Table 7.

Recommendations for intervention design and refinement

Theme	Proposed new BCT	Example delivery to address theme
Environmental context and resources
Limited and inconsistent documentation and records	Restructuring the physical environment; prompts/cues	Creating standardised computer-based documentation requiring staff to enter reason for catheterisation, date of insertion, etc. (i.e. not circumvent system by leaving fields blank).
Transitions of care	Restructuring the social environment	Creating the rule that ward staff transferring patients to another ward check with the staff receiving the patient whether catheterisation is necessary (this rule could be prompted by a checklist for transfer of patients to another ward/hospital or home where staff check if the catheter is needed).
Lack of time to perform alternatives to urinary catheterisation	Adding objects to the environment	Provision of condom catheters, female urination devices and/or local commodes at bedside.
Knowledge
Lack of knowledge of clinical guidelines and local procedural documents	Information to consider including in guidelines/local procedural documents: • Alternatives to catheterisation • How to safely manage infections arising from catheterisation? Whilst the information contained in the guidelines appears to address lack of knowledge in, e.g. link between catheter duration and CAUTI, the issue may be more to do with dissemination. Guideline implementation strategies to accompany recommendations may promote this.
Beliefs about consequences
Convenience and ease of monitoring	Anticipated regret and/or salience of consequences	Getting staff to think about how they would feel if a patient was diagnosed with CAUTI after they had catheterised them for non-medical reasons (this could be delivered as part of a training programme, staff meetings, printed and electronic materials).
	Pros and Cons	Encouraging staff to list the benefits and disadvantages of catheterising for convenience compared with catheterising for medical reasons (this could be delivered as a part of a training programme or suggested face to face in staff).
	Salience of consequences	Providing images emphasising the severity of CAUTI.
	Persuasive communication (Credible source)	Members of Trust leadership and senior members of staff endorsing not catheterising for convenience.
Social influences
Requests from patients and their carers	Social comparison	Staff convey to patients/carers that most patients/carers do not request catheters and explain the reason why this is.
	Demonstration of the behaviour	Staff role modelling challenging patient/carer requests.
Lack of peer support and buy-in	Information about others’ approval	Informing staff engagement with CAUTI-reducing practices is encouraged by peers/senior staff.
Physicians dictate nurses’ practice	Restructuring the social environment	Strategies to empower nurses to lead on catheter decision-making (delivered through peers/senior team members).
	Social comparison	Provide examples of where the HOUDINI protocol has been effectively implemented.
Cultural norms regarding standard catheterisation practice for specific patient groups	Social comparison	Compare rates of catheterisation and corresponding rates of infection between wards/hospitals/primary care practices/nursing homes. Stratifying by professional role will increase the salience of this comparison.
Memory attention and decision processes
Pre-empting subsequent urinary catheterisation	Action planning	Plan who will assess the patient for catheterisation and where this will happen
	Self-monitoring of behaviour	Document the action plan (see above) so there is agreement between staff on different wards whether the patient being transferred requires a catheter and if so, who will insert the catheter.