Variations in risk perceptions: a qualitative study of why unnecessary urinary catheter use continues to be problematic

BACKGROUND: Catheter associated urinary tract infection (CAUTI) is one of the most commonly acquired health care associated infections within the United States. We examined the implementation of an initiative to prevent CAUTI, to better understand how health care providers’ perceptions of risk influenced their use of prevention practices and the potential impact these risk perceptions have on patient care decisions. Understanding such perceptions are critical for developing more effective approaches to ensure the successful uptake of key patient safety practices and thus safer care for hospitalized patients. METHODS: We conducted semi-structured phone and in-person interviews with staff from 12 hospitals. A total of 42 interviews were analyzed using open coding and a constant comparative approach. This analysis identified “risk” as a central theme and a “risk explanatory framework” was identified for its sensitizing constructs to organize and explain our findings. RESULTS: We found that multiple perceptions of risk, some non-evidence based, were used by healthcare providers to determine if use of the indwelling urethral catheter was necessary. These risks included normative work where staff deal with competing priorities and must decide which ones to attend too; loosely coupled errors where negative outcomes and the use of urinary catheters were not clearly linked; process weaknesses where risk seemed to be related to both the existing organizational processes and the new initiative being implemented and; workarounds that consisted of health care workers developing workarounds in order to bypass some of the organizational processes created to dissuade catheter use. CONCLUSIONS: Hospitals that are implementing patient safety initiatives aimed at reducing indwelling urethral catheters should be aware that the risk to the patient is not the only risk of perceived importance; implementation plans should be formulated accordingly.