary coding process, our research team met
regularly to discuss emergent themes and to develop con-
sensus on the final interpretation of the results.
RESULTS
We found variation in the features of UCNDPs used by
study hospitals, as well as commonality in both barriers to
and facilitators of UCNDP implementation and use.
Variation in the Features of UCNDPs
Descriptions of UCNDP features and characteristics var-
ied across hospitals—in particular, there was variation in
how interviewees described the indications and procedures
used by nurses to enact UCNDPs. Some UCNDPs spec-
ified how long an IUC could stay in place (for example,
24–48 hours) before a nurse could remove it, provided no
clinical indications remained at that time. Furthermore,
physicians could write an order at the time of IUC inser-
tion that could prevent the use of the UCNDP; in those
cases, the nurses would need to confer with the physi-
cians to remove the IUC. In other hospitals, however, UC-
NDPs were more physician-driven, requiring a physician
to write an order at the time of catheter insertion for the
UCNDP to be used before a nurse could actually remove
a patient’s IUC. Regardless of the type of UCNDP, physi-
cians had the authority to write “non-removal” orders if
they decided an IUC needed to stay in place longer (for
example, to measure and monitor a patient’s urine output),
and this would prevent the removal of the catheter by the
nurse.
Interviewees commonly commented that UCNDPs gave
nurses more autonomy and independence to decide if a
patient met the criteria for removal, and some nurses ap-
preciated having the ability to take action and remove a
patient’s IUC without a physician order. In contrast, in
hospitals that relied on physician orders to enact the UC-
NDP, nurses noted the need to clarify with the patient’s
physician if the IUC should remain in place or be removed.
Barriers to Implementing UCNDPs
We identified three barriers to UCNDP implementation
and use in acute care hospitals: (1) nurse deference to physi-
cians, (2) physician push-back, and (3) miscommunication
about IUC removal. Next, we describe these barriers in
greater detail, including verbatim quotations that support
our characterization of these barriers.
Nurse Deference to Physicians. Although most hos-
pitals had adopted UCNDPs by the time of the study, sev-
eral interviewees suggested that some nurses were not im-
plementing or consistently using UCNDPs. In these cases,
nurses reported asking physicians if they wanted the IUC
removed, even when the nurses had per-policy authority
to remove the IUC without an order. One interviewee re-
flected, “I have to be honest I still think a lot of our nurses—
we still check with our provider. . . . I do think they need
a little encouragement sometimes. I don’t think we are per-
fect yet. I don’t know if we are going to get perfect. . . . Even
though I know technically we can still do [the UCNDP]”
(assistant nurse manager). We found that, depending on the
hospital, nurses would wait for a physician to tell them to
remove an IUC or check with physicians to see what they
wanted done, rather than use the UCNDP. As an intervie-
wee explained, “I don’t think [the UCNDP] is utilized that
much, honestly. I think more or less, most of us wait for
694 Matthew J. DePuccio, PhD, MS, et al.
the doctor. If I think it should come out, I will at least ask
them” (nurse).
Physician Push-Back. Another barrier we characterized
was physician resistance to use of the UCNDP. For instance,
interviewees described physicians pushing back and want-
ing to keep IUCs in place despite patients meeting clini-
cal indications for removal: “Are there still physicians who
might push back and only want that Foley removed if they
say so? Yes, I imagine that still exists to some extent. I think
that was harder than it could’ve been or maybe should’ve
been, but I think that still exists to some extent” (director
of quality and safety). When physicians pushed back, this
affected UCNDP use because other nurses reported feeling
less empowered to enact the protocol on their own. For ex-
ample, as one nurse manager explained, “. . . most nurses do
not feel comfortable just pulling a Foley. They really want to
get the provider’s permission, despite us having that [UC-
NDP]. That is a big weakness, and a lot of providers have
push-back. They want to keep the Foley, or maybe they are
a covering provider and they are not really quite sure why it
is in, and ‘Don’t you touch it,’ and ‘Let me figure this out,’
and that sort of thing” (nurse manager).
Miscommunication About IUC Removal. Intervie-
wees also indicated that there were times when care team
members did not communicate clearly about when to re-
move IUCs in the context of using the UCNDP. For ex-
ample, in situations in which a physician order to keep an
IUC in place was set to expire, nurses were not always con-
fident they could use the UCNDP. As one nurse reflected,
“. . . sometimes the order falls off, and no one addresses
it. So, an improvement could be an easier sign of saying,
‘This order is going to fall off. Make sure you address it
and get a new order,’ or you are actually going to take it
out” (nurse). Furthermore, when communication among
care team members about the UCNDP was unclear, it led
to future hesitation on the part of nurses to enact the pro-
tocol. For example, as one nurse explained, “[Our assistant
manager] had a patient that she had used her [UCNDP] on
and removed [the catheter], and the team was upset about
it. They said it should have been in, but she had the order
for the [UCNDP], so I think a little bit of miscommunica-
tion there. But, yeah, I think after that too I was definitely
hesitant. If I think it should come out I will at least ask [the
team]” (nurse).
Facilitators of UCNDP Implementation
Our analysis also revealed several facilitators that con-
tributed to the successful implementation and use of UC-
NDPs, including (1) training care team members to use the
UCNDP, (2) discussing IUC necessity and UCNDP use
during rounds, (3) reminding care team members to fol-
low UCNDPs, and (4) developing buy-in for UCNDP use
across the hospital. Interviewees often described these fa-
cilitators in the context of overcoming some of the identi-
Nurse-Driven Protocol Implementation
fied barriers to UCNDP implementation presented above.
Next, we describe these facilitators in greater detail, and we
present Table 3 as a list of strategies that, based on our find-
ings, could facilitate UCNDP implementation and use.
Training Care Team Members to Use the UCNDP.
Training was reported as an important facilitator of UC-
NDP implementation because it gave care team members
an opportunity to learn about the clinical indications for
IUC removal. Training reinforced the use of the UCNDP
and taught care team members, particularly nurses, what to
be aware of when enacting the protocol. From nurse orien-
tations to the informational resources provided at the unit
level, interviewees described how training and education es-
tablished expectations for nurses to take responsibility for
carrying out the UCNDP at the hospital and why UC-
NDPs were important for preventing CAUTIs. Training
was seen as a way to educate frontline staff about what clin-
ical indications they needed to look out for in order to use
the UCNDP appropriately and minimize the risk of leav-
ing an IUC in for too long or having to reinsert it at a later
time. These trainings were also fundamental to encourage
nurses to actively identify patients who no longer required
an IUC. Several interviewees similarly described how UC-
NDPs were emphasized in trainings offered to frontline
staff (for example, unit-specific training programs), mak-
ing it clear that enacting this UCNDP was a priority across
hospital units. For example, one interviewee described that
having ongoing education involving unit-based nurse ed-
ucators and frontline staff enabled a “peer-to-peer kind of
knowledge transfer” (unit nurse manager) that made nurses
more comfortable using a new UCNDP.
Discussing IUC Necessity and UCNDP Use Dur-
ing Rounds. Rounding was another common facilitator
of UCNDP implementation because it made nurses more
aware about using UCNDPs and their management of the
patients who had an IUC in place. Discussions about the
necessity of these catheters during rounds also reportedly
helped nurses become more comfortable with using the
UCNDP and thus made it less likely an IUC would be used
inappropriately. As one interviewee reflected, “We do un-
derstand the protocol, and we do talk to [care team mem-
bers] about things like, we want to know when we’re out
rounding on Foleys, ‘Is this needed? Are we talking about
taking this Foley out, or do you know about bladder scan?
Are you going to bladder scan after you pull it?’ We talk
to them about those kinds of things. So most of the time I
feel really confident about where they are with—and most
of the time when there is a Foley in place” (quality nurse
specialist). We found that all types of rounds (for exam-
ple, nurse rounds, interprofessional rounds) seemed to play
a role in facilitating UCNDP use. For instance, nursing
rounds allowed opportunities to review the placement of
patients’ IUCs and describe challenges related to enact-
ing the UCNDP in the psychologically safe environment
Volume 46, No. 12, December 2020 695

Table 3. Strategies Identified to Facilitate UCNDP Implementation and Use

Strategy
Training care team members to
use the UCNDP
Discussing IUC necessity and
UCNDP use during rounds
Reminding care team members
to follow UCNDPs
Developing buy-in for UCNDP
use across the hospital
UCNDP, urinary catheter nurse-driven protocol; IUC, indwelling urinary catheter; EMR, electronic medical record; CAUTI, catheter-
associated urinary tract infection.
Examples Potential Impact(s)
• Staff orientations that discuss systemwide Develop the knowledge and skills of new
policies for UCNDP implementation and use care team members regarding IUC
• Ongoing educational seminars to review where, removal; provide consistent expectations
when, and how to enact UCNDPs about how UCNDPs should be
implemented across hospital units.
• Conducting rounds to review patient treatment Care team members feel empowered to
goals and plans on IUC use and removal enact UCNDPs more consistently; IUCs
• Coach team members to enact UCNDP during are removed more efficiently; care team
daily rounds. members develop an understanding as to
why an IUC may stay in place despite a
patient meeting clinical indication.
• Managers provide daily reports containing the Care team members and managers are held
names and status of patients who have IUCs. accountable for patients who are eligible
• Whiteboards are visible and updated every shift for catheter removal via an established
to identify care team members responsible for UCNDP; care team members stay
IUC oversight. informed about changes to the status of
• EMR notifications or alerts to prompt nurses to catheterized patients.
check patients who meet clinical indications for
IUC removal
• Designating an advisory committee to review and Increase awareness about the value of
update policies that support UCNDP UCNDPs for reducing CAUTIs; address
implementation UCNDP implementation questions and
• Have interprofessional work groups share ideas identify opportunities to increase nurse
or strategies to motivate frontline staff to enact enactment of an existing or newly
the UCNDP. implemented UCNDP.

of other nurses. Interprofessional rounds allowed real-time
discussion and decision making on the UCNDP and op-
portunity to remove IUCs when this was clinically indi-
cated. Physician rounds could also address patients’ needs
for IUCs, particularly when there was a process in place that
prompts physicians to explicitly consider the opportunity
for catheter removal during those rounds (for example, a
checklist on patients’ doors prompting physicians to think
through the criteria for removal during their rounds).
Reminding Care Team Members to Follow UC-
NDPs. As the goal for a UCNDP is to empower nurses to
remove IUCs when it is appropriate to do so, having pro-
cesses or systems in place to make sure frontline staff follow
UCNDPs was noted as an important facilitator of UCNDP
implementation. In one hospital, managers shared messages
from clinical practice councils with nurses during daily hud-
dles reminding them to use UCNDPs. In other hospitals,
unit managers also maintained a daily list of patients who
had IUCs, which served as a reminder to nurses to use the
UCNDP or to check in with certain patients to see if they
met the criteria for enacting the UCNDP.
Some hospitals developed and incorporated electronic
medical record (EMR) alerts so that nurses and other care
team members would know when it was time for a nurse to
use the UCNDP to take out a patient’s IUC. As one inter-
viewee explained, “Even the [UCNDP], that’s all built into
our EMR and then into our order so that they know, you
know, it’s day two, this catheter needs to come out” (nurse).
In some hospitals, these alerts would happen throughout
the day or at multiple times during a nurse’s shift to make
sure the nurse was keeping track of the patients’ clinical
indications for removal. Having these notifications built
into the EMR was viewed as a helpful reminder for nurses
to follow the UCNDP.
Developing Buy-in for UCNDP Use Across the
Hospital. Interviewees also discussed the importance of
having mechanisms in place to develop buy-in from dif-
ferent departments and levels of management to use UC-
NDPs. Shared governance meetings were one way clini-
cians and managers could share ideas to promote the use of
UCNDPs and encourage nurses to use them consistently.
For instance, one hospital introduced the idea of a “float
pass”—that is, if a nurse used the UCNDP, he or she was
eligible to not have to work on another unit to cover staffing
needs (nurse manager). Interviewees described that getting
the UCNDP endorsed across the hospital necessitated col-
laborative discussions between clinicians and hospital lead-
ership responsible for developing and implementing qual-
ity and patient safety policies. In these cases, collaboratives
and working groups spanning clinical and administrative
domains helped to systematize infection prevention poli-
cies including UCNDPs because stakeholders participating
in those meetings were able to develop agreement about the
appropriateness of the policy and its use across the hospital.
696 Matthew J. DePuccio, PhD, MS, et al.
DISCUSSION
Although CAUTIs remain a prominent patient safety con-
cern, UCNDPs offer hospitals an effective strategy to
mitigate their risk when successfully implemented.20 Our
study suggests that hospitals have opportunities to make
changes to accommodate UCNDP implementation and
promote its use. In studying how health care providers,
managers, and executives described their experiences with
UCNDPs in the context of CAUTI prevention, we found
that some hospitals were having difficulty overcoming
physician push-back and nurse reluctance to enact existing
UCNDPs. We also identified facilitators that contributed to
the successful implementation of UCNDPs in these hospi-
tal settings; specifically, training, rounding, reminding, and
developing buy-in for existing UCNDPs. These facilitators
share similarities with components of other successful UC-
NDP programs11 , 15 , 31 shown to lower rates of IUC use and
reduce infections. For example, the implementation of daily
CAUTI rounds to evaluate patients’ continued need for an
IUC was an important aspect of a multimodal CAUTI pre-
vention bundle that helped reduce both catheter use and
CAUTI rates in a surgical trauma ICU.31
The facilitators we characterized in this study describe
different ways hospitals can encourage nurses to use UC-
NDPs and ultimately prevent patient harm and are consis-
tent with previous research that has identified factors im-
portant in supporting UCNDP implementation and use.26
For instance, one study noted that obtaining consensus
from physicians about the criteria for removing IUCs and
engaging nurse leaders in the decision-making process can
facilitate the implementation of UCNDPs.16 Other quality
improvement initiatives have also identified the importance
of aligning resources and leadership support to ensure that
UCNDPs are implemented as designed.14
Our findings suggest that the implementation of UC-
NDPs requires both hospital leaders and physicians to em-
power nurses to enact the UCNDP. When a physician
pushes back and orders an IUC to be reinserted, nurses
may feel less confident about enacting a UCNDP, making
it more important to have processes in place for the physi-
cian and nurse to discuss the rationale behind reinsertion
(for example, interprofessional rounds). We also found that
miscommunication about IUC removal could potentially
make nurses more reluctant to enact the UCNDP because
it may not be clear to them when removal is appropriate for
certain patients. Our findings about notifying and remind-
ing nurses about patients who have IUCs through the use of
patient lists or EMR alerts are important in the context of
UCNDP implementation. Ensuring an up-to-date record
of which patients have IUCs and which patients meet the
criteria for removal can ensure that all care team members
can hold each other accountable for catheter removal con-
sistent with the UCNDP. In addition, as noted in prior
studies, ongoing verbal or written reminders can serve as
cues for care team members to change their behavior, be-
Nurse-Driven Protocol Implementation
cause they can encourage care team members to assess the
continued need for IUCs and to adhere to specific evidence-
based practices or programs.32 , 33 Hospital units may find
it useful to involve nurses in developing reminder systems,
such as daily reports or checklists, to ensure that the data
are timely and reflect the current state of IUC use in their
areas.
Our research also sheds light on the need for a more
nurse-focused approach to UCNDP implementation. For
example, nurses may have different knowledge about the
importance of timely IUC removal, variable skill levels that
affect their ability to enact the UCNDP, or differing lev-
els of comfort in asserting to the physician their recom-
mendation to remove the IUC34 , 35 (for example, when
a patient meets clinical criteria for removal, but the pa-
tient or physician wants the IUC to stay in place). With-
out addressing these nurse-level concerns, it is possible that
UCNDP implementation will remain incomplete. There-
fore, effective UCNDP implementation will likely involve
prompted, daily assessments of indication-based need and
include nurse authority to remove an IUC without contact-
ing the physician; in this context, nurses will be supported
by broad education, physician counseling, and leadership
endorsement of UCNDP enactment. Nurse training and
developing buy-in for UCNDP enactment can also poten-
tially empower nurses to routinely use UCNDPs and, ulti-
mately, support CAUTI prevention. Finally, by emphasiz-
ing alternatives such as noninvasive collection systems, de-
ploying supplies for safe patient handling, and mobilizing
additional staff,27 , 36 hospitals may further reduce nurses’
reluctance to remove IUCs and thus increase the likelihood
of UCNDP implementation success.
Limitations
Our study has several limitations. First, although the pur-
pose of our research was to examine factors promoting and
limiting UCNDP implementation and use, we did not ex-
plicitly measure implementation effectiveness or success.
Future research may help improve our understanding of
which factors are associated with implementation effective-
ness. Second, we were not able to differentiate physician
participants based on their specialty (for example, urol-
ogy vs. cardiology), and we recognize that this distinction
may influence support of UCNDPs. It will be important
for future research to identify whether differences in physi-
cians’ opinions or preferences about using UCNDPs can
help explain variations in UCNDP implementation and
CAUTI prevention. Third, as the interviews we analyzed
for this study were conducted as part of a broader research
project that examined management practices supporting
HAI prevention, there may be additional barriers to and fa-
cilitators of UCNDP implementation that would be men-
tioned in a study explicitly focused on this topic. Fourth,
we acknowledge that hospitals may have been at different
stages with respect to their implementation of a UCNDP
Volume 46, No. 12, December 2020
(for example, early vs. late stages of implementation). Fur-
ther study, guided by an implementation science frame-
work, for instance, is necessary to understand whether the
implementation time frame might influence UCNDP use
and whether barriers and facilitators might differ based on
this time frame. Finally, our purposive approach to site re-
cruitment resulted in about half of the hospitals we ap-
proached (51.4%) declining to participate in site visits. Al-
though it is possible our findings may be biased by non-
participation, the number and variety of hospitals that did
participate give us confidence that the findings we report
are robust.
CONCLUSION
We found that strategies such as training, rounding, re-
minding, and developing buy-in facilitated UCNDP im-
plementation and were perceived to help hospitals over-
come barriers to using UCNDPs. Our findings thus have
important implications for managers who are responsible
for implementing changes to improve patient safety, and
particularly those focused on infection prevention. Specif-
ically, empowering and supporting nurses to enact UC-
NDPs may be fundamental to facilitating the implementa-
tion of evidence-based practices that can improve the qual-
ity of care delivered and address patient safety issues such as
CAUTI prevention.
Funding. This research was supported by a grant from the Agency for
Healthcare Research and Quality (R01HS024958). The views expressed in
this paper are solely those of the authors and do not represent any US
government agency or any institutions with which the authors are affili-
ated. The Agency for Healthcare Research and Quality was not involved
in study design; in the collection, analysis, and interpretation of data; in
the writing of the report; nor in the decision to submit the article for pub-
lication.
Conflicts of Interest. All authors report no conflicts of interest.
Acknowledgments. The authors thank Jaclyn Volney, Toby Weinert,
Jeanette Gardner, Natalie Gaines, Caroline Sugar, and Meg Suttle, all af-
filiated with the authors’ organization, for their assistance with this project.
We also are grateful to the administrators and frontline staff who partic-
ipated in this study. Finally, we thank the associate editor and anony-
mous reviewers for providing helpful comments on earlier drafts of this
manuscript.
Matthew J. DePuccio, PhD, MS, is Postdoctoral Researcher,
Center for the Advancement of Team Science, Analytics, and
Systems Thinking in Health Services and Implementation Sci-
ence Research (CATALYST), College of Medicine, The Ohio State
University (OSU). Alice A. Gaughan, MS, is Research Manager,
CATALYST. Lindsey N. Sova, MPH, is Project Manager, CATALYST.
Sarah R. MacEwan, PhD, is Postdoctoral Researcher, CATALYST.
Daniel M. Walker, PhD, MPH, is Assistant Professor, Department of
Family and Community Medicine, College of Medicine, OSU, and
Faculty, CATALYST. Megan E. Gregory, PhD, is Assistant Professor,
Department of Biomedical Informatics, College of Medicine, OSU, and
Faculty, CATALYST. John Oliver DeLancey, MD, MPH, is Assistant
Professor, Department of Urology, College of Medicine, OSU, and
Faculty, CATALYST. Ann Scheck McAlearney, ScD, MS, is Professor,
Department of Family and Community Medicine, College of Medicine,
OSU, and Executive Director, CATALYST, matthew.depuccio@osumc.edu.
697
SUPPLEMENTARY MATERIALS
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.jcjq.2020.08.
015.
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