# Lesson learned from implementing measures to prevent urinary tract infection and bladder distension in patients with hip fractures - a process evaluation

## TL;DR

This study evaluates how a program to prevent bladder issues in hip fracture patients was implemented, finding it feasible but complex, with insights for healthcare leaders.

## Contribution

The study provides a detailed process evaluation of a bladder care bundle using organizational theories to improve catheter care in hospitals.

## Key findings

- The intervention was successfully implemented in terms of feasibility, acceptability, and fidelity.
- Factors like feedback on patient outcomes and time for learning supported the implementation process.
- Workforce shortages and production pressures were major barriers to implementation.

## Abstract

Catheter-associated urinary tract infections and bladder distension are common and preventable adverse events. This study presents a process evaluation of a bladder bundle, designed to change healthcare professionals’ way of thinking and acting to prevent these adverse events, using theories of organizational culture, leadership, and an integrated knowledge translation approach.

To enhance understanding of barriers and enablers when implementing recommendations to prevent catheter-associated urinary tract infections and bladder distension. We examined the implementation concepts of feasibility, acceptability and fidelity, guided by the following research questions: (1) To what extent was the intervention delivered as planned? (2) What factors influenced the implementation process, and how did these factors influence implementation outcomes?

A qualitative and quantitative process evaluation was conducted, guided by the Medical Research Council framework. The intervention was implemented between 2016 and 2020, in a Swedish university hospital, across six units involved in hip fracture care. Data was collected through field notes, implementation logs, emails, presentations, and attendance records. Qualitative data were analyzed using deductive and inductive content analysis. Quantitative data, including attendance and adherence rates, were descriptively summarized under the categories of fidelity, dose, reach, context, and mechanisms of impact.

The implementation of the intervention was successful regarding feasibility, acceptability and fidelity, which is important for adoption and ownership of interventions. Factors that triggered change were feedback on patient outcomes and ensuring time for learning and re-learning in a safe milieu. Barriers to the intervention were shortages in the workforce, production pressures and lack of experience in collaboration in change projects involving different organizational units. The implementation program enabled ways to work around barriers on macro, meso and micro levels in the organization.

Implementing practices to prevent both UC-UTIs and bladder distension is feasible but complex and time-intensive. Using theories of organizational culture and leadership, along with a collaborative approach, can support adoption and sustainability of best practices in complex healthcare settings. Findings offer insights for healthcare decision-makers aiming to improve catheter care.

Clinical Trial Registry ISRCTN 17,022,695, retrospectively registered on 23 December 2021, after data collection was completed.

The online version contains supplementary material available at 10.1186/s12877-025-06216-w.