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ABSTRACT

Urinary tract infections (UTIs) are a major public health problem in terms of morbidity and incur the highest total health care cost among urological diseases, exceeding that of chronic renal failure even when renal dialysis and renal transplantation are included. This study was conducted to assess the practice of staff nurses regarding prevention of UTI in clients with indwelling catheter.

An evaluative approach was adopted for the study to determine the effectiveness of structured teaching program on practice among staff nurses regarding prevention of urinary tract infection in patients with indwelling catheter. Pre -experimental, one group pre-test –post-test design was used for conducting the study. The result shows that the mean practice score in the post-test (18.56+- 3.88) was higher than the mean pre-test practice score(10.4+- 4.39),which is highly significant as p value <0.0001.This shows that the structured teaching program was effective in improving the practice of staff nurses regarding prevention of urinary tract infection in patients with indwelling catheter.

Keywords: Catheter associated Urinary Tract Infection (CAUTI), Effectiveness, Practice, Staff nurse

INTRODUCTION

Urinary tract infection represents one of the most common diseases encountered worlwide in medical practice today with more than 150 million UTIs per annum. Although UTI occur in both men and women, clinical studies suggest that the overall prevalence of UTI is more in women. Uncomplicated urinary tract infections in healthy women have an incidence of 50/1000/year. An estimated 50% of women experience at least one episode of UTI at some point in their lifetime and 20% – 40% of women have recurrent episodes. Approximately 20% of all UTIs occur in men. Most episodes of UTI are caused by E- coli (up to 85%) and Staphylococcus saprophyticus(up to 10%)1. Catheter associated urinary tract infection (CAUTI) are a major problem in hospitals inspite considerable spending on education and prevention. About 5,60,000 CAUTI are reported by Centre of disease control and prevention (CDC)every year2. It has been estimated that more than 7 million people visits to emergency units and 100,000 hospitalization annually and accounts for 35% of

nosocomial infection3.

Urinary catheterization is a known cause of bacterial infections, which in the worst-case scenario can be fatal. More than 5 million patients every year is been catheterized. Up to 25 % of patients who are catheterized for more than 7 days will develop catheter associated urinary tract infection. It is the most common nosocomial infection, comprising more than 40 percent of all nosocomial infections 4.

To minimize the risk for introduction of microorganisms into the bladder, urinary catheters should only be inserted by well trained personnels.

Hand hygiene is the most important means of preventing infection and should be performed immediately before and after insertion of the catheter. The Investigator also felt during her clinical experience that many of the staff nurses posted in the medical surgical unit, uro-ward, and post operative wards failed to maintain proper aseptic technique while providing catheter care5.

DOI Number: 10.5958/0976-5506.2018.00525.9

 

 

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So the investigators felt that it is necessary to assess the practice of staff nurses regarding prevention of UTI in clients with indwelling catheter. Further the investigator felt that the written material must be supplied to staff nurses working in the medical surgical wards which will help them in preventing urinary tract infection in patients with indwelling catheter.

NEED FOR STUDY

A catheter is a tube placed in the bladder that excrete urine from the urinary tract. Because this tube stays in place for a long period of time, it is called an indwelling catheter. Catheterization is commonly done in critically ill and post opeartive patients .As the critically ill patients have less immunity they are highly prone to get nosocomial infections. Many hospitalized patients get UTI due to catheterization. These infections are often caused by E- coli and Proteus mirabilis. Individuals needing an indwelling catheter are predisposed to the development of CAUTIs due to the presence of an indwelling catheter and more likely pathogenic multidrug-resistant organisms in the hospital settings. Although the imminent threat of infection from these potent opportunistic nosocomial multiresistant strains, most cases of catheter-associated bacteria or the presence of bacteria in the urine are asymptomatic. However, if an episode of CAUTI becomes symptomatic, the resulting array can range from mild (fever, urethritis, and cystitis) to severe (acute pyelonephritis, renal scarring, calculus formation, and bacteremia)6.

A study was carried by Danbury hospital, USA to test a prevention bundle for catheter related urinary tract infections. They concluded that there are around 560,000 cases of catheter associated urinary tract infection per year. CAUTIs accounts for 23% of health care-associated infections in adult critical care units leading to complications such as cystitis, pyelonephriti, bacteremia, sepsis and increased risk of death. National rates for critical care have reached as high as 8.1 infections per 1000 catheters. Studies from around the world has shown that CAUTIs increase the costs of medical care morbidity and mortality.8

The Indian journal of critical care medicine carried out a study to assess the knowledge and attitude of health care providers regarding the indications for catheterization and method of preventing CAUTI. They concluded that there is a tremendous scope of

improvement in catheterization practices in the hospital settings and education induced intervention would be the most appropriate effort towards reducing the incidence of CAUTI.7

A CAUTI occurs when a patient with an indwelling urinary catheter develops 2 or more signs or symptoms of UTI such as hematuria, fever, flank pain, change in the character of urine and altered mental status.Most hospitals do not have strict guidelines for the prevention of CAUTI. Training the health care personnel and introducing the prevention of CAUTI as a high priority in hospitals is strongly associated with decreased incidence of CAUTI. Many studies have shown that single most important modifiable risk factor for decreasing the incidence of CAUTI is reducing unnecessary catheter use3.

Problem Statement:

A study to assess the effectiveness of structured teaching program on the practices of staff nurses regarding prevention of catheter associated urinary tract infection (CAUTI) among hospitalized patients in selected hospitals of Pune.

OBJECTIVES OF THE STUDY

To assess the practice of nurses regarding prevention of urinary tract infection in patients with indwelling catheter.

To assess the effectiveness of structured teaching program on the practices of nurses regarding prevention of urinary tract infection.

To find out the association of practice among nurses with selected demographic variables.

OPERATIONAL DEFINITION

1) Practices

According to oxford dictionary practices refers to “the actual application or use of an idea, belief, or method, as opposed to theories relating to it:‘the principles and practice of teaching’‘the recommendations proved too expensive to put into practice”

In this study it refers to the method followed by the staff nurse in urinary catheterization.

 

 

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2) Staff nurses

According to oxford dictionary “An experienced nurse less senior than a sister or charge nurse which helps the patient to restore to an healthy state”

In this study it refers to the staff nurses working in the medical surgical wards of the selected hospital in Pune.

3) Catheter associated urinary tract infection(CAUTI)

“A catheter urinary tract infection (CAUTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney in a patient associated with urinary catheter”

METHODOLOGY

An evaluative approach was adopted for the study to determine the effectiveness of structured teaching program on practice among staff nurses regarding prevention of urinary tract infection in patients with indwelling catheter. The present study is aimed at assessing the effectiveness of Structured Teaching Program on practice among staff nurses regarding prevention of urinary tract infection in patients with indwelling catheter in selected hospitals.

The design selected for the present study was Pre -experimental, one group pre-test –post-test design.

The setting of the present study was medical surgical wards of selected hospitals of Pune city. The population for the study was staff nurses working in the medical surgical wards of selected hospital.

Non –probability purposive sampling technique was used for the present study. The sample comprised of 60 staff nurses working in medical surgical wards of the selected hospital.

The data collection method used for the study was observational method to assess the practice related to prevention of urinary tract infection in patients with indwelling catheter. An observation checklist has been prepared as a tool to assess the practice of staff nurses regarding prevention of urinary tract infection in patients with indwelling catheter.

The study was divided into 3 phases.

PHASE 1:Pre-test i.e. assessing the existing

practice of staff nurses regarding prevention of urinary tract infection in patients with indwelling Catheter through observational checklist.

PHASE 2: Structured Teaching program on practice regarding prevention of urinary tract Infection in patients with indwelling catheter.

PHASE 3: Post-test i.e. assessing the practice of staff nurses regarding prevention of urinary tract infection in patients with indwelling catheter.

Development of the tool

The tool for data collection had 2 sections – Section A and B

Section A: Demographic Proforma

This section consists of 5 items for the demographic proforma of the staff nurses regarding their age, gender, educational status , Years of experience and area of work.

Section B: Structured Observational Checklist:-

A structured observational checklist was used collect information regarding the practice of staff nurses on prevention of urinary tract infection in patients with indwelling catheter. This consists of 30 items. Each item was given a score of 1 and total score of the observational checklist was 30.

Arbitrary scoring of prevention of urinary tract infection practices

Good 20-30

Average 10-19

Poor 0-9

Reliability of the tool

The reliability of the tool was calculated to be 0.90 for practice aspects. The co-efficient of equivalence was used to check the observational checklist by inter-rater reliability. Thus the tool was found to be reliable.

Method of data collection:

The pilot study was conducted to assess the feasibility of the study. The subjects of the pilot study were from selected hospital. Sixty staff nurses were selected using non-probability purposive sampling technique.The purpose and nature of the study was

 

 

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explained to the authority to gain cooperation. Then the consent was taken from the willing staff nurses from medical surgical wards.

After obtaining the informed consent for study, on the first day, a pre-test was obtained using observational checklist.On the same day itself, a structured teaching practice was done.The practice of catheterization was after the intervention on the 2nd day.

DATA ANALYSIS

The data obtained was analysed by descriptive and inferential statistics on the basis of objectives of the study.To compute the data a master data sheet was prepared.

Section :1 Demographic proforma

Data on demographic proforma was analysed by frequency and percentage and is presented in tables and figures.

Section II: Practice on prevention of CAUTI

The practice of staff nurses regarding the practice on prevention of CAUTI ,before and after administration of intervention was analysed in terms of frequency, percentage, mean, median, mean percentage and standared deviation and is presented in the form of tables and diagram.

The significant difference between mean pre-test and post -test scores are found out by t -test.

Section III: Association between the practice scores and selected demographic variables

Association of practice scores of staff nurses regarding age, years of experience, and educational status are tested using Chi-square test.

RESULTS AND INTERPRETATION

Section A: Description of the demographic Variables of samples.

Table 1: Frequency and distribution of sample according to demographic variable (n=60)

SNO DEMOGRAPHIC VARIABLES FREQ- UENCY

PERCEN- TAGE

1 Age (in years )

20-30 15 25

31-40 25 41.6

41-50 15 25

51-60 5 8.4

2 Education

GNM 40 66.6

BSC Nursing 20 33.33

MSC Nursing nil 0

3 Years of experience

less than 5 20 33.3

05 to 10 years 10 16.6

10 to 20 years 20 33.3

20 to 30 years 10 16.6

Table 1: shows that maximum percentage(41.6) of subjects were from the age group of 31-40 years wherein (8.4%) of them were in the age group of 51-60 years. Majority (66.6%) of subjects had GNM education , 33.33% had BSc/PBBSc Nursing and none of the subjects had Msc Nursing education. 33.3 % of the subjects had equal percentage of year of experience ie. less than 5 ,and 10-20 years of experience respectively. Remaining 16.6% of the subjects had 20-30 years of total experience.

Section B: Level of practice of staff nurses on prevention of CAUTI

Practice of 60 staff nurses was assessed by using observational checklist and analysed by descriptive statistics as presented in table 2.

Table 2: Frequency and percentage Distribution of sample based on level of practice

Level of practice Range of score Pre-test Post-test

Frequency Percentage Frequency Percentage Poor 0-9 27 45 0 0 Average 10-19 29 48.33 42 70 Good 20-30 4 6.6 18 30

 

 

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The data presented in table 2 shows that in pre-test majority (48.33%)of the the staff nurses had average practice, 45% of staff nurses had poor practice and 6.6 % had good practice on prevention of CAUTI .

In post-test (70%) of staff nurses had average practice and 30% had good practice whereas none of the staff nurses had poor practice on prevention of CAUTI.

Table 3: Mean, Median, standard Deviation and mean percentage and t’- value of pre-test and post-test practice scores

Mean Standard Devi-ation Mean percent- age

Mean difference of pre-test and post test t test value

Pre-test 10.4 4.39 34.66 8.16 12.76

Post-test 18.56 3.88 61.86

Data in the table 3 shows that the mean practice score in the post-test was (18.56+- 3.88) was higher that the mean pre-test practice score(10.4+- 4.39), which is highly significant as p value <0.0001.This shows that the structured teaching program was effective in improving the practice of staff nurses regarding prevention of urinary tract infection in patients with indwelling catheter.

Section C: Association between pre-test practice score and demographic proforma

There were no significant difference in the pre-test knowledge score with selected demographic variables such as age, and year of experience, educational status

DISCUSSIONS

In this study the seriousness of CAUTIs in the hospitalised patients, decreasing the CAUTI rate by 50% was a tremendous leap forward in the study and this effort helped to minimize the CAUTI rate and increased the practice of staff nurses. This study also provided standardization in nursing practice when caring for patients with urinary catheters. The bedside checklist and interventions provided further consistency in care as a reminder to staff to perform all aspects of CAUTI prevention. Limitations in this study included lack of randomization for group assignments. For ethical reasons, standard catheter care could not be withheld in the patients, thus eliminating the possibility of a true control group for this study. Further, it would not be feasible from a nursing work-flow perspective to effectively sort the patient assignments based on bundled versus non-bundled catheter care to form a control group. Finally, results were collected on adult patients in medical surgical units and as such, results

are not generalizable to pediatric patients. During the pre-intervention time period, patients with indwelling cathters were cleansed daily with chlorhexidine wipes. This may have also had a positive impact in reducing CAUTIs, although the chlorhexidine wipes were never used on mucosal areas such as the perineum/meatus.

CONCLUSION

The findings of the study show that there is a highly significant difference between the pre-test and post-test practice scores of the group. The Structured Teaching program significantly brought out an improvement in the practice aspect among nurses working in medical surgical wards regarding prevention of urinary tract infection in patients with indwelling catheters. There is no significant association between practice scores with the selected demographic variables like age, educational status, years of experience and as p value >0.05. The study could help in increasing the practice among staff nurses regarding prevention of urinary tract infection in patients with indwelling catheters.

Ethical Clearance: It is been taken from Research Advisory Committee(RAC), Symbiosis College of Nursing.

Source of Funding:- Self

Conflict of Interest: Nil

REFERENCES

1. Alyson W. Blanck, Moreen Donahue, Laurie Brentlinger, Kristy Dixon Stinger, Carol Polito. A quasi-experimental study to test a prevention bundle for catheter associated urinary tract infections. Journal of Hospital Administration. March 27, 2014.

 

 

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2. Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M., Wald, H. Indwelling urinary catheter management and catheter associated urinary tract infection prevention practices in Nurses Improving Care for Healthsystem Elders hospitals. American Journal of Infection Control. 2012; 40(8): 715-720.

3. Tsuchida, T., Makimoto, K., Ohsako, S., Fujino, M., Kaneda, M., Miyazaki, T., et al. Relationship between catheter care and catheter associated urinary tract infections at Japanese general hospitals: A prospective observational study. International Journal of Nursing Studies. 2008; 45(3): 352-361.

4. Kazi MM, Harshe A, Sale H, Mane D, Yande M, et al. (2015) Catheter Associated Urinary Tract Infections (CAUTI) and Antibiotic Sensitivity Pattern from Confirmed Cases of CAUTI in a Tertiary Care Hospital: A Prospective Study. Clinical Microbiology 4:193. doi: 10.4172/2327- 5073.1000193

5. Yatim J, Wong KS, Ling ML, Tan SB, Tan KY, Hockenberry M. A nurse-driven process for timely removal of urinary catheters. International Journal of Urological Nursing. 2016 Nov 1;10(3):167-72.

6. Parry MF, Grant B, Sestovic M. Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal. American journal of infection control. 2013 Dec 31;41(12):1178-81.

7. Blanck AM, Donahue M, Brentlinger L, Stinger KD, Polito C. A quasi-experimental study to test a prevention bundle for catheter-associated urinary tract infections. Journal of Hospital Administration. 2014 Mar 27;3(4):p101.

8. Lee JH, Kim SW, Yoon BI, Ha U-S, Sohn DW, Cho Y-H. Factors That Affect Nosocomial Catheter- Associated Urinary Tract Infection in Intensive Care Units: 2-Year Experience at a Single Center. Korean Journal of Urology. 2013;54(1):59-65.doi:10.4111/ kju.2013.54.1.59.

 

 

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