Catheterization is the insertion of a hollow tube through the urethra and into the bladder; this practice traces its roots to antiquity when use of bronze tubes or reeds for catheterization were described in a papyrus dated circa 1500 BC.1,2 Intermittent catheterization (IC) is the regular insertion of a catheter into the bladder via the urethra or surgically created tract, followed by drainage in intravesical contents and removal of the catheter.3–5 The history of IC is closely linked to the management of patients with neurogenic bladder dysfunction with spinal cord injury. While the risk of urinary tract infection, pyelonephritis, and urosepsis was recognized as a prevalent cause of death following traumatic spinal cord injury, urinary bladder drainage mainly relied on spontaneous voiding, whenever possible, or expression of the bladder via manual pressure applied to the suprapubic area (Credé maneuver) before the development of vulcanized rubber and other materials used as the substrates for modern urethral catheters.2
Intermittent catheterization for management of soldiers with traumatic spinal cord injury was advocated by some during World War II, while others warned against disastrous consequences including urethral trauma, urinary tract infection (UTI), urosepsis, and death.3 Although many soldiers with traumatic spinal cord injuries sustained during World War II were treated in a palliative care setting, the emergence of specific wards and rehabilitation facilities specializing in treatment of patients with spinal cord injuries led to the rise of IC as a desirable technique for managing neurogenic bladder dysfunction.4 For example, patients admitted to the spinal cord injury center at Stoke Mandeville in the United Kingdom were managed with IC using a strict aseptic technique involving gowns, sterile gloves, and surgical masks. While sterile IC dramatically reduced the prevalence of UTI, pyelonephritis, vesicoureteral reflux, and deteriorating renal function, the burden of aseptic technique did not lend itself to long-term care in the home. During the mid-20th century, the clinical utility of IC was revolutionized when Lapides and colleagues5 introduced the concept of IC using clean rather than sterile technique. Clean intermittent catheterization (CIC) is based on the hypothesis that regular evacuation of the urinary bladder is more important for prevention of symptomatic UTI than is the use of aseptic technique. Subsequent research in adults with myelomeningocele and neurogenic bladder dysfunction supports this hypothesis.6 Patients were taught to wash their hands, apply lubricant to a 14F (French) red rubber catheter, gently insert the catheter until urine flows and stops (indicating complete evacuation of the bladder), followed by catheter removal. Patients were taught to catheterize every 2 to 4 hours based on urologic assessment. Catheters were used multiple times, and patients were advised to clean the catheter with a detergent solution, rinse thoroughly, and air dry between catheterizations. Lapides' group advocated using RNs to teach CIC to patients.5
Clean intermittent catheterization is currently used for a variety of indications including neurogenic bladder dysfunction, non-neurogenic bladder disorders such as prostatic enlargement resulting in urinary retention (with or without incontinence), drainage of urine following augmentation enterocystoplasty, management of nocturia in persons with incomplete bladder emptying, and prevention of recurrent urethral strictures.7–10 While the basic principles of CIC have not changed since its widespread adoption in the 1970s, innovations in catheter technology that have the potential to improve the ease of catheter insertion, reduce urethral trauma, and reduce symptomatic UTI have been adopted into practice.1 For example, single-use intermittent catheters with a hydrophilic coated substrate were developed in the 1980s that incorporated a polymer surface capable of absorbing water, resulting in a lubricated surface without the use of external lubricant. The water required to create this self-lubricating feature may be obtained either from the catheter package or from an external water source. Catheters have also been designed with a bag attached that enable users to perform catheterization without directly touching the surface of the catheter. Catheters of varying lengths have also been introduced; for example, shorter catheters have been designed for females that are easier to store and carry. In addition, catheters with a Coudé or Tiemann tip with clearly marked knobs or stripes are available for men with prostatic enlargement.1
In order to gain greater insights into clinical practice in the area of CIC, 38 interactive sessions were held with nurses and other clinicians that combined education about CIC with facilitated feedback concerning clinical decision-making using an anonymous electronic feedback system. Feedback during these sessions revealed considerable variability related to selection of intermittent catheters, inclusion of persons other than the patient in CIC education, use of clinical practice guidelines for CIC, and clinical decision-making when presented with specific case scenarios. This study is a follow-up to the feedback gathered from the interactive sessions; no data from the interactive sessions were used for the current study. The purpose of this study was to describe nursing practice and clinical decision-making related to IC.
A cross-sectional survey design guided data collection and analysis; the survey was made available online, and respondents were provided the proper URL and unique password allowing access. Inclusion criteria for survey respondents were nurses and other clinicians practicing in the United Stated who regularly care for adults 18 years or older with neurogenic or non-neurogenic lower urinary tract dysfunction in any care setting. Exclusion criteria were nurses caring for pediatric patients younger than 18 years and nurses practicing outside the North America. Nurses were invited from a random sample of members from specialty practice nursing organizations whose members' practice includes management of individuals with neurogenic bladder dysfunction or non-neurogenic bladder dysfunction including urinary retention, with or without incontinence. These organizations included the Association of Rehabilitation Nurses (ARN), Society of Urologic Nurses and Associates (SUNA), Wound, Ostomy and Continence Nurses Society (WOCN), Nurses Specialized in Wound Ostomy and Continence Care (NSWOCC, formerly CAET), Urology Nurses of Canada (UNC), and International Continence Society (ICS) members identifying as nurses. The survey was distributed online via a third party administrator (Key Survey, Braintree, Massachusetts) over a period of 9 months.
Study procedures were reviewed and approved by the Western Institutional Review Board (Olympia, Washington; approval #20170940). Respondents who visited the online survey Web page first viewed a written explanation of the purpose of the survey and were provided information on data management including protection of privacy of individual responses. Completion of the questionnaire acted as consent to study participation. All data were stored in a secured and encrypted database and reported in the aggregate.
The questionnaire comprised 50 items and required approximately 35 to 40 minutes to complete. It was constructed by the authors (M.G., T.N., M.A.W.) and a panel of 4 advanced practice RNs with experience and expertise in urologic, rehabilitation, and continence nursing, respectively. Six items focused on demographic data related to the respondents' professional nursing practice, 2 items queried level of practice (licensed or practical nurse, RN, advanced practice RN) and role within current practice (clinician, manager, educator), 2 items queried highest earned degree and specialty practice certifications, 1 item queried number of years in specialty practice involving continence care, and 1 item queried current practice setting. Thirteen items queried facility policies and practice patterns related to use of indwelling and intermittent catheters. Twenty-three items focused on individual decision-making regarding IC practice; specific topics included readiness for IC instruction, instructions provided to the patient and/or family or lay caregivers, catheter selection including catheter substrate, use of clean versus sterile technique with catheterization, follow-up assessment to evaluate adherence, and success of IC program.
Finally, 8 items queried IC selection in 4 case scenarios: a 20-year-old male patient with paraplegia and neurogenic bladder dysfunction following a T6 spinal cord injury; a 45-year-old female patient with multiple sclerosis and neurogenic bladder dysfunction; a 79-year-old male patient with urinary retention attributed to prostatic enlargement; and a 19-year-old female patient with paraparesis and neurogenic bladder dysfunction owing to myelomeningocele. Queries focused on catheter selection (catheter length and French size). Responses to these items were divided into 2 categories: safe practice versus inappropriate practice. Best practice responses were based on 100% consensus from the expert opinions of the nurses who authored the survey, coupled with recommendations from practice guidelines when possible. Inappropriate responses were unlikely to lead to successful evacuation of the bladder via IC. No responses were included that represented a positive danger when teaching IC to a patient or caregiver.
The questionnaire was independently evaluated for face validity and clarity by 12 colleagues of the original 4 nurse experts who designed the questionnaire. In addition, a sample of 6 items that addressed IC-related nursing practice was evaluated for internal consistency using the Cronbach α. Analysis revealed acceptable consistency (Cronbach α = 0.851).11
Data were analyzed using IBM SPSS Statistics 25 (Statistical Package for the Social Sciences, Armonk, New York). We used descriptive analyses to evaluate outcomes. Based on the outcome variables, we used Pearson correlations, χ2, or Fisher's exact test to evaluate relationships between years of practice, or holding certification and IC outcomes.
Three hundred forty-three nurses responded to the online survey, yielding a margin of error of 5.3%. The majority (70.0%; n = 240) identified themselves as RNs (Table). Eighty-six (25.0%) identified as advanced practice RNs, 15.5% (n = 56) indicated they were nurse practitioners, and 8.7% (n = 30) were clinical nurse specialists. Six (1.7%) indicated they were licensed practical or vocational nurses, and 3.2% (n =11) identified themselves as “other”; this last category included nurse administrators with advanced degrees in a nonclinical field such as business administration.
In addition to clinical practice, 41.0% (n = 140) indicated duties as managers or educators. The mast majority (81.8%) held academic degrees. All but one participant responded to the item that queried certification; the majority of respondents (75.9%; n = 260) held at least one certification; the most common was rehabilitation nursing, followed by WOC, and urologic nursing. Slightly less than a quarter (24.1%) did not hold specialty practice certification. Most nurses (70.5%; n = 242) indicated 11 or more years of experience in their specialty practice, 11.9% (n = 41) had 5 years or less experience, and 10.8% (n = 37) had 16 years or more experience in specialty practice. The most common practice setting for respondents was an inpatient rehabilitation unit (32.7%; n = 112), followed by ambulatory urologic clinic (29.2%; n = 100), inpatient medical-surgical unit (16.0%; n = 54), home health care service (9.0%; n = 31), and outpatient rehabilitation service (8.5%; n = 29). Less than 1 in 20 (1.5%) practiced in a critical care setting.
Intermittent Catheterization Education
We asked respondents about their current practices related to IC. Slightly more than half (51.5%; n = 175) estimated they taught IC to 10% or less patients, 30.0% (n = 103) indicated teaching IC to 11% to 25% of patients, 9.0% (n = 31) taught IC to 26% to 50% of their patients, and 6.7% (n = 23) taught IC to more than half of their patients. Less than half (48.1%; n = 165) indicated teaching a lay caregiver such as a family member to perform IC, and 16.9% (n = 58) indicated they never or seldom teach catheterization to anyone except the patient. Nevertheless, most respondents (61.2%; n = 210) indicated confidence that patients and/or families understood teaching 70% or more of the time and 91.6% (n = 314) indicated that more than half of patients or lay caregivers understood instructions related to IC. Practice setting influenced the likelihood that nurses believed patients and/or caregivers understood instruction; 63.0% of nurses practicing in medical-surgical units believed patients and/or caregivers understood instruction, whereas 75.9% of nurses practicing in inpatient rehabilitation units and 87.0% of nurses practicing in ambulatory care urologic clinics indicated confidence that instruction was understood. Similarly, 75.2% (n = 258) indicated that 70% or more of patients and/or caregivers were able to effectively self-catheterize or catheterize a family member based on return demonstration following nurse education.
A majority of respondents (68.0%; n = 233) stated they have decision-making control with power to influence patients, physicians, and other health care professionals based on their continence care knowledge and skills. They also indicated they had the authority or ability to mobilize resources and gain access to products and supplies to initiate a program of IC for their patients.
Respondents were asked to identify sources and guidelines related to intermittent and related catheterization policies used in daily practice. The vast majority indicated awareness of policies related to indwelling catheterization within their facility's policies and practice materials (82.8%; n = 284), and 77.6% (n = 266) acknowledged that their facilities also have policies guiding IC practices. However, responses showed considerable variability when asked about which policies or guidelines they used to guide routine clinical decision-making related to IC practice. Respondents were allowed to identify more than 1 response to this item. Almost half (46.4%; n = 158) indicated they based their practice on policies generated by the facility they practiced in, but 25.4% (n = 87) indicated they relied on their own best practice. One-third of nurses who indicated using their own best practice related to IC care had 16 years or more experience in their specialty practice. We analyzed this association and found that greater experience in continence care is related to use of their own best practice (r = 0.775, P = .035).
Responses varied considerably when nurses were asked to identify clinical guidelines or external sources for IC practice; participants were able to choose more than 1 response for this item. Slightly more than one-third of respondents (34.1%; n = 117) indicated they used guidelines from SUNA, an organization that does have IC guidelines for males and females. Respondents also indicated they used guidelines from the Centers for Disease Control and Prevention (37.4%; n = 127), American Urological Association (28.9%; n = 99), American Nurses Association (23.3%; n = 80), and Association for Professionals in Infection Control and Epidemiology (15.5%; n = 53).
When asked about the types of catheters available for use in IC, a majority of respondents (85.4%; n = 293) indicated use of uncoated catheters made of various substrates including polyvinyl chlorides, followed by hydrophilic coated catheters (52.5%; n = 185), touchless catheter systems (51.9%; n = 178), and gel-coated catheters (35.6%; n = 122). Less than 1% (0.6%; n = 2) indicated they had no intermittent catheters available in their facility. Participants were asked about technique used when providers or staff performed IC within their facility; 63.8% (n = 219) indicated using a sterile technique (handwashing, followed by use of sterile gloves, sterile drapes, cleansing the area with povidone-iodine or chlorhexidine gluconate solution, insertion of a sterile, single-use catheter), while 31.5% (n = 108) indicated single-use catheters with clean technique (handwashing, followed by use of clean gloves, cleansing meatus with soap and water or cleansing solution, and insertion of a catheter that was discarded following use).
Respondents were asked about choice of catheter type based on substrate (material of construction) and coating (hydrophilic or gel) versus no-touch catheter insertion systems, and use of sterile or clear technique when instructing patients and/or caregivers to perform IC in the home setting. The vast majority (99.1%; n = 340) indicated single catheter use, whereas 0.9% (n = 3) indicated catheter cleaning and reuse.
Responses to the 4 case scenarios described earlier were divided into 2 categories: safe and inappropriate. The first scenario described teaching IC to a 20-year-old male patient with a T6 spinal cord injury. Most respondents (90%; n = 309) selected a catheter that was 12 to 18 inches (of sufficient length to pass through the urethra and into the bladder vesicle), whereas 10.0% (n = 34) inappropriately selected a short catheter (6-10 inches) which was too short to traverse the urethra and reach the bladder vesicle in a 20-year-old male patient. Most respondents selected a 14F or 16F catheter (66.4% and 17.8%, respectively), but 16.0% (n = 55) selected a 12F catheter (this response was deemed inappropriate because of the likelihood of experiencing difficulty when catheterizing a male urethra in a spinal cord–injured patient, especially in those with detrusor striated sphincter dyssynergia, a prevalent finding in spinal cord–injured patients).12 Approximately 15.1% (n = 52) of respondents chose a Coudé tipped catheter for this patient, while 85% chose a straight tipped catheter; both responses were deemed safe. We analyzed selection of a safe versus inappropriate choice based on years of experience or certification. No differences were found when respondents with 16 years or more experience were compared to nurses with lesser experience (Fisher's exact test, P = .874), or when nurses with certification in WOC, urologic, or rehabilitation nursing were compared to nurses without certification (χ2 test, P = .707).
The second case scenario queried teaching IC to a 45-year-old female patient with multiple sclerosis, urinary retention, and good upper extremity function. Thirty-one percent of nurses (n = 106) chose a catheter length for this scenario of 12 to 18 inches, and 69% selected a shorter catheter length (6-10 inches); both responses were deemed safe. A high proportion of nurses (94%; n = 322) chose a straight tipped catheter, whereas 6.0% selected a Coudé tipped catheter; both were deemed safe, but a Coudé tipped catheter is not indicated for a female with an anatomically normal urethra. Most respondents selected a 12F or 14F catheter (26.1% and 61.8%, respectively); both responses were deemed safe. We analyzed the relationship between nurses with 16 years or more experience and selection of a Coudé versus straight tipped catheter but found no significant association (Fisher's exact test, P = .103). Similarly, we found no significant differences when comparing nurses based on certification versus no certification (χ2 test, P = .654).
The third scenario focused on teaching IC to a 79-year-old male patient with prostatic enlargement and urinary retention. The majority of nurses selected a catheter length of 12 to 18 inches (91%; n = 312) versus 9.0% who selected a 6- to 10-inch catheter (an inappropriate selection deemed very unlikely to pass through the urethra and successfully reach the bladder vesicle). Similarly, 89% of respondents (n = 305) chose a Coudé tipped catheter, whereas 11% chose a straight tipped catheter for this patient. Both responses were deemed safe, though the expert nurse panel concurred that a Coudé tipped catheter, specifically designed for insertion in men with prostate enlargement, is more advisable than a straight tipped catheter. Respondents selected 14F or 16F size (55.1% and 23.8%, respectively; n = 271), whereas 72 (20.9%) chose a 12F catheter, deemed an inappropriate response due to its smaller French size. We found no statistically significant difference in catheter selection when nurses with more than 16 years of experience were compared to those with lesser experience (Fisher's exact test, P = .554). We also found no significant difference is catheter selection based on certification (χ2 test, P = .464).
The final scenario queried teaching IC to a 19-year-old female patient with myelomeningocele. Seventy-five percent of nurses (n = 257) chose a 6- to 10-inch catheter, and the remaining 25% chose a 12- to 18-inch catheter; both were deemed safe responses. Respondents were not asked to select a straight versus Coudé tipped catheter for this scenario. However, they were asked to select catheter sizes ranging from 5F to 14F. Approximately 12% (n = 41) of respondents chose a catheter in the range of 5F to 8F for this patient; this response was deemed inappropriate because of the difficulty created for effectively emptying urine from the bladder of an adult female. We analyzed the relationship between selection of catheter size (5F-8F vs 12F-14F) and years of experience; nurses with less than 5 years of experience were significantly more likely to select a small catheter size as compared to respondents with 16 years or more experience (χ2 test, P = .015). Analysis based on certification also revealed no significant differences between years of experience (χ2 test, P = .847).
We evaluated clinical decision-making related to IC using a cross-sectional survey of 343 nurses with experience in teaching continence care including teaching IC. Despite evidence that respondents had knowledge and experience in this area of care, we found considerable variability in responses to multiple key questions including resources used to guide IC practice, who should be taught IC, and the length, French size, and substrate of catheters. We also found that a substantial portion of nurses selected inappropriate catheters in response to 4 prevalent scenarios for teaching IC. We searched the medical literature over a period of 10 years and found no other studies describing IC practices among nurses.
Respondents indicated experience in caring for and teaching patients with continence issues. Most (70%) were RNs, 15.5% were advanced practice RNs, and only 1.7% were licensed practical or vocational nurses. The majority held a college degree; 38.8% held a baccalaureate degree, 37.9% held a master's degree, and 5.0% held a doctorate degree. Most (75.9%) were certified in rehabilitation, urologic, or WOC nursing whose practice includes IC teaching, and 68.0% indicated decision-making control with power to influence patients, physicians, and other health care professionals related to IC practice. We purposely sought out nurses with experience in caring patients and conducting IC teaching in order to describe best IC-related practices. This was to minimize variability in responses had we queried nurses with little to no experience in this area of care. These assumptions are supported by the findings of van Rijswijk,13 who evaluated an electronic clinical pathway for nurses in the area of wound care. Participants were asked to complete assessments and select topical therapy for patients with acute or chronic wounds. She found that certified wound care nurses were more likely to make correct or safe assessments or dressing selections than were nurses without specialty practice certification in this area of care.
Nevertheless, we found considerable variability in IC-related practices in several key areas. Respondents indicated a variety of sources used to guide IC practice, including guidelines from SUNA, Centers for Disease Control and Prevention, American Urological Association, American Nurses Association, and Association for Professionals in Infection Control and Epidemiology. We searched MEDLINE and the Internet using the Google search engine (Google, Mountainview, California) for policies related to IC. We located clinical guidelines that address nursing practice related to IC including education, catheter selection, and interventions to promote adherence to IC. We found 3 guidelines that provide statements related to nursing practice of IC from SUNA, Israeli Urological Association, and Australian and New Zealand Urologic Nurses Society.14–16 In contrast, while the Centers for Disease Control and Prevention, American Urological Association, American Nurses Association, and Association for Professionals in Infection Control and Epidemiology have guidelines that include indications for IC, our search revealed no policies regarding IC education, catheter selection, or strategies to enhance adherence to IC. We also found articles reviewing IC nursing practice that combined best practice and evidence-based practice recommendations from the individual authors.17–19
Respondents indicated awareness of various catheter designs, including uncoated, coated, hydrophilic, and gel-coated catheter, as well as catheters of various lengths, with various types of tips. The strongest consensus among nurses (99.1%) was related to teaching patients and caregivers to employ single-use catheters versus reusable catheters requiring cleaning between insertions. This policy is most likely attributable to the 2007 policy from the US Centers for Medicare & Medicaid Services that paved the way to reimbursement for single-use catheterization from the historic tradition of catheter reuse.20 In contrast to this high level of agreement concerning single catheter use when teaching IC, responses varied concerning who should be targeted to perform IC. Less than half of nurses (48.1%) indicated a lay caregiver or family member was taught to perform IC. We have observed this practice to be common in the rehabilitation setting owing to concern that acute illness may transiently render the neurologically impaired patient unable to perform self-IC or in the care of persons with congenital anomalies such as myelomeningocele who rely on parents or caregivers to perform IC until they are able to assume this aspect of self-care.21
While we anticipated some variability when nurses were asked to select a catheter for use in IC teaching, we anticipated a low response rate to catheter selections deemed inappropriate. Each of the scenarios was selected because of its prevalence among patients managed by IC. We purposely avoided inserting complicating factors into catheter selection such as the presence of a urethral stricture, a false passage (epithelialized tract with a blind ending) created by unsuccessful catheterization, or psychosocial factors likely to challenge readiness to learn IC. Within each scenario, we selected multiple answers deemed safe that were intended to reflect observed variability in practice; however, we also created options deemed inappropriate because of the likelihood that the catheter selected would not ensure successful and efficient catheterization and bladder drainage. We were surprised to find that inappropriate response rates varied from 9.0% to 21.0%. Selections with the highest proportion of inappropriate responses focused on catheter size and length in males; 10.0% and 16.0% of nurses selected a catheter that was too short or too small for a young adult male with a spinal cord injury and neurogenic bladder dysfunction. Similarly, 9.0% and 20.9% of nurses selected inappropriate catheter length and size when presented with a scenario of a 79-year-old male patient with prostatic enlargement. The reasons for these selections are unclear; for example, one reason may be attributable to less familiarity with the urethral anatomy of a male with prostate enlargement particularly among nurses practicing in a rehabilitation setting who primarily care for younger adults such as a spinal cord injury center or less familiarity with the shorter 6- to 10-inch catheters primarily used in the ambulatory care setting.
Catheter length is not an issue when teaching IC to female patients because they are able to be successfully catheterized with shorter or longer catheters. However, when presented with a case of a 19-year-old adult female patient with neurogenic bladder due to myelomeningocele, 9.0% of nurses selected a 6F to 8F catheter, appropriate for pediatric rather than adult patients. We do not know whether respondents may have envisioned a child rather than adult female when visualizing IC teaching in a patient with spina bifida. We also observed that 6.0% of nurses selected a Coudé tipped catheter for an adult female with neurogenic bladder due to multiple sclerosis. While not inappropriate, these catheters are rarely used for IC in females and more costly than straight tipped catheters.
STRENGTHS AND LIMITATIONS
We acknowledge several limitations that may influence the generalizability of our findings. Data relied on reported practice patterns rather than direct observation of daily practice when teaching IC. The survey included 50 items and required 30 to 40 minutes to complete. We cannot be certain whether respondents experienced fatigue and answered items near the end of the survey without carefully reading the stem of the question or statement. The primary strength was random selection of nurse members from societies whose specialty practice includes IC teaching. In addition, the response rate was sufficiently robust to provide a margin of error of 5.3%.
We surveyed a group of 343 nurses experienced in IC teaching and found considerable variability in multiple areas of practice including sources used to provide guidance for IC education and related practice, who to include when teaching IC, and catheter selection including length, French size, and tip configuration. Based on these findings, we urgently recommend development of evidence- and consensus-based guidelines for IC practice including technique and content of education, who to include in IC teaching, and catheter selection.