Embed Size (px)
Citation preview
Learning Needs of Nurses
Working With Patients
Requiring Long Term Urinary
Catheter Care.
Kevin J Holmes
A dissertation submitted in part fulfilment of a
Master of Arts in Adult Education,
University of Malta.
May, 2013
University of Malta Library – Electronic Theses & Dissertations (ETD) Repository
The copyright of this thesis/dissertation belongs to the author. The author’s rights in respect of this
work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any
successive legislation.
Users may access this full-text thesis/dissertation and can make use of the information contained in
accordance with the Copyright Act provided that the author must be properly acknowledged.
Further distribution or reproduction in any format is prohibited without the prior permission of the
copyright holder.
ii
UNIVERSITY OF MALTA
FACULTY OF EDUCATION
DECLARATION
Student’s I.D. /Code: 150879M
Student’s Name & Surname: Kevin John Holmes
Course: Master of Arts in Adult Education
Title of Dissertation/Thesis:
Learning needs of nurses working with patients requiring long term catheter care.
I hereby declare that I am the legitimate author of this Dissertation/Thesis and that
it is my original work. No portion of this work has been submitted in support of an
application for another degree or qualification of this or any other university or
institution of learning.
____________________________
KEVIN J HOLMES
_____________________
Date
iii
DEDICATION
To Denise and Karl.
iv
ACKNOWLEDGEMENTS
Sincere thanks go to my supervisor, Dr. Michelle Camilleri for her invaluable
assistance, guidance, support and patience.
I would like to significantly thank my wife, Denise for her love and endless
support. She has put up with me throughout this work. I also want to thank our
son Karl. At a very tender age he has taught me so much. He allowed me insight
into some of the same barriers to attending training which I investigated and
discussed within this work. Thanks to Karl I now understand the participants
better.
Gratitude is also due to Professor Peter Mayo for his support throughout this
course of studies. Was it not for him, none of this would have been possible!
Last but undoubtedly not least, I would like to thank those who helped me out in a
way or another amongst which are my colleagues in Urology, Ms. Rebecca Cachia
Fearne, Ms. Fiona Sammut, Ms. Anna Curmi and the participants of this study who
participated over and above their other commitments.
v
TABLE OF CONTENTS
Title page ………………………………………………………………………………………………………………………….i
Declaration of Authenticity ……………………………………………………………………………………………..ii
Dedication ………………………………………………………………………………………………………………………iii
Acknowledgements ………………………………………………………………………………………………………..iv
Table of Contents …………………………………………………………………………………………………………….v
List of Tables …………………………………………………………………………………………………………………viii
List of Graphs …………………………………………………………………………………………………………………..x
List of Terms and Abbreviations ……………………………………………………………………………………..xi
Abstract ………………………………………………………………………………………………………………………..xiii
Chapter 1 - Introduction
1.1 Introduction ................................................................................................................ 1
1.2 The researcher practitioner, the context and the theoretical framework ................. 3
1.3 Continuous professional development & learning needs assessment ....................... 5
Chapter 2 - Literature review
2.1 Introduction ................................................................................................................ 7
2.2 Critical appraisal of the literature ............................................................................... 9
2.2.1 Urethral catheters and their care ....................................................................... 9
2.3 Needs assessment ..................................................................................................... 14
2.3.1 Training needs assessment .................................................................................... 15
2.4 ARCS Theory of Motivation ...................................................................................... 17
2.5 Conclusion ................................................................................................................. 18
Chapter 3 - The Method
3.1 The Research Question, Aim and Objectives ............................................................ 19
3.2 Operational Definitions ............................................................................................. 19
3.3 The Research Design ................................................................................................. 20
3.4 The Research Setting ................................................................................................ 22
3.5 The Target Population and Sampling Technique ...................................................... 23
3.6 The Research Tools ................................................................................................... 24
3.6.1 The questionnaire .............................................................................................. 25
3.6.2 The Focus Group Interview ................................................................................ 27
vi
3.7 Enhancing the quality of the study ........................................................................... 27
3.7.1 Enhancing Validity and Reliability of the Questionnaire ................................... 28
3.7.2 Enhancing Validity of the Focus Interview ......................................................... 29
3.8 Data collection .......................................................................................................... 30
3.8.1 The Survey .......................................................................................................... 30
3.8.2 The Focus interview ........................................................................................... 31
3.9 Data analysis ............................................................................................................. 32
3.10 Ethical Considerations ............................................................................................. 33
Chapter 4 - The findings
4.1 Introduction .............................................................................................................. 38
4.2 Response rate and demographic data ...................................................................... 38
4.3 Statistical analysis ..................................................................................................... 42
4.4 Insertion or change of urethral catheter .................................................................. 44
4.5 Knowledge of catheterisation ................................................................................... 45
4.6 Technique - Patient comfort and Trauma ................................................................. 50
4.7 Control of infection ................................................................................................... 55
4.8 CPD and Training ....................................................................................................... 69
4.9 Planning and conduction of training ......................................................................... 80
4.10 Themes emerging from the focus interview ........................................................... 87
Chapter 5 - Analysis and Discussion of the findings
5.1 Introduction .............................................................................................................. 95
5.2 Changing and caring for urethral catheters .............................................................. 97
5.3 Knowledge deficit ................................................................................................... 100
5.4 Pre and post registration training ........................................................................... 102
5.5 Development, delivery and certification of training ............................................... 106
5.6 Barriers .................................................................................................................... 109
5.7 Strengths and limitations of the study .................................................................... 112
5.9 Conclusion ............................................................................................................... 114
Chapter 6 - Conclusion
6.1 Conclusion ............................................................................................................... 115
6.2 Recommendations .................................................................................................. 116
6.2..1 Further research ............................................................................................. 116
6.2.2 Education ......................................................................................................... 117
vii
6.2.3 Management and Practice ............................................................................... 117
References ........................................................................................................................ 119
Appendix 1 - The questionnaire …………………………………………………………………………………..148
Appendix 2 - Focus Interview Schedule
………………………………………………………….……………15657
Appendix 3 - Letter of Information - Pilot study……………………………………………………………158
Appendix 4 - Letter of information - Questionnaire ….....................................................159
Appendix 5 - Letter of information - Focus Group ............................................................ 160
Appendix 6 - FREC and UREC Approvals ........................................................................... 161
Appendix 7 - Approval by the Director of Nursing, Mater Dei Hospital ........................... 162
Appendix 8 - Approval by the Director of Elderly and Community Care .......................... 163
Appendix 9 - Approval by the Data Controller, Primary Health Care ............................... 164
viii
LIST OF TABLES
Title Table number Page
Search terms and number of articles retrieved 2.1 8
Response rate 4.1 38
Gender and practice setting of the respondents 4.2 40
Qualifications and years of experience of the respondents 4.3 41
Setting and years of experience of respondents 4.4 42
Description of level of association - University of Toronto 4.5 43
Who inserts the catheter by practice setting 4.6 44
Comments on why they do not insert urinary catheters 4.7 44
Association between years of experience and knowledge of catheterisation 4.8 46
Association between qualification and knowledge of catheterisation 4.9 47
Association between practice setting and knowledge of catheterisation 4.10 48
Knowledge of catheterisation by attendance to related CPD 4.11 49
Attendance to related courses by practice setting 4.12 49
Association between gender and knowledge of the technique 4.13 51
Association between years of experience and knowledge of the technique 4.14 52
Association between qualification and knowledge of the technique 4.15 53
Association between practice setting and knowledge of the technique 4.16 54
Association between practice setting and knowledge of infection control 4.17 55
Assoc between practice setting and knowledge of infection control 4.18 57
Assoc between years of experience and knowledge of infection control 4.19 58
Assoc between years of experience and knowledge of infection control 4.20 60
Assoc between qualifications and knowledge of infection control 4.21 61
Assoc between qualification and knowledge of infection control 4.22 63
Association between setting and knowledge of signs and symptoms of infection 4.23 65
Association between years of experience and knowledge of signs and
symptoms of infection
4.24 66
Association between qualifications and knowledge of signs and symptoms of
infection
4.25 68
Association between undergraduate training and years of experience 4.26 70
Association between CPD training and years of experience 4.27 70
Comments of those who attended a CPD on the topic 4.28 71
Comments of those who did not attend CPD 4.29 71
Association between undergraduate training and qualifications 4.30 72
Association between continuing education and qualifications 4.31 72
Association between continuing education and practice setting 4.32 73
ix
Association between considering attendance to training and years of experience 4.33 74
Association between considering attendance to training and qualifications 4.34 74
Association between considering attendance to training and practice setting 4.35 75
Association between considering attendance to training and gender 4.36 76
Cross tabulation of undergraduate training and CPD 4.37 76
Cross tabulation of Q17 with negative answers to Q15 and Q16 4.38 77
Cross tabulation of negative response to Q15, 16, 17 to gender 4.39 78
Cross tab of negative response to Q15, 16, 17 to years of experience 4.40 78
Cross tabulation of negative response to Q15, 16, 17 to qualification 4.41 78
Cross tab of negative response to Q15, 16, 17 to practice setting 4.42 79
Cross tabulation of negative response to Q15, 16, 17 to Q5 4.43 79
Cross tabulation of years of experience and willingness to finance own studies 4.44 84
Reasons justifying own financing of CPD 4.45 85
Reasons justifying why not to finance own CPD 4.46 85
Payment options chosen 4.47 85
Themes emerging from the focus group 4.48 88
x
LIST OF GRAPHS
Title Chart number Page
Individuals who perform catheter care 4.1 45
Choices regards development of training 4.2 81
Choices regards delivery of training 4.3 81
Environment most appropriate for training 4.4 82
Preferred mode of delivery 4.5 83
Preferred mode of assessment 4.6 83
What respondents expect of a CPD course 4.7 86
What respondents expect of a CPD course 4.8 86
Barriers to attendance 4.9 87
xi
LIST OF TERMS AND ABBREVIATIONS
Term / Abbreviation Definition
A&E Accident and Emergency Department
AACCN American Association of Critical Care Nurses
ANZUNS Australia and New Zealand Urological Nurses Society
BC Before Christ
BAUN British Association of Urology Nurses
Catheter In this work, this term refers to a urinary / urethral catheter as described in the introductory chapter. It does not refer to intravascular, epidural or other types of catheters.
CAUTI Catheter Acquired Urinary Tract Infections
CNP Certificate in Nursing Practice
CDC Centers for Disease Control and Prevention
CINAHL Cumulative Index of Nursing and Allied Health Literature
CME Continuing Medical Education
CNE Continuing Nurse Education
CPD Continuous Professional Development
EN Enrolled Nurse
EAUN European Association of Urology Nurses
EBSCO Elton B. Stephens Company Academic Search Engine
FREC Faculty of Education Research Ethics Committee
FHS Faculty of Health Sciences
HC Health Center
LID Low Inference Descriptors
LNA Learning Needs Assessment
LTC Long Term Catheter
LTCC Long Term Catheter Care - includes change of catheter
MCMN Maltese Council of Nurses and Midwives
MDH Mater Dei Hospital
MHEC Ministry of Health, the Elderly, and Community Care
MMDNA Malta Memorial District Nurse Association
xii
NA Needs Assessment
NHS National Health Service - United Kingdom
NICE National Institute of Clinical Excellence
NGO Nongovernmental organization
Nosocomial Hospital acquired
NMC Nursing and Midwifery Council - United Kingdom
NO Nursing Officer
PDN Practice Development Nurse
PHC Primary Health Care - Mostly comprises of Health Centres
p.p Per person
RR Response Rate
RCN Royal College of Nursing, UK
S&S Signs and Symptoms
SUNA Society of Urology Nurse Associates
SN Staff Nurse
TNA Training Needs Assessment
UK The United Kingdom of Britain and Northern Ireland
UKCC The United Kingdom Central Council for Nursing, Midwifery, and Health Visiting
UN United Nations
UOM University of Malta
UREC University of Malta Research Ethics Committee
UTI Urinary Tract Infection
Urology A speciality dealing with problems of both the upper and lower urinary tract.
WHO World Health Organisation
xiii
ABSTRACT
A urinary catheter is a hollow tube which is inserted into a person's bladder via the
urethra allowing drainage of urine. Its use may vary from minutes to a permanent,
lifelong solution. Urinary catheters are resorted to as the last resort as a solution to
urinary problems. The link between long term catheterisation (LTC) and older age
has major implications in an era of a global ageing population. More persons will
have to resort to living with a LTC and as such, LTC care is crucial in decreasing
the need for acute hospital admissions.
This research study investigated the knowledge and training needs of Maltese
nurses who care for persons who need catheterisation of the urinary bladder and/or
urinary catheter care. A cross-sectional design was used to obtain a snapshot of the
knowledge of the population. In this study, the design is both descriptive and
analytical augmented by using a mixed method approach. It was conducted by
means of a questionnaire followed by a focus interview. The areas which were
deemed most important were not sampled but all their population included
(Accident and Emergency and Community). A stratified random sample of nurses
from within the acute hospital wards was recruited due to data protection
constraints.
The results show that locally there is a need for post-registration training and
education about the topic. Nurses need and seem willing to be equipped with this
knowledge and relevant skills. These results are not much different from those of
others abroad. The barriers to attending training have been mentioned in
previously published literature. Some recommendations for practice, further
research, management and education are provided in the last chapter.
Key search terms: Training needs, Learning needs, Nurses, Catheterisation,
Catheter care, Malta.
Chapter 1
Introduction
1
1.1 Introduction
A urethral catheter1 is a hollow tube made of latex or silicone which is inserted into
a person's bladder via the urethra. This catheter allows free drainage of urine from
the bladder, collection of specimens or instillation of drugs. Although self
catheterisation is possible, a permanently indwelling catheter is usually changed by
a trained clinician using an aseptic technique. The duration of the catheter in
situation may vary from minutes to a permanent, lifelong solution for some
Urological problems. Short term catheterisations are done to instil medications or
dyes into the bladder or to obtain a sterile urine sample. Medium term
catheterisations are usually resorted to in post operative periods of limited mobility
or as a wound healing adjunct.
A long term urinary catheter (LTC) is ideally resorted to when all other bladder
management options have failed. Therefore it is most often used by people who
cannot void. Most of these patients have problems with an enlarged prostate or an
incompetent bladder and for some reason or other are not candidates for a surgical
intervention. Bhardwaj, Pickard, & Rees (2010) found that 14.5% of in-patients at
their trust had an indwelling catheter. The data of the Centers for Disease Control
and Prevention [CDC2] (2012) estimates that 15%-20% of in-hospital patients
receive a urinary catheter. This means that at any one time in our state run hospital
hosting 906 beds (The Foundation Programme Malta, 2011), 136-181 patients have
an indwelling urethral catheter. Besides, a total of 1200 catheter changes are
carried out annually by the Malta Memorial District Nurses Association
[MMDNA, Malta's major community domiciliary nursing unit] (Personal
communication, 2011). This means that approximately 140 patients live with a
LTC in the community.
1 Throughout this work 'catheter' will refer to a urinary/urethral catheter.
2 CDC - Centers for Disease Control and Prevention, accessed at http://www.cdc.gov/
2
These do not include another 20 patients who use specially designed catheters
changed exclusively by Urology Outreach3 staff. A significant number of others
who have their catheter changed by a privately paid-for practitioner who are not on
any database. A LTC is defined by the European Association of Urology nurses
[EAUN4] (2012:13) as one which stays in situation for more than 14 days. For
practical reasons, locally we still refer to a LTC as one which stays in situ` for
more than 6 weeks, sometimes indefinitely. The catheter is changed at intervals by
a qualified nurse depending on the indicated length of stay. A LTC carries a
significant risk of catheter associated urinary tract infections (CAUTI) and related
sepsis (generalised infection), blockage, urethral injury and bladder stones (Miles
& Schroeder, 2009; Pellowe, 2009; Marklew, 2004). After long years of use, a
bladder tumour may also develop.
Although urinary catheters should be resorted to as the last option, Hazelett, Tsai,
Gareri, & Allen (2006) report inappropriate use in 21%-50% of cases. It is
estimated that 15%-25% of hospitalised patients receive a catheter (Saint et al,
2000) whilst up to 10% of those in long term care live with a LTC (Sorbye et al,
2005). Locally, no accurate data exists as to how many people live in the
community with a LTC. Only 127 patients are known to the system5 (Personal
Communication, Dec 2010) and this number does not account for those cared for
in the private setting or others in the acute setting who are catheterised for a
short/medium period of time. Whilst anyone might need a urinary catheter due to a
variety of reasons including accidental trauma, the large majority of those with a
LTC are males above 60 years of age. The link between LTC and older age has
major implications in an era whereby the world is experiencing an ageing
population. The World Health Organisation [WHO] (2012) and the United
3 Urology Outreach, launched in January, 2012, is a specialist outreach of the acute hospital service.
It is the first of its kind and offers support to, patients and their carers and to other nurses -
https://ehealth.gov.mt/HealthPortal/health_institutions/hospital_services/mater_dei_hospital/clinical
_services/urology_outreach_service.aspx 4 EAUN - The European Association of Urology Nurses accessed at http://www.uroweb.org/nurses/
5MMDNA change an average of 1100 catheters per year. At an average change per patient of once
every 6 weeks, this means that a total of 127 patients have a LTC. Other changes might be needed
due to blockage or infection.
3
Nations [UN] (2002) estimate that by the year 2050 the population above 60 years
of age will double and that over 80 years will quadruple. This means that more
persons will have to resort to living with a LTC and as such, LTC care (LTCC) is
crucial in decreasing the need for acute hospital admissions related to catheter
problems (Madigan & Neff, 2003; Gurjal, Kirkwood & Hinchliffe, 1999; Johnson
et al, 1993).
1.2 The researcher practitioner, the context and the
theoretical framework
I have been a nurse for the past 14 years, during which time I practiced within
various areas related to Urology care. These areas include the Urology Ward
within the acute general hospital, Nursing Homes in the community and
perioperative care. Fifteen months ago I was entrusted to set up a Urology
Outreach service in order to provide specialist care within the patients' homes and
so release bed capacity within hospital. This role has broadened my view of
Urology and exposed me to the concept of integrated care, catheterisation and
LTCC in other areas of care. This is only part of my role. I am also involved in
staff training, undergraduate education, clinical research and have an interest in
developing practice as reflected in the post graduate training I have pursued over
the years. I aim at being a change agent and to disseminate current research based
practice mostly with regards to catheterisation and catheter care.
Through my experience and feedback collected from patients and their carers over
the years, I have built the impression that various nurses within different healthcare
sectors have limited knowledge of urinary catheter insertion/change and care. This
lack of education often results in acute admissions to Urology due to trauma or
CAUTI. It is estimated that annually these admissions cost the Maltese health
sector over €60,000 and 13 hospital bed nights (Personal Communication, Nov
4
2011), not taking into consideration the effect on the patients' biopsychosocial
wellbeing. Most of these admissions can be easily reduced and some avoided
altogether if a correct insertion technique is adopted and catheter care guidelines
followed. Two main issues are at stake. First, the training which can be provided
in an undergraduate programme. Such programmes are limited in time and cannot
afford to cover topics such as LTCC in depth. Second is the lack of any
continuous professional development (CPD) initiatives aimed at the topic since the
launch of the CPD program locally in 1993 (Borg Xuereb, 2006). During my years
of practice I have met scores of qualified nurses who followed the traditional
course of studies (prior to the entry of Nursing within the tertiary educational
field). These state that they have never had any training on catheterisation and
LTCC in their 'undergraduate' days and that most of their learning was either by
trial and error or informally through a colleague. A large majority of these are
female nurses who currently form the largest portion of the Primary Health Care
(PHC) and MMDNA workforce. On the other hand, what is provided online by
reputable bodies (BAUN6, SUNA
7, EAUN) is also limited as it does not offer any
practical components. Consequently, I believe that the Maltese nurses might be
lacking the necessary evidence base to practice safely, resulting in CAUTI and
traumatic events, extended hospital stays and an increase in referrals to hospital.
This lack of knowledge has other implications especially when considering the
heavily burdened Accident & Emergency Department of Mater Dei Hospital
[MDH] (Caruana, 2012).
The theoretical framework chosen as a guide for this study is Keller's (1979)
ARCS Model of Motivational Design. This model is made up of four components:
Attention, Relevance, Confidence and Satisfaction. Keller based his model on
Tolman's and Lewin's expectancy value theory which is in turn based on the
presumptions that people are motivated to learn if there is value in the learning
6 BAUN: British Association of Urology Nurses. Further information at http://www.baun.co.uk
7 SUNA: Society of Urologic Nurses and Associates. Further information at http://www.suna.org
5
presented and if they have an optimistic expectation of succeeding. Further
explanation on this theory is presented in Chapter 2.
1.3 Continuous professional development & learning
needs assessment
The advancements in research pose demands on today's health care systems. One
of these demands is keeping abreast with the latest advancements. CPD initiatives
assist professionals in keeping themselves updated systematically, a lifelong
learning philosophy for the management of change (Jarvis, 1996). Lifelong
learning has been reported by Oulton (2006), Buchan & Calman (2005) to be a
mechanism through which workforce development, recruitment and retention of
nurses are promoted. Provision of evidence of CPD is a mandatory requirement
for renewal of licensure for nurses in most countries (Forbes, While, & Ullman,
2006; Nursing and Midwifery Council, 2002; O'Kell, 1986). According to Skees
(2010), Drey, Gould, & Allen (2009) nurses have a responsibility to undertake
continuing nursing education (CNE). In the last decade, The Maltese Directorate
of Nursing Services and Standards has introduced CPD schemes for nurses with
the aim of assisting them in keeping up with the transition to a knowledge based
economy as envisaged by the Commission of European Economies (2001). This
initiative could ultimately improve the quality of health care delivery and retention
of the nursing workforce. The research findings of Drey et al (2009) indicate the
lack of opportunities for relevant training as an important reason for the lack of job
satisfaction.
The development of effective strategies supporting CPD are an international
growing interest. Such frameworks have for years been in place in countries like
the United Kingdom [UK] (National Health Service [NHS], 1999), Ireland (NCPD
Nurses and Midwives, 2004), and Malaysia (Abdullah, 2008), just to mention a
6
few. In conjunction with the intensification of globalisation, this and other tools
like the internet (Seloilwe, 2005) are now providing nurses with access to a wide
range of learning resources. On the other hand, one has to consider the argument
put forward by Matsuda (2008) in that lately, the governments in many countries
are putting an emphasis on the economy. This emphasis coupled with the
increasing complexity and demands of modern health care, the ever growing
knowledge base, and the less time available due to the long shifts which nurses
work make learning needs assessment (LNA) an invaluable asset for planning
(Iqbal & Khan, 2011) of financially viable and relevant CPD (Forbes et al, 2006).
The cost of education is deemed by Reddy (1979) as being high to both the
organisation and to the individual and therefore careful analysis has to precede any
CPD activity to make sure that it returns its worth to the employee and to the
service (Forbes et al, 2006; Cohen, 1985). Case in point is the implementation of
an online learning programme for improving catheter related education by Wolters
et al (2006) which proved to significantly reduce the costs of care by educating and
empowering health personnel. Consequently, this resulted in a reduced amount of
Urology referrals to hospital. This is congruent with Grant's opinion (2002), who
contends that when a LNA has been conducted, learning is linked to practice and is
more likely to lead to a change in it. Akhtar-Danesh et al (2010) state that personal
incentive drives the educational effort and thus, LNA is crucial for the educational
process. This claim further stresses the importance of conducting this study locally
in order to understand the situation in Malta. A critical review of the relevant
literature ensues.
Chapter 2
Literature review
7
2.1 Introduction
An extensive search of the literature was conducted using multiple sources. Two
databases were searched: CINAHL®
(Cumulative Index to Nurses and Allied
Health Literature) and EBSCO®
Information Services (Elton B. Stephens
Company Academic Search Engine), both available at the E-Library of the
University of Malta (UOM). Other literature was found through the internet search
engine Google Scholar®. A manual search was also carried out including
correspondence with various authors. This correspondence yielded two full text
articles of which only an abstract was originally retrieved. The reference lists of
the articles retrieved were also checked manually. The UOM Library Catalogue
was searched for books, monographs, and dissertations. A significant amount of
reading allowed a better grasp of the concept of training needs assessment (TNA),
catheterisation, LTCC and CPD in general.
The literature retrieved was published between 1985 and 2012. The only limitation
set to the search was that articles had to be published in English. No literature in
other languages was retrieved. Publication date, country of origin, or type of
publication were not limited in any way. Primary sources were given priority but
when the original article could not be retrieved secondary sources had to be cited.
It appears that locally nobody has investigated the subject to date and so no local
studies were retrieved. The majority of the studies were published in Europe, the
United States of America and the UK. Key words, terms and their combinations
used during the search are found in Table 2.1 (overleaf) where a number of articles
retrieved from different sources have been clustered according to the search terms.
8
Search term/s No. of articles retrieved
Continuing Education Needs + Nurse(s)
9 Continuing Medical Education + Nurse(s)
CNE + Nurse(s)
CME + Nurse(s)
Continuous Professional Development + Nurse(s)
7 CPD + Nurse(s)
Training needs + analysis + Nurse(s)
9 Training needs + assessment + Nurse(s)
TNA
16 Training needs analysis
Learning Needs Analysis + Nurse(s) 9
Urology
10
Urinary catheter + Knowledge
Urethral catheter + Knowledge
Urethral / Urinary catheter + Care
Urethral / urinary catheter + Nurse(s)
Table 2.1: Search terms and number of articles retrieved.
The literature used for building the questionnaire was based on the latest guidelines
published by internationally established bodies in the last three years: the EAUN,
the Royal College of Nursing [RCN]8, the CDC, the National Institute for Health
and Care Excellence [NICE]9 and the Australia and New Zealand Urological
Nurses Society [ANZUNS]10
.
8 The Royal College of Nursing can be accessed at http://www.rcn.org.uk/
9 National Institute of Clinical Excellence can be accessed at http://www.nice.org.uk/
10 Australia and New Zealand Urological Nurses Society can be accessed at http://www.anzuns.org/
9
2.2 Critical appraisal of the literature
The Maltese and the British11
(UKCC12
, 1986) preregistration nursing education
share a similarity; both aim to equip nurses with skills and knowledge applied to a
generalist setting. Locally, further education (general or specific) is up to the
individual whilst in the UK it depends on the specialisation one decides to pursue.
CPD in Malta is not mandatory whilst in the UK it is regulated by the Nursing and
Midwifery Council (NMC). The degree to which both these methods achieve their
aims has drawn some scepticism in the literature (Werrett, Helm, & Carnwell,
2001; Whittaker, Davies, Thomson, & Sheperd, 1997). Case in point is the
knowledge and practice of catheterisation of the urinary bladder and urinary
catheter care of health professionals who care for patients with LTCs.
2.2.1 Urethral catheters and their care
An indwelling urinary/urethral catheter is a tube which is inserted into the urinary
bladder through the urethra to allow drainage of urine. The earliest recorded use of
catheters was around 3000 B.C (Calleja, 2012). The Foley catheter13
was
developed in the 1900s and since then no major developments in this concept have
been made. Major developments have been made to the use of different catheter
materials. Nowadays, several different catheters exist, the majority of which still
use the same concept developed by Dr. Foley.
11 There seems to be some discrepancy as to what the term "British" refers to: that pertaining to
Great Britain (England, Scotland, and Wales) or the United Kingdom (Great Britain and Northern
Ireland). In this text "British" refers to that pertaining to the United Kingdom of Britain and
Northern Ireland. 12
UKCC - The United Kingdom Central Council for Nursing, Midwifery, and Health Visiting.
This has changed to Nursing and Midwifery Council (NMC) - http://www.nmc-uk.org/ 13
Dr. Frederic Eugene Basil Foley, MD (April 5, 1891 – March 24, 1966) - An American Urologist
designed the Foley Catheter, a tube with an anteriorly placed inflatable balloon serving as an anchor
for it to stay in place.
10
In the literature it is clear that as primary users of devices, nurses have to be
competent in their use and care so as to avoid serious consequences (Fitter, 1986;
Germon, 1987; McConnell, 1987 in McConnell, Cattonar, & Manning, 1996).
LTCC is integral to an independent life with minimal need for acute
hospitalisations (Medigan & Neff, 2003; Gurjal, Kirkwood & Hinchliffe, 1999;
Johnson, Russell, Lockatell, Zulty & Warren, 1993).
The objective of a research study by Kneil, Pellow & Potter (2008) was to
determine the compliance with the standards of care for indwelling LTCs
published by the NICE (2011). This audit sought to establish the quality of LTCC
in the patients' own homes who are extremely vulnerable and prone to
hospitalisations. Data was collected by reviewing the documentation and
evaluation of clinical practice. The documentation reviewed was chosen by the
community nurses caring for the patients whilst data on clinical practice was
collected by a questionnaire. The results indicated that there was adherence to the
standards of care published by the NICE and where this differed, the reasons were
documented. A major flaw was that the documentation assessed was chosen by the
participants and passed on to the research team. This method of data collection
could have yielded a convenience sample and introduced bias. The authors also
state that clinical practice was not observed to avoid the Hawthorne Effect14
bias.
Rather than avoiding observations because of the possibility of observer effect one
would expect the authors to cite the length of time needed for an observer to "fade
into the setting" (Holloway & Wheeler, 2011:116) and so avoid this repercussion.
The use of an e-questionnaire made it easier for the respondents to conduct a fast
internet search while filling it up, biasing their responses. The response rate could
not be calculated since the researchers often sent the tools to a generic email
address. These methodological flaws and the small number of tools returned
(n=25) compromise confidence in the results.
14 Chiesa and Hobbs (2008:69) have found two conflicting uses of the term 'Hawthorne Effect'. In
this text it is used with the intent of it meaning the following: "the tendency for people to behave
differently when they know they are being studied..."
11
A response rate (RR) of 81% was yielded off a self-administered questionnaire
survey of 440 health care workers in Michigan by Mody, Saint, Galecki, Chen &
Krein (2010). The aim was to assess knowledge of catheter care. Of the 356
respondents, 90% were aware of glove use, meatal care and hand washing issues.
The majority were aware that daily cleansing was important but the results do not
state if the respondents were aware of how to carry out meatal care correctly.
Significant discrepancies were reported by half the participants who were less
aware of research proven recommendations with regards to breaking the closed
system (Johnson, Kuskowski & Wilt, 2006; Allepuz-Palau, Rossullo-Urgell &
Vague-Rafart, 2004; Al-Habdan, Sadat-Ali & Corea, 2003) and routine bladder
irrigations (EAUN, 2012; Hagen, Sinclair & Cross, 2010). This data, like the one
of the following study by Fleming, Day & Glanfield, (2000) is quite worrying
when considering that nurses are at the forefront of "routine care and problem
solving associated with patients who have indwelling urinary catheters" (Fleming
et al, 2000:237).
Fleming et al (2000) conducted a survey of 60 nurses working in rehabilitation and
long term care in Sydney, Australia. The tool was a 36-item questionnaire which
included demographic data, knowledge and practice questions related to the
management of urinary catheters. Three methodological flaws were identified at
first glance. These were a small sample size, the total/target population was not
stated, and the use of a convenience sampling technique. Whilst generalisation of
findings is impossible the survey yielded similar results to that of Mody et al
(2010) which had a very good RR and a larger sample. The total knowledge score
had a mean of 11.37 and a median of 11 out of a maximum possible of 22. They
report incorrect catheter selection (>20% incorrect), choice of cleansing agent prior
to catheter insertion (>50% incorrect), balloon inflation solution (23% incorrect),
reason for securement of the tube (97% incorrect) and collection of a mid-stream
catheter sample (92% incorrect). Calleja (2012) deems all these items as crucial to
12
safe catheter care and so it is not surprising that the incidence of CAUTI is as high
as 20%-30% (Pratt & Pellowe, 2010).
The results of a cross-sectional audit by Bhardwaj et al (2010) about documented
adherence to relevant standards are encouraging. This audit included data from the
records of all catheterised patients within their Health Care Trust. The results
show adherence to set standards although some bias may have been present as the
ward staff themselves chose the date for data collection. On the other hand, their
reported low rate of CAUTI (4.5%) is in line with the results. However it was not
stated if the Trust staff had undergone any training prior to the audit although it is
NMC policy that nurses have to undertake a compulsory amount of CPD hours
annually for their contract of service to be renewed.
According to Chetcuti (2008), the effects of CPD on clinical practice have been the
aim of several research studies. One in particular is that by McConnell et al (1996)
who argued that education about equipment is important to both nurses and their
patients. Having said this, they iterate that it is also in itself problematic since it
varies greatly, congruent with the findings of Bray & Sanders below. Despite this
variation, one finds that those respondents who reported consulting literature in
Fleming et al's study had significantly better knowledge scores than those who did
not. This should encourage those planning to conduct educational initiatives
targeted to the specific needs of the nurses as identified by themselves.
In an audit conducted in Liverpool, Bray & Sanders (2007) collected data of
catheter use by reviewing the records of patients admitted over an 8 month period.
They also sent a questionnaire to 384 nurses and 174 doctors investigating the level
of knowledge of the skill and training received. A RR of 42% was yielded.
Limited knowledge was demonstrated and 70% of participants never had any
formal training. Medical staff reported some patchy training which was provided
ad hoc on the job. The authors reported that at the time of print, an advanced
13
practice nurse role had been introduced to address these discrepancies, a role which
is missing locally. Similar results were obtained by a questionnaire survey given
out to 356 health professionals by Williams, Taylor, Bates, Tincello, & Richmond
(2003) conducted in the UK. It yielded a poor RR of 34% which calls for careful
consideration and interpretation of the results of bladder care knowledge. Overall
this study found poor levels of knowledge and significant differences in between
doctors, nurses and midwives.
A larger scale study conducted by means of a self-administered questionnaire by
McNulty et al (2005) yielded similar results. The aim was to determine the
reported knowledge of catheter care standards published by NICE and the
Association of Continence Care. A 52% RR was obtained after delivering 1438
questionnaires in 37 randomly selected nursing homes. No difference was found in
between the districts sampled although in comparison to a previous similar audit in
1998 the authors noticed a marked improvement in practice. One wonders how an
improvement in practice was reported when the authors did not state if
observations were carried out. Of the nurses who replied, 83% have received
training with regards to catheterisation and catheter care. Despite the training and
the improvement reported, the authors still found areas of non compliance.
In the light of the literature reviewed, one concludes that through the years an
overall knowledge deficit and practice discrepancies in LTCC have been
constantly demonstrated. This has to be considered in view of the plethora of
knowledge and guidelines which exist, most of which are freely available on the
internet. The results of audits such as that by McNulty strengthen the argument for
periodic re-training and updating.
14
2.3 Needs assessment
A needs assessment (NA) is a process of data collection about an expressed or
implied need. It is implied that after the data is collected action is directed towards
addressing the need/deficiency identified. Barbazette (2006) explains that there are
multiple ways of addressing a deficiency, one of which is training. A TNA is
valuable not just to determine the need but also to answer critical questions asked
prior to any 'corrective' intervention: how? why? who? when? where? and what?
These questions guide future planning of training to best suit the needs of the
workforce.
The basics of a NA are the following: the organization's goals, jobs and
competencies, and the individuals to be trained. The organisation is in this case a
health system, defined by the WHO (2007) as an organization, people and actions
whose primary intent is the promotion, restoration or maintenance of health. In
relation to catheterisation and catheter care, the primary, secondary, and tertiary
aspects of healthcare boil down to preventing the need for catheterisation, safe
catheterisation if needed, prevention of related complications and safe living with a
catheter with minimal need for acute hospitalisation. Within this organisation,
nurses have to be competent in inserting, changing, and caring for LTCs. The term
competence is defined by McGrath, MacMillan, & Venka Taraman (1995:251) as
"the degree to which the firm or its subunits can reliably meet or exceed
objectives". The main objective in relation to LTCC is the minimization of
complications and acute hospitalisation. Failure to do so might indicate lack of
competence. This leads to the third pillar of NA, the individuals to be trained. The
individuals investigated in this work are local nurses who come into contact with
patients with LTCs. A TNA is to be carried out to judge if training is indicated and
if so, how to go about planning and conducting it.
15
2.3.1 Training needs assessment
A distinction between needs assessment and needs analysis should be made as
authors such as Kaufmann (in Holton, Bates & Naquin, 2000) state that these are
erroneously being used synonymously. A needs assessment has three main
purposes: to identify gaps between current and desired practice; to prioritise the
gaps; and to select the most important ones to address. A needs analysis is a
process by which one analyses the causes of the gaps.
According to Knowles (in Grant, 2002) the necessity to learn and the identification
of learning needs are fundamental to self-directed learning. Grant (2002) further
asserts that for education to link to a change in practice, a NA has to be conducted.
Having said this, a major disadvantage of TNA cited by Nash (2005) is that at
times the perceived needs of individuals might not reflect themselves in
organisational needs. This gap has to be given due attention if it is to be overcome
and practice be improved in a non threatening way. The ways in which this study
tries to overcome this hurdle are discussed later.
The three broad classes of TNA cited in the literature by Cekada (2010) and
Barbazette (2006) are Organisational Analysis, Task Analysis and Individual
Analysis. Although these have to be considered separately, this TNA falls under
the three classes. Individual Analysis deals with the needs of the individual
professional and lies at a basic level of data collection from the individual
participant. Data is gathered and analysed in the light of the one skill which is
deemed very important in the literature discussed in this chapter, LTCC. This falls
under the cap of Task Analysis as described by Cekada (2010), Brown (2002),
Miller & Osinski (1996). This type of analysis identifies the skills and knowledge
required to perform a task and compares them to a current, research based standard
such as the internationally accredited guidelines mentioned. Ultimately, it is also
16
organisational in that it analyses where training is needed and also, depending on
the tool used, under what circumstances it will be provided.
TNA has been deemed by Green et al (2009), Gould, Kelly, White (2004), Hicks &
Hennessy (1997) as vital in establishing the CPD needs of the healthcare
workforce, in targeting participants and being informed before commissioning
education or training initiatives and in ensuring that the service needs are met. A
major local issue and a need of the service is the reduction of unnecessary and
avoidable hospital admissions due to lack of LTCC knowledge or practice. Chang,
Tseng, Hsiao & Wang (2003) advocate that a difference in training needs might
exist between acute and primary care nurses. In the current study LTCC falls
within the domain of both community/primary health and acute care nurses. As
defined in Chapter 1, the former try to prevent hospitalisation and the latter make
their utmost to keep it as short as possible. With regards to prevention of
hospitalisation due to complications of catheterisation one would mention
education on safety, trauma and infection prevention. The same applies for in-
patients as any of these would signify an extended length of stay.
Various sources of NA exist and the ones which pertain to this work are related to
the researcher's own experiences in direct patient care: mistakes; patients'
feedback; patients' unmet needs; clinical incidents; gap analysis; and external peer
review. The importance of TNA is iterated in the literature when planning or
developing services and clinical practice (Cekada, 2010; Nash, 2005; Brown,
2002). Nash holds that it is crucial to assess the need in relation to both the
professional and the client group affected while Cekada asserts that certain
challenges which an organisation might need to address could require special tools
for conducting the TNA. This is congruent with the reasoning behind the current
TNA whereby, as discussed in the next chapter, a tool had to be purposefully built.
17
2.4 ARCS Theory of Motivation
John Keller (1979) developed the ARCS theory of motivation in learning. It is
based on four major factors being attention, relevance, confidence and satisfaction.
Each contains a set of methods which can be used to motivate learners and can
easily be adapted to the setting of continuing nurse education.
According to Poulsen, Lam, Cisneros and Trust (2008), attention can be gained
through perceptual or inquiry arousal and variability and delves into the surprise
factor, curiosity and sensation seeking. Keller holds that grabbing the learner's
attention is crucial as once they are interested, they will be motivated to learn
further. Relevance, similar to Knowles' theory of Andragogy, points at material or
topics which are relevant to the learner. Once it is of relevance, then motivation
will ensue. If relevance is not conveyed using the learner's language and examples
in their own current practice, then attention will be lost. Confidence relates to the
confidence of the individual that s/he is able to pursue the goal and overcome the
challenges set. Poulsen et al assert that positive reinforcement and timely, relevant
feedback are important to instil confidence. On the other hand, Keller contends
that a very difficult challenge which cannot be overcome might deter the student
and can ultimately also demotivate. Satisfaction is drawn by the outcomes and if
the learners feel good about their achievements, then they will maintain motivation
(Harvey-Cielto et al, 2013). Poulsen et al (2008) also assert that freshly learnt
skills have to be practiced "as soon as possible in as authentic a setting as possible"
(p:3). This theory has been deemed relevant to the current study since it's four
pillars can enlighten the process of analysis and discussion of the data collected
and also act as a guide during the planning of a course of training, if indicated.
18
2.5 Conclusion
A strength in this literature review is the exhaustive search carried out covering
major health databases, online publications, search engines, paper records, and
journals. One major limitation is that there is a plethora of research based material
with regards to LTCC but a dearth in relation to TNAs on the topic. This indicates
a gap in the literature whereby it seems that such TNAs are either not being carried
out or not being published. Maybe the latter is not being done for fear of exposing
possible lack of knowledge in relation to such an important aspect of care.
The best RR was achieved by Mody et al (2010) who found some knowledge
discrepancies in some areas which improved since 2008 although this does not
necessarily reflect clinical practice. Overall the studies reviewed have reported
low RRs, biases and a lack of knowledge. Bhardwaj et al (2010) found compliance
with standards although bias in the data collection process is suspected. One has to
be cautious when interpreting the results. Having said this, all the studies
unanimously reported a knowledge deficit and practice discrepancies.
Chapter 3
The Method
19
3.1 The Research Question, Aim and Objectives
During my years of experience working in Urology I noticed that evidence based
urinary catheter care, despite being so common and widely practiced, is lacking.
Thus, I have decided to embark on this study to answer this question: What are the
learning needs of nurses working with patients with long term urinary catheters?
The aim of this study is to identify areas of knowledge deficit reflecting themselves
in practices which are not research based, possibly outdated and dangerous. If
indicated, the deficit could eventually be addressed. The objectives set to achieve
this aim are the following: to check the knowledge of Maltese nurses in relation to
LTCC; to find out if the nurses have ever attended CPD initiatives related to
LTCC; and to seek their views on issues related to an educational programme
should this be indicated.
3.2 Operational Definitions
The importance of CPD has already been discussed at in the introduction chapter.
In this study, CPD (Continuous Professional Development) is defined as an
important means of lifelong knowledge exchange (University of Stirling, 2008)
which enables nurses to expand and fulfil their potential, equips them "to meet the
needs of patients" (Calman, 2008:2) and allows them to maintain fitness to practice
(NMC, 2010).
The Maltese public health sector (under the MHEC15
) systematically delivers
healthcare through multidisciplinary professionals practicing in preventive,
curative, rehabilitative and end of life services. The Primary Health Care
Department (PHC) delivers Primary Care and focuses on "promotion of health,
15 MHEC - Ministry of Health, the Elderly, and Community Care
20
early diagnosis of disease or disability and prevention of disease" (Anderson et al,
2002:1402). PHC is based in the community and incorporates the Health Centres
(HCs) around the island (a.k.a polyclinics). The HCs also provide limited
secondary care through specialised clinics such as diabetes, well baby,
hypertension, podiatry, physiotherapy and dentistry clinics amongst others.
Anderson et al (2002: 1551) describe Secondary care as "an intermediate level of
healthcare that includes diagnosis and treatment, performed in a hospital...".
Tertiary care refers to " a specialised, highly technical level of healthcare"
(Anderson et al, 2002:1693). Both secondary and tertiary care locally are
delivered within Mater Dei Hospital (MDH). Community care is defined by
Anderson et al (2002:401) as being "concerned with the health of members of a
community" and includes PHC and MMDNA nurses. The latter predominantly
delivers domiciliary nursing in Malta although some overlap with HCs exists. The
National Cancer Institute (2013) states that end of life care "provides physical,
mental, and emotional comfort, as well as social support, to people who are living
with and dying of advanced illness". It is often complex and can be provided in
acute, oncology or community settings through MMDNA or Hospice nurses.
3.3 The Research Design
The research design is deemed by Polit & Hungler (1999) as being the researcher’s
overall plan for answering the research question and thus incorporates important
decisions. These decisions follow accompanied by the rationale behind them.
Several design options were considered when planning this study since this
research aims to identify any knowledge deficit at a point in time. Thus, a
longitudinal design was deemed inappropriate. A dearth of research on the topic
exists both locally and abroad, described by Morse (1996) as immaturity of a
concept. In the social sciences, an immature concept is often researched using an
exploratory descriptive design aiming to define the problem. This design was also
21
inappropriate since the problem has been defined through my years of experience
in Urology. Most problems often occur when procedures are not done properly or
outdated practices are performed. A cross-sectional design was deemed
appropriate in order to obtain a snapshot of the knowledge of the population.
According to Coggon, Rose, & Barker (2012) this design allows gathering of data
and sheds light into aspects of the population which might be impinging on the
current situation and a way to tailor any interventions accordingly. According to
Barratt & Kirwan (2009) cross-sectional studies can be descriptive or analytical but
the majority can include aspects of both. The descriptive aspect of this study was
deemed to be limited on its own and so it was decided to augment it using a mixed
method approach.
Time is a factor in any research study. This is even more so when the study is part
of an academic course of studies. It is important to point out that the design of the
study was somewhat limited by the time factor. On the other hand, a major
strength of this design applicable to the current research is that data collection
happens only once and is not prolonged such as in longitudinal studies. A
weakness is the susceptibility to low response bias which has been addressed later.
Coggon et al (2012) hold that a major challenge of this design is the possible
presence of cohort differences which can give rise to bias. These differences might
arise from the experiences that a particular cohort goes through, for example
community nurses in comparison to acute care nurses. Thus, a representative
sample was recruited and clustering into smaller groups when necessary. To have
a representative sample, Barratt & Kirwan hold that the sample size should be
large enough. This issue was addressed and will be discussed in the section about
sampling in page 23. The authors also discuss data collection methods and suggest
both questionnaires and interviews, another reason to consider a mixed method
approach to this research.
Denzin (2009) refers to the use of multiple data sources as data triangulation, a
mixed method which establishes validity. The major sources of data in this study
22
are: my own observations over the years as a practitioner; the data gathered from a
quantitative questionnaire; and that collected by a focus group interview.
Runciman (2002) and Jick (1979) argue that in a mixed method approach both
qualitative and quantitative aspects complement each other. Halloway & Wheeler
(2011) call this between-method triangulation whereby the data collected by one
method is 'checked' by another. Denzin further states that the combination of
methods used to study the same phenomenon results in a gain of the best of both
worlds (Weinreich, 2006). According to Burke Johnson, Onwuegbuzie (2004) and
Seale (1999) this blending of approaches results in superior research whereby the
biases of different methods cancel each other. The mixed approach yielded a more
complete picture to this NA and allowed for triangulation as described by
Halloway, Wheeler (2011) and Bryman (2006).
3.4 The Research Setting
This study was conducted in different MHEC settings where nurses practice and
care for patients with urinary catheters. These areas included MDH, all the HCs,
MMDNA and Hospice. The latter two are non-governmental organisations funded
by the MHEC. Other health care institutions like the Mental Hospital were
excluded since caring for patients with urinary catheters is quite rare and far apart.
The private setting was not included for three main reasons. Firstly, acquisition of
institutional permissions would be too time consuming; secondly, the majority of
the nurses working in the private sector do so on a part-time basis resulting in most
being given the questionnaire twice possibly compromising the data or the RR; and
finally, the private sector is very small when compared to the MHEC. Nurses in
the sister island of Gozo were also excluded because they had some training on the
subject in question during the time of data collection and this could bias the results.
23
3.5 The Target Population and Sampling Technique
Nurses, as opposed to relatives, carers, patients or doctors were chosen for a
variety of reasons. Firstly and most importantly, nurses are the ones who
insert/change the large majority of urinary catheters and would also be the
recipients of training should this be indicated. Secondly, nurses are the ones who
spend most time with both patients and carers and are in an ideal position to teach
catheter care. Thirdly, since I am a nurse myself, I hoped that they would identify
with me as a colleague and in so doing improve the RR.
The target population is defined by Polit, Tatano, & Hungler (2001) as the entire
population on which the study will focus. The target population of this study
comprises all the nurses employed by the MHEC at the time of data collection
which also comprised a large percentage of those working within the private sector
on a part-time basis. Due consideration was given to the sample to be recruited for
the survey. Barratt & Kirwan (2009) assert that the larger the study the less likely
the results are due to chance alone. On the other hand, investigating the whole
population would have temporal and financial implications and as asserted by
Olsen & St. George (2004), would be neither feasible nor necessary. Gerrish &
Lacey (2010) state that the sample size is usually defined after considering the
resources available and the practicality of obtaining the sample. Due to data
protection reasons access to the names and place of work of nurses employed with
the MHEC was not granted making systematic random sampling impossible.
Access was instead granted to the total numbers of nurses employed in the
different areas within the acute hospital only. A stratified random sample was
chosen from this list after discussion with a statistician. Care was taken to have all
strata within MDH represented and a balance between gender, years of experience,
grade, and speciality (Surgery, Medicine, Specialities, etc) was struck (n = 112).
Both specialist and practice development nurses were excluded since due to the
nature of their job descriptions, their knowledge might be different from that of the
other nurses. All the nurses in the HCs (n = 180) and MMDNA /Hospice nurses (n
24
= 47) were recruited. The last two were grouped to protect the identity of the small
number of Hospice nurses and secondly because, after discussion with their
nursing officer I noticed that their demographics and level of academic education
were similar to that of the MMDNA nurses.
The participants of the focus group were recruited by convenience sampling. One
focus group interview was carried out with PHC nurses who were attending
training. This choice made it easily accessible and guaranteed attendance as they
were all gathered for training. Litosseliti (2007) suggests that one has to strike a
balance between similarity and difference when sampling for a focus interview
since a homogenous group may result in very few diverse opinions. Care was
taken to have a mix of gender, academic levels, and years of experience in the
group. The common element was their area of practice.
3.6 The Research Tools
This research aimed to find out the knowledge and learning needs of nurses related
to LTCC. Field observations and documentary evidence were so not considered.
In the first part of the data collection a survey was used to assess knowledge and
also to gain some insight into their perceptions of training. Rattray & Jones (2007)
assert that this is useful when little is known about the subject. The questionnaire
allows collection of data from different sources in a short period of time (Sproull,
1988), an important aspect since this work had a specific deadline. Consideration
was also given to the findings of Gibson & Hawkins (2004) who found that a
guarantee of anonymity to a homogenous group may produce substantially the
same results by a survey as those produced by interviews, at a much smaller cost.
Face to face interviews allow for direct contact at the expense of anonymity
whereas the collection of surveys through collection boxes guaranteed anonymity
and possibly an increase in participation. Polit & Hungler (1999) suggest that the
interviewer should be a neutral agent, something which I could not be due to the
25
nature of my clinical duties. In face to face interviews there was also the
possibility of interviewer bias where I could have affected the participants'
responses through the interactions between us. Therefore, a survey was deemed to
be more appropriate.
Surveys are often criticised for gathering relatively superficial information.
Although Polit, Beck & Hungler (2001) assert that their broad scope actually
surpasses this disadvantage, I decided that the quantitative data should be enriched
by the qualitative aspect. To achieve triangulation, a focus group interview was
conducted with nurses who had participated in the survey, results of which were
used as the guide for leverage of discussion. This was deemed useful to get an
insight of the emotions, world views, thoughts, and experiences moulding the
participants' perceptions (Litosseliti, 2007) which in turn affect behaviour and
practice. This also provided strength and grounding to the findings of the survey.
In fact, Sewell (2007) holds that the actual words of the participants are harder to
dismiss and consequently the results can be treated with more confidence and
greater illumination.
3.6.1 The questionnaire
The search in the literature provided no suitable tool for data collection and despite
the temporal and financial disadvantages mentioned by Sproull (1988) I decided to
build the tool myself. This process involved a thorough search of the literature and
evidence with regards to the topics to be addressed by the questions in the survey.
Parahoo (2006) holds that a questionnaire is a suitable tool for collecting data on
facts, knowledge, attitudes, beliefs, and opinions. The maintenance of anonymity
of the respondents allowed more freedom and honesty in answering the questions,
something which might not have been achieved by face to face interviews. I also
considered Bowling's (2002) point that questionnaires avoid the risk of interview
bias. Having said this, questionnaires are not without disadvantages and are often
26
criticised for not yielding deep and rich data (Bowling, 2002), of having a low RR
(Polit et al, 2001) and of not offering a chance to clarify any misinterpretations
(Gerrish & Lacey, 2010). These shortcomings were addressed as well. Accuracy
of data was important and so validity testing and a pilot study were conducted and
are discussed later. To enhance richness and depth, the focus group interview was
conducted after the data collection by the questionnaire using the data to lever
discussion. This process provided some clarification and more insight into the
data. The design of the tool was given a great deal of attention. Questionnaires
which are very unpleasant to the eye can hinder the response rate. Sanchez
(1992:206) acknowledges that the design of a tool can "help or hurt the quality of
data collected" but is often overlooked. Hartley, Davies & Burnhill (1977) advised
that spacing of the text should be consistent so as to portray a pleasant look. The
spacing of the questions and text were manipulated to convey a complex structure
as an easy read. A number of different formats were given to colleagues to decide
which one looked less complex and was easy to read through. Minor changes were
implemented upon their suggestions.
The questionnaire (refer to Appendix 1) comprised of 29 items in three sections;
demographic data, knowledge, and views of content, design, delivery, and possible
barriers to attendance of CPD initiatives. It included both open and closed ended
questions. Closed ended questions obtained quantitative data while the open ended
questions generated qualitative data. Cormack (2000) argues that this mix allows
respondents a sense of freedom which ultimately results in generation of rich data.
Mateo, Kirchoff (1991) and Galloway (1997) suggest that questions with a range
of predetermined answers should provide more freedom and thus the option to tick
'others' was added together with space where to list answers which were out of the
categories listed. The English language was deemed appropriate for the tool as the
participants were all qualified nurses who trained and used textbooks written in the
English language. The questionnaire and letters were proof read by a graduate
teacher of the English language.
27
3.6.2 The Focus Group Interview
The questionnaire itself and the data collected were used to guide the focus group
discussion (refer to Appendix 2). Litosseliti (2007) holds that strength in this
method lies in collecting data in a non-threatening way. It might not go in as much
depth as face to face interviews but it captures the multi facets of a situation
(Greenbaum, 1998). This step was important in the present study. Greenbaum
asserts that focus interviews are less time consuming than face to face interviews
although transcription of focus data might take longer. Care was taken to address
the major pitfalls in conducting focus interviews listed by Litosseliti. Firstly, the
size and number of participants, discussed later on together with considerations
related to the environment where the interview took place. Secondly, coverage of
topics which was guaranteed by using the survey and its data. Thirdly is structure
and flexibility which influenced the decision of which type of focus interview was
to be conducted. Punch's (2005) observations aided this decision. A semi
structured approach allowed for the researcher's inexperience in moderating a
focus interview. To avoid interviewer bias, the researcher acted only as a
moderator. This will be discussed further in the section about trustworthiness of
the data.
3.7 Enhancing the quality of the study
In order to enhance the quality of the study various strategies to ensure rigor in the
design have been adopted. These will be explained in detail in terms of the
questionnaire and the focus group as the strategies for these two methods are
somewhat different.
28
3.7.1 Enhancing Validity and Reliability of the Questionnaire
Validity is defined by Polit & Hungler (1999:412) as “the degree to which an
instrument actually measures the variable it seeks to measure”. In order to assure
validity Rattray & Jones (2007) assert that items should be generated from a
number of sources. In the current study the sources included consultation with
experts in the field, extensive review of the literature and guidelines published by
international bodies, and previous experiences by the researcher himself. The
research question, aim and objectives were revisited frequently during the building
of the tool to make sure that the variables remained true to them. To ensure
content validity the building of the questionnaire followed an exhaustive search of
the literature on LTCC. This ensured that the questions addressed both unchanged
knowledge but also that found in current literature. Two experienced colleagues in
Urology also evaluated the tool. Face validity was assessed by the supervisor and
by two nurse managers in charge of the Urology Units. The criteria for choosing
these people to assess validity were relevant training, clinical experience, and
academic qualifications as suggested by Grant & Davis (1997). No changes were
made after their reviews.
Reliability refers to consistency over time where a tool can be relied upon to
consistently give the same result on the condition that the aspect being measured
has not changed (Rebar, Geresch, Macnee & McCabe, 2011). A test-retest was not
carried out due to time constraints and for fear of contamination of the sample.
Should the participants of the test-retest discuss with sample participants and instil
in them queries which they look up, that would bias the survey results. Neuman
(2000) asserts that conducting a pilot study is one of four measures used to
increase reliability. Ogier (1998) describes the pilot study as a preliminary small
scale study which is used to test the tool prior to implementation of the actual study
whilst Robson (2002), Cluett & Bluff (2000) assert that it helps identify problems
which may need changes. A pilot study was conducted with a small number of
nurses (n = 10) within the Urology unit of MDH prior to conduction of the actual
29
study. The aims of the pilot were made explicit both verbally and by a letter of
information (Appendix 3) since Arain, Campbell, Cooper & Lancaster (2010)
sustain that this is important in order to avoid the risk of having it poorly reported.
It has been acknowledged that these nurses have more knowledge of the topic but
otherwise had the same characteristics as the participants of the actual study. For
the reason stated earlier, they were not included in the sample. The aim of the pilot
was to make sure that the questions were understood well (Bowling, 2002) and to
identify questions that needed changes (Polit & Hungler, 1999). Minor changes to
the wording of two questions was suggested.
3.7.2 Enhancing Validity of the Focus Interview
The idea of validity originated in the quantitative paradigm and often refers to
Type 116
and Type 217
errors. In qualitative terms, Silverman (2010) asserts that to
claim validity one has to satisfy certain criteria. One criterion is known as the
Hawthorne effect; my impact and values as a researcher practitioner on the
participants. I acted as a moderator and did not participate in the discussion so as
not to influence it or otherwise affect the contributions of the participants. I
considered myself part of the tool rather than part of the group although I am aware
that my presence, being known to the participants, established and experienced in
the field, might have affected their interactions. Triangulation is also cited by
Silverman. To a certain extent this has been achieved by comparing different types
of data generated by the survey, the interview, and my own experience in Urology.
Due to time constraints respondent validation has not been done in the traditional
way by going back to the participants with the transcribed text so that they validate
it. On the other hand the data generated by the survey, which also belonged to the
participants of the focus group, was used as an interview guide. In a sense, it was
validated and discussed by the respondents.
16 Type 1 error - rejection of the null hypothesis, believing that a statement is true when it is not.
17 Type 2 error - incorrectly supporting the null hypothesis, rejecting a statement which is true.
30
Thorough training of the interviewer and extensive testing of the interview
schedule were deemed unfeasible for this small scale study as they would be too
time consuming. As opposed to face to face interviews, fixed choice answers were
used sparingly as these would not have generated discussion. Every effort has
been made to satisfy the criterion of low-inference descriptors (LIDs), a must in
interviews. Pulkkinen (2003) suggests that the use of verbatim quotes is a
common type of LID. Digitally recording the interviews made it in part possible to
satisfy this need. The quotes were reported accurately thanks to the transcription
from the digital recordings combined to field notes taken during the interviews.
The other LIDs concern transcription and presentation of the extracts.
Transcription has been done meticulously inserting field notes all along. This
made it possible to satisfy the third criterion of using LIDs, the presentation of
extracts. The extracts have been presented as verbatim quotes grounding the
quantitative results.
3.8 Data collection
3.8.1 The Survey
The questionnaires were delivered by hand to the respective nursing officers
(N.Os). This guaranteed anonymity to the respondents. The N.Os were instructed
to give out and collect the tools but not to coerce any of the respondents to return
them. The scope of the research was explained by a letter of information which
accompanied each questionnaire (Refer to Appendix 4). It explained the purpose
of the study and asked participants to participate. Returning an empty tool or not
returning it at all meant that the respondent refused to participate. This avoided
them signing a consent form, exposing their identities, and possibly decreasing
participation. Separate envelopes were provided for them to return the
questionnaire which had to be left with the respective N.Os. I visited the N.Os
three times in all (after 1 week, 2 weeks, and 4 weeks of delivery) and collected the
31
questionnaires. The data collection process lasted six weeks in total. A reminder
was not sent for temporal and financial purposes.
3.8.2 The Focus Group Interview
The aim of the focus session was to give more meaning and grounding to the
quantitative data. The participants were asked to participate in the focus group and
given a letter of information (Refer to Appendix 5). They were informed that the
interview would be digitally recorded and that verbatim responses would be
included in the final write up of the study. Anonymity could not be guaranteed as
all the participants knew each other but confidentiality was given priority. The
participants were assured that nobody except myself would have access to the
recordings/transcripts or their identities and that all the material collected would be
destroyed after the study is finalised. Any queries were clarified with the
researcher beforehand and the consent forms were collected duly signed on the day
of the interview.
A maximum number of six participants was set. Groups larger than this are known
to be difficult to manage resulting in less detail, less depth, and less diverse
accounts being gained. Litosseliti (2007) asserts that this is especially so when the
researcher is inexperienced in the use of the focus interview. Efforts were made
not to allow my inexperience hinder the flexibility I wished to allow during the
sessions. The digital recording made it easier in that topics could be revised during
the discussion and the sequence of the questions changed as indicated by the
discussion. Open statements were used and as suggested by Davies et al (2006). I
only intervened to refocus on the subject, empower those merely listening,
clarifying and giving feedback. Decisions about going in detail into a particular
topic had to be made there and then depending on the topic in question and its
relevance to the clinical picture or the possibility of organising a training initiative.
In the next section, I shall discuss the methods of data analysis.
32
3.9 Data analysis
The quantitative data was analysed using descriptive statistics and presented in
tables and graphs. Inferences about the general population of nurses are not being
drawn as the sample consisted only of nurses practicing in three major areas.
Qualitative analysis depends on the purposes of the study (Punch, 2005) but the
methods used must be systematic, disciplined and transparent. Thematic analysis
of the transcripts was made following a method suggested by Burnard (1991).
The first step was transcription, changing the medium from a digital recording to a
written one. Participant verification was not performed due to time constraints.
Gibbs (2010) holds that this process introduces issues of accuracy, fidelity and
interpretation. One counter measure to the loss of any of the latter was
transcription checking, whereby the transcripts were re-read whilst listening to the
audio recordings. This made sure that the written material was true to the
recording. The handwritten notes were taken whilst checking the time on the
recorder ensuring that they were inserted where they actually belonged in the
transcript. No specialised software was used during transcription for fear of it
being too complicated to master. Windows Media Player® was used to play the
digital recordings. To maintain the respondents' anonymity to the reader, their
identities were listed separately and then each was assigned a code (F1 to F6) by
which they have been cited in the text. Thematic analysis started by first reading
through the transcripts, identifying general themes and listing several subheadings
within them. After rereading and further listing, similar headings were grouped.
Theme checking was omitted due to time constraints. The themes were then
grouped and presented in tables although unfortunately numeric objectivity of the
analysis diminishes richness. Verbatim quotes were used to make up for this. The
results are presented in the following chapter which also discusses the findings of
the focus group interview. A section about the ethical considerations of this study
follows.
33
3.10 Ethical Considerations
Ethical issues have been given due consideration throughout the research process,
from the choice of the subject to publication and dissemination of the results. The
basis of ethical principles in research is protection of human participants from
harm in the form of a breach in privacy, confidentiality, anonymity, or coercion to
participate.
Ethical approval has been granted by the Faculty of Education Research Ethics
Committee (FREC) and the University of Malta Research Ethics Committee
(UREC) (Refer to Appendix 6). Institutional permissions for data collection have
been granted by the relevant authorities: The Director Nursing MDH (Appendix 7),
the Director of the Elderly and Community Care (Appendix 8), the Data protector
of Primary Health Care (Appendix 9). The nursing managers were contacted and
explanations about the research given prior to the data collection. In order to
respect the participant’s right to make informed, voluntary decisions about study
participation (Polit, Tatano, & Hungler, 2001), a letter of information was
delivered to every participant in which I introduced myself, invited the participant
to take part in the study, and described what it entailed (Refer to Appendices 4 and
5 respectively).
With regards to the survey, the signing and return of a consent form would result in
loss of anonymity of the participants to the researcher and a possibility of a poor
response. It was made clear in the letter of information that a filled and returned
questionnaire was meant to signify agreement to participate. Empty or unreturned
questionnaires signified unwillingness to participate. The letter of information
made clear that they could refuse or withdraw participation at any time without
penalty. Participants of the focus interview signed a consent form, supplied in
duplicate for their own records which stated that they could refuse participation at
any time without penalty, that only the researcher would have access to their
34
data/identity, and that all would be destroyed after the study is finalised. They
were instructed that the interviews would be digitally recorded and that verbatim
quotes would be included in the text.
Anonymity could only be guaranteed to the participants of the survey. The
questionnaires were all identical bearing no marks or codes. In instances where a
combination of years of experience, gender, grade, or place of work could possibly
identify individuals, bracketing with other, larger groups was performed.
Anonymity could not be guaranteed to the focus participants as they were all
known to the researcher and themselves. In turn, confidentiality was guaranteed
by following suggestions by Frankfort-Nachmias, Nachmias (1996), Mateo &
Kirchoff (1991). The letter of information explained that verbatim quotes would
be included in the study after the respondents were assigned a code so that none of
them could be identified. Only the researcher had access to the data and
confidentiality was also meticulously respected in the write up of the
findings/discussion. Access to the results was guaranteed. A bound copy will be
placed in the Library of the UOM and a soft copy forwarded to those who desire it.
The next chapter will present the findings and discuss them in relation to the local
context.
Chapter 4
The findings
38
4.1 Introduction
The data collected by the questionnaire consists of both qualitative and quantitative
data. Each question was analysed and some data is presented in raw figures.
Along the chapter percentages have been rounded to the nearest value and
statistical tests carried out presented accordingly. Themes emerging from the
focus interview are presented towards the end of the chapter. The following
section presents a demographic overview of the sample followed by the section
regarding the knowledge of catheterisation and catheter care. Data about CPD is
presented in the last section.
4.2 Response rate and demographic data
Table 4.1 below presents the data of the population, sample, and RR. The
Orthopaedic and Surgical nurses were clustered together as both fall within the
specialism of surgery.
Setting Population Sample Valid replies Valid replies %
MMDNA 40 40 3 7.5
PHC 180 180 71 39.4
Hospice 7 7 6 85.7
A&E 58 58 13 22.4
Surgical 136 70 79
87.8 Orthopaedic 39 20
Medical 137 86 72 90
Adult Intensive Care 66 35 21 60
Totals 663 496 (75% of population) 265 53% response rate
Table 4.1: Response rate.
The sample consisted of 496 participants (75% of the total population of interest -
n = 663). Two hundred and sixty five (n = 265) questionnaires were returned duly
filled yielding a response rate of 53%. A decision was taken not to sample the
39
MMDNA, PHC and Accident and Emergency (A&E). Since these nurses are
either often in contact with the most problematic catheterisations or otherwise
involved in the care of such patients prior to admission to hospital, they were
deemed more important and were "over-sampled". This term has been used by
Pascoe et al (2007) when they recruited all the nurses of certain geographical areas
which were of particular interest to them, as those mentioned previously are to this
study. The Surgical and Orthopaedic wards were clustered together as they are
both essentially wards caring for patients who will undergo or have undergone
some sort of surgery. The Medical wards rendered the highest response rate (90%)
whilst the lowest was yielded by the MMDNA (7.5%).
The sample consisted of Staff and Enrolled Nurses holding various pre and post
registration qualifications, practicing in three major settings: the community
(Hospice, MMDNA and PHC), Emergency care (MDH Accident and Emergency),
and the acute wards (MDH Wards). The whole population of both Community and
A&E was included as they are often in contact with the most problematic
catheterisations. The least represented were those with less than three years of
experience (n = 28) and the most represented were those with sixteen or more
years of experience (n = 100) half of which practice in PHC. Quan (2012)
advocates that most nurses move from a practice setting to the other to 'fine-tune'
their career or to keep it interesting. This might apply to the current setting
whereby the demographic data shows that as experience increases (>4 years of
experience) nurses start to shift towards the community settings. The majority of
the respondents were females (n = 161; 61%) compared to males (n = 103; 39%).
Gender data was missing for one respondent. As is illustrated by Table 4.2
overleaf, the majority of females practice in PHC (n = 61; 23%) whilst the majority
of male respondents in Surgical/Orthopaedic wards (n = 51; 19%). No male nurses
practice in the Hospice setting and no males from MMDNA replied.
40
Setting
Tot
al
Med
ical
Sur
g/O
rtho
Inte
nsiv
e
A&
E
MM
DN
A
PH
C
Hos
pice
Gender
Female 42 28 13 8 3 60 6 160
Male 30 51 8 5 0 10 0 104
No response 0 0 0 0 0 1 0 1
Total 72 79 21 13 3 71 6 265
Table 4.2: Gender and practice setting of the respondents.
As illustrated in Table 4.3 overleaf, the grade of Staff Nurse (SN) was the
commonest grade (n = 199). The gross numeric discrepancy between the grades of
EN18
and SN19
is not due to a sampling defect. During the last decade there has
been a major shift of ENs to SNs. Most ENs completed the conversion course
organized by the Directorate for Nursing Services and Standards, Malta. The aim
of the course was harmonization of the academic status of the profession in
keeping with the standards set by the European Union. Academically, the Diploma
in Nursing Studies is most prevalent (n = 69) whilst the least common is the
Master's degree (n = 11). There were different Master's degrees amongst which
were Health Science, Health Services Management, and Youth and Community
Nursing. Data for one respondent was missing. One respondent reported having a
certificate in Ophthalmic Nursing and another a PG Diploma in Nutrition and
Dietetics. No doctoral degrees were reported although the author is aware that
more than six PhDs are being pursued by SNs practicing within the clinical setting.
Data for one respondent is missing.
18 Enrolled Nurse (EN): Formerly known as State Enrolled Nurse, this grade was the most common
grade in the nursing profession. An EN could qualify traditionally or otherwise, since the shift of
nursing education into University, by obtaining a Certificate in Nursing Practice. 19
Staff Nurse (SN): Formerly known as State Registered Nurse. As the EN, an SN can have
traditional education or otherwise, since the shift into tertiary education, a Diploma or Degree in
Nursing. The possibility of following a Conversion Course from an EN to an SN is also possible.
41
Qualifications
Tot
al
EN
Tra
ditio
nal
EN
CN
P
SN
Tra
ditio
nal
SN
Con
vers
ion
SN
Dip
lom
a
SN
BS
c
SN
MS
c
Years of Experience
< or = to 1 year 0 0 1 0 5 7 0 13
2-3 yrs 0 0 1 1 7 6 0 15
4-9 yrs 1 1 1 6 27 18 5 59
10-15 yrs 0 8 6 23 21 15 4 77
> or = to 16yrs 9 2 39 32 9 7 2 100
Total 10 11 48 62 69 53 11 264
Table 4.3: Qualifications and years of experience of the respondents.
With regard to years of experience, the least represented category was nurses with
less than or equal to (< =) 1 year of experience (n = 13). The most prevalent was
(> =) 16 years or more (n = 100). Table 4.4 shows that those with the least
experience were mostly practicing in the acute setting. This trend starts to shift out
to the community by 4-9 years of experience and above. The majority of most
experienced respondents was prevalent in PHC, followed by the Medical, Surgical
and Orthopaedic wards. The least present were in A&E and MMDNA although
these had the least RR and therefore this might not reflect a true picture. Three
large settings were not included, namely mental health, long term care, and the
oncology hospital as these seem to be the least problematic with regards to the
topic.
42
Setting
Total Medical Surgical &
Ortho. Intensive A&E MMDNA PHC Hospice
Years of Experience
< or = to 1 year 4 3 4 2 0 0 0 13
2-3 yrs 7 3 2 3 0 0 0 15
4-9 yrs 25 13 6 5 0 8 2 59
10-15 yrs 18 34 5 2 3 13 2 77
> or = to 16yrs 18 26 4 1 0 49 2 100
Total 72 79 21 13 3 70 6 264
Table 4.4: Setting and years of experience of respondents.
4.3 Statistical analysis
Williams (2012) suggests that when a questionnaire contains only categorical data,
there is no need to check distribution and normality. This was discussed with a
local experienced statistician who also provided the same advice. The statistical
test mainly used was the Pearson's Chi Square Test. When this test's assumptions
were violated, as suggested by Weaver (2009), I conducted and reported the
Fisher's Exact Test. Often times minimal differences were noted in the results of
both tests but as suggested by the statistician, the Fisher's Exact was reported.
When a significant association was found (p = <0.05) the effect size has been
reported. Yatani (2012) suggests that effect size is usually calculated using the
Cohen (1988) criteria. These criteria stipulate that a p value of 0.10 denotes a
small effect; 0.30 a medium effect; and 0.50 or more a large effect. Pallant (2007)
asserts that when tables are larger than 2x2 (like the ones in question) one has to
report the Cramer's V measurement, which takes into account the degrees of
freedom. This has been done in all tables. The effect size reported has been
calculated using the criteria reproduced overleaf as suggested by Pallant
(2007:217).
43
1. Subtract 1 from the number of categories in the row variable (R-1).
2. Subtract 1 from the number of categories in the column variable (C-1).
3. Pick the smaller value which results.
4. If (R-1 or C-1) = 1 - Small effect: 0.01; Medium: 0.30; Large: 0.50
5. If (R-1 or C-1) = 2 - Small effect: 0.07; Medium: 0.21; Large: 0.35
6. If (R-1 or C-1) = 3 - Small effect: 0.06; Medium: 0.17; Large: 0.29
The level of association is often reported using the criteria in Table 4.5 below
(reproduced from the CHASS20
page of the University of Toronto). Cramer's V is
the statistic used to measure the strength of an association since this is always
indicated when tables are larger than 2x2. In 2x2 tables one would use the Phi
statistic but there are no such tables in this chapter.
Level of Association
Verbal Description Comments
0.00 No Relationship Knowing the independent variable does not reduce the number of errors in predicting the dependent variable at all.
.00 to .15 Not generally useful Not acceptable
.10 to .20 Weak Minimally acceptable
.20 to .25 Moderate Acceptable
.25 to .30 Moderately Strong
.30 to .35 Strong
.35 to .40 Very Strong
.40 to .45 Worrisomely Strong Either an extremely good relationship or the two variables are measuring the same concept
.45 to .99 Redundant The two variables are probably measuring the same concept.
1.00 Perfect Relationship If we the know the independent variable, we can perfectly predict the dependent variable.
Table 4.5 - Description of level of association - University of Toronto.
20 CHASS - Computing in the Humanities and Social Sciences Department, University of Toronto,
2010.
44
4.4 Insertion or change of urethral catheter
In response to the following question (Q5): "In your area of practice, who inserts
or changes an indwelling urethral catheter?", it transpired that the majority of
catheters were inserted or changed by nurses (n = 219). As one can notice in
Table 4.6 below, the two settings which differed in relation to this question were
PHC and Hospice.
Setting
Tot
al
Med
ical
Sur
g &
Ort
ho
Inte
nsiv
e
A&
E
MM
DN
A
PH
C
Hos
pice
Who inserts?
Nurses 72 79 21 13 3 30 1 219
Doctors 0 0 0 0 0 2 0 2
We don't insert 0 0 0 0 0 37 5 42
Total 72 79 21 13 3 69 6 263
Table 4.6: Who inserts the catheter by practice setting.
Those who ticked the third option in Q5 (We do not insert or change urethral
catheters) were asked to comment further on why they do not do this procedure.
The comments have been grouped under broader themes and presented overleaf.
Theme Number of responses
Not or rarely done at Health Centre 10
Patients referred to MMDNA 6
Not in job description or Not in our specialization 4
PHC Policy 3
Not trained 3
Needs expertise 1
Table 4.7: Comments on why they do not insert urinary catheters.
45
When asked, "Within your institution/organization, who performs catheter care on
a daily basis?" (Q11) the majority of respondents chose Nurses only, or otherwise
Nurses and others (excluding 'Informal carers' or 'Others'). Seventeen respondents
chose a combination of nurse, carer, and informal carer (family, etc). The results
are presented in Graph 4.1 below.
Graph 4.1: Individuals who perform catheter care.
4.5 Knowledge of catheterisation
Four main questions tested knowledge related to catheterisation (Q6, Q7, Q8, and
Q9). They focused on important aspects of the technique; lubrication, anaesthesia,
patient comfort, trauma, and control of infection. Four statements within Q6
measured knowledge of when to catheterise and choice of catheter. Specialized
catheters used almost exclusively within Urology were excluded.
0
20
40
60
80
100
120
Nurses Nurses and others
Nurses OR Carer and
Informal carer
Others - incl Nursing students
All No reply
46
The data presented in this section has been gathered by the questions relating to
knowledge of the technique of catheterisation. These were statements and the
respondents had to tick "Agree", "Disagree" or "I don't know" per statement. Since
I was after knowledge both "I don't know" and wrong answers were taken to
indicate lack of knowledge.
Q6a: Is the bladder management of choice for neurological conditions.
Q6b: Is definitely the best option for incontinent patients.
Q6e: The biggest size is the best option.
Q6f: A 12Fr sized catheter is usually the best option for both sexes.
Years of experience
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
<=
1 y
r
2-3
yrs
4-9
yrs
10-1
5 yr
s
>=
16y
rs
Q6a
wrong 9 9 42 50 66 176 - 67.4%
Assumptions of Chi-square test violated
0.86 right 4 6 16 27 32 85 - 32.6%
Q6b
wrong 2 7 26 32 31 98 - 37.7%
Assumptions of Chi-square test violated
0.17 right 11 8 32 45 66 162 - 62.3%
Q6e
wrong 1 4 12 21 19 57 - 21.9%
Assumptions of Chi-square test violated
0.52 right 12 11 46 56 78 203 - 78.1%
Q6f
wrong 4 8 27 39 51 129 - 49.6%
0.64
1
260
0.098
0.098
right 9 7 31 38 46 131 - 50.4%
Table 4.8: Association between years of experience and
knowledge of catheterisation.
47
As one can see in Table 4.8 above, knowledge was lacking in 22% - 57% of
answers. A Chi-square test for independence was conducted to see if there were
any associations between years of experience and knowledge. When the
assumptions concerning the minimum expected cell frequency were violated, the
Fisher's Exact Test was conducted. Since the p values are all >0.05 (Q6a p = 0.86;
Q6b p = 0.17; Q6c p = 0.52; Q6a p = 0.64) one assumes that there was no
significant association between knowledge and years of experience. The values for
Phi and Cramer's V are the same. A reason for this is given in the StatPac
Statistics Manual (2013) which states that in tables larger than two-by-two the Phi
statistic may be interpreted exactly like the Cramer's V. On the other hand, a
statement by The Department of Economics within IOWA University (2013) states
that since the Phi statistic "is only appropriate for 2x2 tables" one should use
Cramer's V instead.
Qualification
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
EN
Tra
ditio
nal
EN
CN
P
SN
Tra
ditio
nal
SN
Con
vers
ion
SN
Dip
lom
a
SN
BS
c
SN
MS
c
Q6a
wrong 6 9 32 40 46 35 8 176 - 57.4%
Assumptions of Chi-square test violated
0.967 right 4 2 15 21 23 17 3 85 - 32.6%
Q6b
wrong 6 3 12 22 34 18 3 98 - 37.7%
Assumptions of Chi-square test violated
0.120 right 4 8 35 38 35 34 8 162 - 62.3%
Q6e
wrong 4 3 9 11 12 16 2 57 - 21.8%
Assumptions of Chi-square test violated
0.422 right 6 9 38 49 57 36 9 204 - 79.2%
Q6f
wrong 3 6 25 35 34 20 6 129 - 49.4%
Assumptions of Chi-square test violated
0.393 right 7 6 22 25 35 32 5 132 - 50.6%
Table 4.9: Association between qualification and knowledge of catheterisation.
48
The same tests have been conducted and no significant association was been found
between knowledge of catheterisation and academic qualification (Q6a p = 0.96;
Q6b p = 0.12; Q6e p = 0.42; Q6f p = 0.39). As one can see in Table 4.10 overleaf,
a significant association has been indicated between knowledge and setting in Q6e
(p = 0.001) and Q6f (p = 0.002). The effect size, according to the modified Cohen
criteria explained previously, in both Q6e and Q6f is small.
Setting
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
Med
ical
Sur
gery
& O
rtho
Inte
nsiv
e
A&
E
MM
DN
A
HC
s
Hos
pice
Q6a
wrong 54 45 12 7 3 51 4 176 - 67.4%
Assumptions of Chi-square test violated
0.060 right 16 34 9 6 0 18 2 85 - 32.6%
Q6b
wrong 30 32 9 2 1 23 1 98 - 37.7%
Assumptions of Chi-square test violated
0.475 right 40 47 12 11 2 45 5 162 - 62.3%
Q6e wrong 26 17 7 2 0 5 0 57 - 21.8%
0.001
0.001 right 44 62 14 11 3 64 6 204 - 78.2%
Q6f wrong 39 39 8 0 2 39 2 129 - 49.4%
0.006
0.002 right 31 40 13 13 1 30 4 132 - 50.6%
Table 4.10: Association between practice setting and knowledge of catheterisation.
A question testing broader knowledge (Q6a) was answered correctly by 32% of
respondents who were deemed be more knowledgeable or otherwise got it right
due to chance. Sixty two percent of respondents had some awareness about less
invasive techniques used to manage incontinence (Q6b), investigated by Pfisterer
et al (2007). These were not taken on by this study. Less positive were results to
Q6e and Q6f, relating to catheter size whereby 21% and 49% (respectively)
answered wrongly. This is a basic but crucial element which can have serious
repercussions like pain, trauma, bladder over activity and leakage (Theriault,
49
Ward-Smith, and Soper, 2012; Wilson, 2011). Overall the questions which had the
most wrong answers were Q6a and that with the least was Q6e. High percentages
within the wrong answers prevail irrespective of years of experience, setting or
qualification. As seen in Table 4.11 overleaf, fifteen respondents attended some
sort of CPD course related to the topic. Table 4.12 overleaf illustrates the practice
setting compared to responses to Q16.
Q6wrong
Total q6a q6b q6c q6d q6e q6f q6g q6h q6i
Q16: Have you pursued any CE courses related to
urethral catheterisation/catheter
care?
No CPD 42 20 4 20 5 30 5 2 15 52
Yes CPD 9 3 2 4 0 9 0 0 2 15
Table 4.11: Knowledge of catheterisation by attendance to related CPD.
Q16: Have you pursued any CE courses related to urethral catheterisation/catheter care?
NO YES Total
Practice setting
Medical 68 2 70
Surgical & Orthopaedic
74 5 79
Adult Intensive Care
20 1 21
A&E 13 0 13
MMDNA 1 2 3
PHC 56 15 71
Hospice 6 0 6
Table 4.12: Attendance to related courses by practice setting.
50
4.6 Technique - Patient comfort and Trauma
The major issues when considering the technique were control of infection, patient
comfort, and trauma. Control of infection will be dealt with in the next section.
Knowledge of the lubricant used was investigated. This has implications on
comfort, trauma and infection. Females comprised the majority who answered
incorrectly, either because they were the majority within the sample or because of
the lack of training they admitted to. A strong association was reported between
gender and Q7a (Male patients - A water based gel with anaesthetic (ex:
Instillagel)) and Q7d (Female patients - A water based gel without anaesthetic (ex:
KY Jelly/Aquagel)). Forty three percent wrong answers prove that anaesthetic is
only used for males and a non anaesthetic containing gel for females. This is not
ideal. Unless contraindicated, females benefit from the anaesthetic based gel
which has properties missing in the water based gel. Secondly, the lubricant used
for catheterisation has to be sterile. The water based gel can never be so due to the
way the container has to be pierced open. The same results emerged in years of
experience, qualification and practice setting, indicating lack of knowledge evident
across the sample. Nurses also seem unaware of how to apply the local anaesthetic
gel (Q8 - 67% wrong answers). This is demonstrated on the inner packet of the
currently supplied product as its improper use might cause discomfort, trauma
(Devine, 2003), and possibly infection (Mangnall, 2012; Sperling, Lummen, and
Rubben, 2005; Bardsley, 2005; de Courcy-Ireland, 1993; Stickler and Chawla,
1987). When asked about the position of the penis during catheterisation (Q9 -
38% wrong; n = 101) it was indicated that there is a strong need for rectification of
the situation.
On the whole, knowledge was lacking in 27% - 71% of respondents. The Chi-
square test for independence (with Yates Continuity Correction) was carried out
for all questions. Where the assumptions were violated, the Fisher's Exact Test
was applied. Table 4.13 overleaf illustrates the significant but weak association
between gender and Q7a (p = 0.01; Cramer's V 0.17), Q7d (p = 0.02; Cramer's V
51
0.15), and Q9 (p = 0.02; Cramer's V 0.15). Table 4.14 shows that there was no
significant association between years of experience and knowledge whereas there
was a significant but moderate association between qualification and Q7b (p =
0.03; Cramer's V 0.23). The other questions and qualification did not have a
significant association as demonstrated in Table 4.15.
Gender
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
Fem
ale
Mal
e
Mis
sing
Q7a wrong 52 20 1 73 - 27.9%
Assumptions of Chi-square test violated
0.174 0.012 right 107 82 0 189 - 72.1%
Q7b wrong 49 26 0 75 - 28.6%
Assumptions of Chi-square test violated 0.573 right 110 76 1 187 - 71.4%
Q7c wrong 90 56 0 146 - 55.7%
Assumptions of Chi-square test violated 0.602 right 69 46 1 116 - 44.3%
Q7d wrong 78 35 0 113 - 43.1%
Assumptions of Chi-square test violated
0.155 0.025 right 81 67 1 149 - 56.9%
Q7e wrong 48 25 0 73 - 27.9%
Assumptions of Chi-square test violated 0.565 right 111 77 1 189 - 72.1%
Q7f wrong 44 38 0 82 - 31.3%
Assumptions of Chi-square test violated 0.176 right 115 64 1 180 - 68.7%
Q8 wrong 112 63 1 176 - 67.2%
Assumptions of Chi-square test violated 0.256 right 47 39 0 86 - 32.8%
Q9 wrong 69 31 1 101 - 38.5%
Assumptions of Chi-square test violated
0.152 0.026 right 90 71 0 161 - 61.5%
Table 4.13: Association between gender and knowledge of the technique.
52
Years of Experience
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
<=
1 y
r
2-3
yrs
4-9
yrs
10-1
5 yr
s
>=
16y
rs
Q7a wrong 6 7 12 25 22 72 - 27.6%
Assumptions of Chi-square test violated 0.071 right 7 8 46 52 76 189 - 72.4%
Q7b wrong 4 7 16 25 23 75 - 28.7%
Assumptions of Chi-square test violated 0.357 right 9 8 42 52 75 186 - 71.3%
Q7c wrong 9 12 31 43 51 146 - 55.9%
0.267 4 261 0.141 0.141 right 4 3 27 34 47 115 - 44.1%
Q7d wrong 6 11 26 33 37 113 - 43.3%
0.144 4 261 0.162 0.162 right 7 4 32 44 61 148 - 56.7%
Q7e wrong 4 7 15 23 24 73 - 28%
Assumptions of Chi-square test violated 0.471 right 9 8 43 54 74 188 - 72%
Q7f wrong 4 9 21 25 23 82 - 31.4%
Assumptions of Chi-square test violated 0.059 right 9 6 37 52 75 179 - 68.6%
Q8 wrong 7 9 39 49 71 175 - 67%
Assumptions of Chi-square test violated 0.518 right 6 6 19 28 27 86 - 33%
Q9 wrong 5 7 19 29 40 100 - 38.3%
Assumptions of Chi-square test violated 0.828 right 8 8 39 48 58 161 - 61.7%
Q12b wrong 10 12 43 56 66 187 - 71.4%
Assumptions of Chi-square test violated 0.686 right 3 3 15 20 34 75 - 28.6%
Q12f wrong 5 7 25 25 36 98 - 37.4%
Assumptions of Chi-square test violated 0.701 right 8 8 33 51 64 164 - 62.6%
Table 4.14: Association between years of experience
and knowledge of the technique.
53
Qualifications
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
EN
Tra
ditio
nal
EN
CN
P
SN
Tra
ditio
nal
SN
Con
vers
ion
SN
Dip
lom
a
SN
BS
c
SN
MS
c
Q7a wrong 5 5 10 18 14 19 2 73 - 27.9%
Assumptions of Chi-square test violated
0.164 right 5 7 37 43 55 33 9 189 - 72.1%
Q7b wrong 7 3 9 18 16 20 2 75 - 28.6%
Assumptions of Chi-square test violated
0.236 0.033 right 3 9 38 43 53 32 9 187 - 71.4%
Q7c wrong 6 8 21 36 34 35 6 146 - 55.7%
Assumptions of Chi-square test violated
0.297 right 4 4 26 25 35 17 5 116 - 44.3%
Q7d wrong 7 5 16 29 24 28 4 113 - 43.1%
Assumptions of Chi-square test violated
0.143 right 3 7 31 32 45 24 7 149 - 56.9%
Q7e wrong 6 3 9 17 15 21 2 73 - 27.9%
Assumptions of Chi-square test violated
0.055 right 4 9 38 44 54 31 9 189 - 72.1%
Q7f wrong 6 3 11 16 20 23 3 82 - 31.3%
Assumptions of Chi-square test violated
0.122 right 4 9 36 45 49 29 8 180 - 68.7%
Q8 wrong 8 9 34 41 47 31 6 176 - 67.2%
Assumptions of Chi-square test violated
0.731 right 2 3 13 20 22 21 5 86 - 32.8%
Q9 wrong 4 8 19 21 23 22 4 101 - 38.5%
Assumptions of Chi-square test violated
0.475 right 6 4 28 40 46 30 7 161 - 61.5%
Q12b wrong 7 9 32 43 49 39 8 187 - 71.4%
Assumptions of Chi-square test violated
0.968 right 3 2 16 18 20 13 3 75 - 28.6%
Q12f wrong 3 3 20 22 23 22 5 98 - 37.4%
Assumptions of Chi-square test violated
0.884 right 7 8 28 39 46 30 6 164 - 62.6%
Table 4.15: Association between qualification and knowledge of the technique.
Following is Table 4.16 which shows that there is a significant association between
Practice setting and Q7, Q9, Q12b, and Q12f. For these, the p value was always
<0.05. Effect size is small for all associations. The level of association for Q7d
(Cramer's V 0.38), Q7e (Cramer's V 0.45), and Q12f (Cramer's V 0.33) is strong
54
while that for Q9 (Cramer's V 0.26) and Q12b (Cramer's V 0.27) is moderately
strong. According to the criteria presented in Table 4.5, the others are not useful.
Practice setting
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
Med
ical
Sur
gica
l
& O
rtho
p
Crit
ical
A&
E
MM
DN
A
PH
C
Hos
pice
Q7a
wrong 34 18 9 0 0 11 1 73 - 27.9%
Assumptions of Chi-square test violated
0.000
0.000 right 36 61 12 13 3 59 5 189 - 72.1%
Q7b
wrong 40 16 11 0 0 7 1 75 - 28.6%
Assumptions of Chi-square test violated
0.000 0.000 right 30 63 10 13 3 63 5 187 - 71.4%
Q7c
wrong 53 39 14 5 1 30 4 146 - 55.7%
Assumptions of Chi-square test violated
0.002 0.001 right 17 40 7 8 2 40 2 116 - 44.3%
Q7d
wrong 50 23 13 4 1 20 2 113 - 43.1%
Assumptions of Chi-square test violated
0.388 0.000 right 20 56 8 9 2 50 4 149 - 56.9%
Q7e
wrong 41 13 9 0 0 9 1 73 - 27.9%
Assumptions of Chi-square test violated
0.457 0.000 right 29 66 12 13 3 61 5 189 - 72.1%
Q7f wrong 49 17 11 0 0 4 1 82 - 31.3%
Assumptions of Chi-square test violated
0.572 0.000 right 21 62 10 13 3 66 5 180 - 68.7%
Q8 wrong 43 48 15 8 1 56 5 176 - 67.2%
Assumptions of Chi-square test violated
0.085 right 27 31 6 5 2 14 1 86 - 32.8%
Q9 wrong 38 21 8 1 1 29 3 101 - 38.5%
Assumptions of Chi-square test violated
0.262 0.003 right 32 58 13 12 2 41 3 161 - 61.5%
Q12b wrong 60 59 17 8 1 38 4 187 - 71.4%
Assumptions of Chi-square test violated
0.279 0.001 right 11 19 4 5 2 32 2 75 - 28.6%
Q12f wrong 38 33 11 1 0 15 0 98 - 37.4%
Assumptions of Chi-square test violated
0.330 0.000 right 33 45 10 12 3 55 6 164 - 62.6%
Table 4.16: Association between practice setting and knowledge of the technique.
55
4.7 Control of infection
The questions in this section tested knowledge of prevention of CAUTI (Q12,
Q14) including potential entry points of infection (Q10) and signs and symptoms
of CAUTI (Q13). Tables 4.17 through to 4.22 illustrate the results of questions 10,
12, and 14 in relation to practice setting, qualifications, and years of experience.
Setting
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
Med
ical
Sur
g &
Ort
ho
Inte
nsiv
e
A&
E
MM
DN
A
PH
C
Hos
pice
Q10a wrong 26 23 5 4 2 44 2 106 - 40.5%
0.296 0.000 right 44 56 16 9 1 26 4 156 - 59.5%
Q10b wrong 37 41 12 7 2 44 1 144 - 55%
Assumptions of Chi-square test violated
0.436 right 33 38 9 6 1 26 5 118 - 45%
Q10c wrong 26 25 9 3 1 39 1 104 - 39.7% Assumptions of
Chi-square test violated
0.221 0.042 right 44 54 12 10 2 31 5 158 - 60.3%
Q10d wrong 28 33 9 4 1 47 3 125 - 47.7% Assumptions of
Chi-square test violated
0.242 0.012 right 42 46 12 9 2 23 3 137 - 52.3%
Q10e wrong 21 26 4 5 1 21 2 80 - 30.5%
Assumptions of Chi-square test violated
0.907 right 49 53 17 8 2 49 4 182 - 69.5%
Q10f wrong 34 36 10 4 1 38 2 125 - 47.7%
Assumptions of Chi-square test violated
0.748 right 36 43 11 9 2 32 4 137 - 52.3%
Q12a wrong 14 26 4 1 0 17 1 63 - 24%
Assumptions of Chi-square test violated
0.330 right 57 52 17 12 3 53 5 199 - 76%
Q12c wrong 14 13 6 4 0 11 2 50 - 19.1%
Assumptions of Chi-square test violated
0.540 right 57 65 15 9 3 59 4 212 - 80.9%
Q12d wrong 21 19 9 1 1 28 3 82 - 31.3%
Assumptions of Chi-square test violated
0.093 right 50 59 12 12 2 42 3 180 - 68.7%
Q12e wrong 34 36 12 4 3 26 1 116 - 44.3%
Assumptions of Chi-square test violated
0.144 right 37 42 9 9 0 44 5 146 - 55.7%
56
Q12g wrong 40 37 9 2 0 36 2 126 - 48.1%
Assumptions of Chi-square test violated
0.074 right 31 41 12 11 3 34 4 136 - 51.9%
Q12h wrong 29 10 5 1 0 9 1 55 - 21%
0.310 0.001 right 42 68 16 12 3 61 5 207 - 79%
Q12i wrong 46 29 14 1 0 22 2 114 - 43.5%
0.352 0.000 right 25 49 7 12 3 48 4 148 - 56.5%
Q12j wrong 48 29 11 1 1 11 1 102 - 39.9%
0.431 0.000 right 23 49 10 12 2 59 5 160 - 61.1%
Q12k wrong 61 60 17 11 0 46 4 199 - 76% Assumptions of
Chi-square test violated
0.266 0.008 right 10 18 4 2 3 24 2 63 - 24%
Q12l wrong 62 51 18 5 2 34 4 176 - 67.2%
0.351 0.000 right 9 27 3 8 1 36 2 86 - 32.8%
Table 4.17: Association between practice setting and
knowledge of infection control.
In Table 4.17 one can see that 8 items about knowledge of infection control were
found to be significantly associated to where the respondents practice. Q10c and
Q10d (Cramer's V 0.22; 0.24) show a moderate association; Q10 and Q10k
(Cramer's V 0.29; 0.26) show a moderately strong association; Q10h, Q10i and
Q10l (Cramer's V 0.31; 0.35; 0.35) show a strong association; Q10j (Cramer's V
0.43) shows an extremely strong relationship. Table 4.18 overleaf shows a
significant association between practice setting and Q14 except for Q14a (p =
0.10). The Cramer's V readings show that the associations range from moderate
(0.20 - 0.25) to extremely strong (0.40 - 0.45)
57
Setting
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
Med
ical
Sur
g &
Ort
ho
Inte
nsiv
e
A&
E
MM
DN
A
PH
C
Hos
pice
Q14a wrong 20 16 4 0 0 22 0 62 - 23.6%
Assumptions of Chi-square test violated
0.107 right 50 63 17 13 3 49 6 201 - 76.4%
Q14b wrong 28 20 8 0 1 16 2 75 - 28.5%
Assumptions of Chi-square test violated
0.217 0.026 right 42 59 13 13 2 55 4 188 - 71.5%
Q14c wrong 45 19 10 2 0 9 0 85 - 32.3%
Assumptions of Chi-square test violated
0.461 0.000 right 25 60 11 11 3 62 6 178 - 67.7%
Q14d wrong 39 25 8 0 1 19 1 93 - 35.4%
Assumptions of Chi-square test violated
0.299 0.000 right 31 54 13 13 2 52 5 170 - 64.6%
Q14e wrong 37 16 9 0 0 11 0 73 - 27.8%
Assumptions of Chi-square test violated
0.392 0.000 right 33 63 12 13 3 60 6 190 - 72.2%
Q14f wrong 31 20 8 1 0 5 3 68 - 25.9%
Assumptions of Chi-square test violated
0.350 0.000 right 39 59 13 12 3 66 3 195 - 74.1%
Q14g wrong 32 14 9 1 0 8 0 64 - 24.3%
Assumptions of Chi-square test violated
0.363 0.000 right 38 65 12 12 3 63 6 199 - 75.7%
Q14h wrong 53 38 14 3 2 22 4 136 - 51.7%
Assumptions of Chi-square test violated
0.369 0.000 right 17 41 7 10 1 49 2 127 - 48.3%
Q14i wrong 41 15 7 0 0 5 0 68 - 25.9%
Assumptions of Chi-square test violated
0.487 0.000 right 29 64 14 13 3 66 6 195 - 74.1%
Q14j wrong 38 20 8 0 0 6 1 73 - 27.8%
Assumptions of Chi-square test violated
0.417 0.000 right 32 59 13 13 3 65 5 190 - 72.2%
Table 4.18: Association between practice setting and
knowledge of infection control.
The wrong answer for Q10, Q12, and Q14 was given by 19% (n = 50) to 76% (n =
199) of respondents. A large number of statements within these questions had
significant associations in relation to the practice setting. These were found when
58
Chi square or Fisher's Exact Tests were carried out. Similar results were found
when years of experience and qualifications were related to these questions and
some statements had significant associations indicated, as can be seen by the
results in Tables 4.19, 4.20, 4.21, 4.22. One statement only, Q10a, had moderately
significant association with setting, years of experience, and qualifications.
Years of experience
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
<=
1 y
r
2-3
yrs
4-9
yrs
10-1
5 yr
s
>=
16y
rs
Q10a wrong 2 5 18 28 52 105 - 40.2%
0.012 4 261 0.222 0.222 right 11 10 40 49 46 156 - 59.8%
Q10b wrong 10 10 29 36 58 143 - 54.8%
0.151 4 261 0.161 0.161 right 3 5 29 41 40 118 - 45.2%
Q10c wrong 5 6 18 26 49 104 - 39.8%
0.121 4 261 0.167 0.167 right 8 9 40 51 49 157 - 60.2%
Q10d wrong 4 8 24 33 55 124 - 47.5%
0.190 4 261 0.153 0.153 right 9 7 34 44 43 137 - 52.5%
Q10e wrong 3 7 16 25 29 80 - 30.7%
Assumptions of Chi-square test violated
0.644 right 10 8 42 52 69 181 - 69.3%
Q10f wrong 6 9 20 41 49 125 - 47.9%
0.189 4 261 0.153 0.153 right 7 6 38 36 49 136 - 52.1%
Q12a wrong 3 3 17 20 20 63 - 24%
Assumptions of Chi-square test violated
0.713 right 10 12 41 56 80 199 - 76%
Q12c wrong 1 4 11 10 24 50 - 19.1%
Assumptions of Chi-square test violated
0.304 right 12 11 47 66 76 212 - 80.9%
Q12d wrong 4 5 13 17 43 82 - 31.3% Assumptions of
Chi-square test violated
0.208 0.022 right 9 10 45 59 57 180 - 68.7%
Q12e wrong 3 8 26 36 43 116 - 44.3%
0.519 4 262 0.111 0.111 right 10 7 32 40 57 146 - 55.7%
59
Q12g wrong 3 4 33 37 49 126 - 48.1%
0.907 4 262 0.173 0.173 right 10 11 25 39 51 136 - 51.9%
Q12h wrong 2 4 10 19 20 55 - 21%
Assumptions of Chi-square test violated
0.777 right 11 11 48 57 80 207 - 79%
Q12i wrong 6 8 26 33 41 114 - 43.5%
0.921 4 262 0.059 0.059 right 7 7 32 43 59 148 - 56.5%
Q12j wrong 9 9 20 34 30 102 38.9%
0.013 4 262 0.220 0.220 right 4 6 38 42 70 160 - 61.1%
Q12k wrong 11 13 46 57 72 199 - 76%
Assumptions of Chi-square test violated
0.687 right 2 2 12 19 28 63 - 24%
Q12l wrong 9 12 38 49 68 176 - 67.2%
Assumptions of Chi-square test violated
0.855 right 4 3 20 27 32 86 - 32.8%
Table 4.19: Association between years of experience and
knowledge of infection control.
One statement in Q10 was answered correctly by 70% of respondents; others had a
staggering 40% - 55% incorrect answers. Less than half of the statements in Q12
were answered incorrectly except for Q12k (76%) and Q12l (67%). These two
indicate a lack of knowledge of bacteriuria21
. Increasing microbial resistance is
mainly due to overprescribing of antibacterials and Khawcharoenporn et al (2011)
and Colgan et al (2006) advocate prudent antibiotic prescribing to avoid microbial
resistance. Lack of this knowledge might mean that nurses seldom question any
such prescription treating asymptomatic bacteriuria.
Incorrect answers for Q10, Q12, and Q14 were given by up to 76% (n = 199) of
respondents. In a list of signs and symptoms (S&S) of a urinary tract infection
(UTI) the majority (40% - 72%) either ticked the wrong answer or otherwise did
21 Bacteriuria - The presence of bacteria in the urine. It is normal for bacteriuria to develop after 7-
10 days with a catheter. This is called colonisation unless there are signs and symptoms of CAUTI
when it would need to be treated with antibacterials.
60
not know if the symptom was attributable to UTI. The least incorrect answers (9%
- 33%) were in relation to the commonest S&S of UTI (fever, burning sensation,
pyuria22
, cloudy urine).
Years of experience
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
<=
1 y
r
2-3
yrs
4-9
yrs
10-1
5 yr
s
>=
16y
rs
Q14a wrong 1 4 9 12 35 61 - 23.3% Assumptions of Chi-
square test violated 0.230 0.008
right 12 11 48 65 65 201 - 76.7%
Q14b wrong 2 5 15 18 34 74 - 28.2% Assumptions of Chi-square test
violated 0.446
right 11 10 42 59 66 188 - 71.8%
Q14c wrong 5 6 23 25 25 84 - 32.15 Assumptions of Chi-square test
violated 0.200
right 8 9 34 52 75 178 - 67.9%
Q14d wrong 2 7 19 30 34 92 - 35.1% Assumptions of Chi-square test
violated 0.452
right 11 8 38 47 66 170 - 64.9%
Q14e wrong 4 5 16 21 26 72 - 27.5% Assumptions of Chi-square test
violated 0.959
right 9 10 41 56 74 190 - 72.5%
Q14f wrong 5 4 16 22 20 67 - 25.6% Assumptions of Chi-square test
violated 0.461
right 8 11 41 55 80 195 - 74.4%
Q14g wrong 3 4 15 23 18 63 - 24% Assumptions of Chi-square test
violated 0.419
right 10 11 42 54 82 199 - 76%
Q14h wrong 7 8 35 38 47 135 - 51.5% 0.518 4 262 0.111 0.111
right 6 7 22 39 53 127 - 48.5%
Q14i wrong 3 5 17 20 23 68 - 26% Assumptions of Chi-square test
violated 0.827
right 10 10 40 57 77 194 - 74%
Q14j wrong 6 6 16 21 23 72 - 27.5% Assumptions of Chi-square test
violated 0.326
right 7 9 41 56 77 190 - 72.5%
Table 4.20: Association between years of experience and
knowledge of infection control.
22 Pyuria - presence of white cells in the urine possibly indicating infection.
61
Qualifications
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
EN
Tra
ditio
nal
EN
CN
P
SN
Tra
ditio
nal
SN
Con
vers
ion
SN
Dip
lom
a
SN
BS
c
SN
MS
c
Q10a wrong 7 5 29 21 24 16 4 106 - 40.5%
Assumptions of Chi-square test violated
0.259 0.008 right 3 7 17 41 45 36 7 156 - 59.5%
Q10b wrong 5 8 31 30 33 32 5 144 - 55%
Assumptions of Chi-square test violated
0.277 right 5 4 15 32 36 20 6 118 - 45%
Q10c wrong 3 6 25 26 22 16 6 104 - 39.7%
Assumptions of Chi-square test violated
0.137 right 7 6 21 36 47 36 5 158 - 60.3%
Q10d wrong 5 6 27 30 31 23 3 125 - 47.7%
Assumptions of Chi-square test violated
0.605 right 5 6 19 32 38 29 8 137 - 52.3%
Q10e wrong 1 4 18 19 19 17 2 80 - 30.5%
Assumptions of Chi-square test violated
0.606 right 9 8 28 43 50 35 9 182 - 69.5%
Q10f wrong 3 5 28 28 32 25 4 125 - 47.7%
Assumptions of Chi-square test violated
0.507 right 7 7 18 34 37 27 7 137 - 52.3%
Q12a wrong 1 4 8 19 19 9 3 63 - 24%
Assumptions of Chi-square test violated
0.325 right 9 7 40 42 50 43 8 199 - 76%
Q12c wrong 0 2 6 12 20 10 0 50 - 19.1%
Assumptions of Chi-square test violated
0.111 right 10 9 42 49 49 42 11 212 - 80.9%
Q12d wrong 3 2 19 16 23 19 0 82 - 31.3%
Assumptions of Chi-square test violated
0.143 right 7 9 29 45 46 33 11 180 - 68.7%
Q12e wrong 5 5 21 30 27 25 3 116 - 44.3%
Assumptions of Chi-square test violated
0.807 right 5 6 27 31 42 27 8 146 - 55.7%
Q12g wrong 5 7 26 30 31 22 5 126 - 48.1%
Assumptions of Chi-square test violated
0.834 right 5 4 22 31 38 30 6 136 - 51.9%
Q12h wrong 2 4 7 14 13 12 3 55 - 21%
Assumptions of Chi-square test violated
0.699 right 8 7 41 47 56 40 8 207 - 79%
Q12i wrong 6 6 19 25 31 25 2 114 - 43.5%
Assumptions of Chi-square test violated
0.491 right 4 5 29 36 38 27 9 148 - 56.5%
Q12j wrong 3 4 14 23 27 27 4 102 - 38.9% Assumptions of Chi-square test
0.429
62
right 7 7 34 38 42 25 7 160 - 61.1% violated
Q12k wrong 9 10 32 46 48 44 10 199 - 76%
Assumptions of Chi-square test violated
0.170 right 1 1 16 15 21 8 1 63 - 24%
Q12l wrong 5 7 31 42 45 40 6 176 - 67.2%
Assumptions of Chi-square test violated
0.534 right 5 4 17 19 24 12 5 86 - 32.8%
Table 4.21: Association between qualifications and
knowledge of infection control.
63
Qualifications
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
EN
Tra
ditio
nal
EN
CN
P
SN
Tra
ditio
nal
SN
Con
vers
ion
SN
Dip
lom
a
SN
BS
c
SN
MS
c
Q14a wrong 5 3 12 19 15 7 1 62 - 23.6% Assumptions of Chi-square test
violated 0.127
right 5 9 36 43 53 45 10 201 - 76.4%
Q14b wrong 4 4 15 18 17 15 2 75 - 28.5% Assumptions of Chi-square test
violated 0.919
right 6 8 33 44 51 37 9 188 - 71.5%
Q14c wrong 4 5 10 16 25 23 2 85 - 32.3% Assumptions of Chi-square test
violated 0.125
right 6 7 38 46 43 29 9 178 - 67.7%
Q14d wrong 4 5 16 21 23 21 3 93 - 35.4% Assumptions of Chi-square test
violated 0.966
right 6 7 32 41 45 31 8 170 - 64.6%
Q14e wrong 4 5 9 17 20 15 3 73 - 27.8% Assumptions of Chi-square test
violated 0.635
right 6 7 39 45 48 37 8 190 - 72.2%
Q14f wrong 0 4 10 14 23 16 1 68 - 25.9% Assumptions of Chi-square test
violated 0.152
right 10 8 38 48 45 36 10 195 - 74.1%
Q14g wrong 1 6 10 17 13 15 2 64 - 24.3% Assumptions of Chi-square test
violated 0.298
right 9 6 38 45 55 37 9 199 - 75.7%
Q14h wrong 6 8 19 28 39 31 5 136 - 51.7% Assumptions of Chi-square test
violated 0.272
right 4 4 29 34 29 21 6 127 - 48.3%
Q14i wrong 2 4 12 15 16 16 3 68 - 25.9% Assumptions of Chi-square test
violated 0.956
right 8 8 36 47 52 36 8 195 - 74.1%
Q14j wrong 3 5 12 10 25 17 1 73 - 27.85 Assumptions of Chi-square test
violated 0.080
right 7 7 36 52 43 35 10 190 - 72.2%
Table 4.22: Association between qualification and
knowledge of infection control.
Following is the presentation of the analysis of Q13 in Tables 4.23, 4.24, and 4.25.
This question included a list of S&S. Amongst them were those of a UTI and the
respondents were asked to tick if, in relation to UTI, each was "True" or "False".
64
Since the aim was finding out knowledge, the "Don't know" options were clustered
with the wrong answers.
In 8 statements, the majority of respondents (40% - 72%) either ticked the wrong
answer or otherwise did not know if the symptom was attributable to UTI. The
least wrong answers (9% - 33%) were in relation to the commonest S&S of UTI
namely, fever, burning sensation, pyuria and cloudy urine.
A Chi-square test for independence indicated moderately to strongly significant
associations between seven S&S and practice setting. Where the assumptions of
the Chi-square test were violated, the Fisher's Exact Test has been reported. The
effect size for all associations was small. These seven S&S are listed below.
Q13a: Frequent urethral spasms
Q13e: Altered mental status
Q13i: Dark coloured urine
Q13j: Burning sensation without other symptoms
Q13l: Presence of pus in the urine - Pyuria
Q13m: Cloudy urine
Q13o: Fever of 38 degrees Celsius or more
65
Setting
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
Med
ical
Sur
g &
Ort
ho
Inte
nsiv
e
A&
E
MM
DN
A
PH
C
Hos
pice
Q13a wrong 44 31 11 6 2 27 0 121 - 45.8%
Assumptions of Chi-square test violated
0.250 0.007 right 27 48 10 7 1 44 6 143 - 54.2%
Q13b wrong 46 50 12 12 3 39 4 166 - 62.9%
Assumptions of Chi-square test violated
0.165 right 25 29 9 1 0 32 2 98 - 37.1%
Q13c wrong 57 53 17 10 2 49 3 191 - 72.6%
Assumptions of Chi-square test violated
0.364 right 14 26 4 3 1 21 3 72 - 27.4%
Q13d wrong 50 45 13 7 0 37 4 156 - 59.3%
Assumptions of Chi-square test violated
0.136 right 21 34 8 6 3 33 2 107 - 40.7%
Q13e wrong 54 43 13 0 1 43 2 156 - 59.3%
Assumptions of Chi-square test violated
0.342 0.000 right 17 36 8 13 2 27 4 107 - 40.7%
Q13f wrong 25 32 8 7 0 34 2 108 - 40.9%
Assumptions of Chi-square test violated
0.525 right 46 47 13 6 3 37 4 156 - 59.1%
Q13g wrong 13 10 4 0 0 7 0 34 - 12.9%
Assumptions of Chi-square test violated
0.478 right 58 69 17 13 3 64 6 230 - 87.1%
Q13h wrong 26 31 8 3 0 35 3 106 - 40.2%
Assumptions of Chi-square test violated
0.390 right 45 48 13 10 3 36 3 158 - 59.8%
Q13i wrong 37 48 10 9 2 56 4 166 - 62.9%
Assumptions of Chi-square test violated
0.229 0.019 right 34 31 11 4 1 15 2 98 - 37.1%
Q13j wrong 40 21 7 6 1 12 1 88 - 33.3%
Assumptions of Chi-square test violated
0.331 0.000 right 31 58 14 7 2 59 5 176 - 66.7%
Q13k wrong 27 21 6 4 1 10 1 70 - 26.5%
Assumptions of Chi-square test violated
0.056 right 44 58 15 9 2 61 5 194 - 73.5%
Q13l wrong 30 18 6 0 0 6 0 60 - 22.7%
Assumptions of Chi-square test violated
0.340 0.000 right 41 61 15 13 3 65 6 204 - 77.3%
Q13m wrong 26 13 5 0 0 7 1 52 - 19.7%
Assumptions of Chi-square test violated
0.288 0.001 right 45 66 16 13 3 64 5 212 - 80.3%
Q13n wrong 32 23 7 2 0 17 2 83 - 31.4% Assumptions of Chi-square test
0.094
66
right 39 56 14 11 3 54 4 181 - 68.6% violated
Q13o wrong 5 3 2 0 1 13 0 24 - 9.1%
Assumptions of Chi-square test violated
0.233 0.032 right 66 76 19 13 2 58 6 240 - 90.9%
Q13p wrong 56 62 15 13 2 52 4 204 - 77.6%
Assumptions of Chi-square test violated
0.336 right 15 17 6 0 1 18 2 59 - 22.4%
Table 4.23: Association between setting and
knowledge of signs and symptoms of infection.
Years of experience
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
<=
1 y
r
2-3
yrs
4-9
yrs
10-1
5 yr
s
>=
16y
rs
Q13a wrong 6 11 23 38 42 120 - 45.6%
0.169 4 263 0.156 0.156 right 7 4 35 39 58 143 - 54.4%
Q13b wrong 7 12 36 50 60 165 - 62.7%
Assumptions of Chi-square test violated
0.592 right 6 3 22 27 40 98 - 37.3%
Q13c wrong 11 11 40 56 72 190 - 72.5%
Assumptions of Chi-square test violated
0.893 right 2 4 18 21 27 72 - 27.5%
Q13d wrong 8 9 36 45 57 155 - 59.2%
0.986 4 262 0.307 0.307 right 5 6 22 32 42 107 - 40.8%
Q13e wrong 7 9 36 47 56 155 - 59.2%
0.945 4 262 0.053 0.053 right 6 6 22 30 43 107 - 40.8%
Q13f wrong 6 8 22 28 43 107 - 40.7%
0.707 4 263 0.091 0.091 right 7 7 36 49 57 156 - 59.3%
Q13g wrong 1 3 6 12 11 33 - 12.5%
Assumptions of Chi-square test violated
0.710 right 12 12 52 65 89 230 - 87.5%
Q13h wrong 4 7 24 30 40 105 - 39.9%
0.936 4 263 0.056 0.056 right 9 8 34 47 60 158 - 60.1%
67
Q13i wrong 5 11 37 47 65 165 - 62.7%
Assumptions of Chi-square test violated
0.388 right 8 4 21 30 35 98 - 37.3%
Q13j wrong 6 7 23 28 23 87 - 33.1%
Assumptions of Chi-square test violated
0.065 right 7 8 35 49 77 176 - 66.9%
Q13k wrong 2 5 13 29 20 69 - 26.2%
Assumptions of Chi-square test violated
0.720
right 11 10 45 48 80 194 - 73.8%
Q13l wrong 4 4 13 25 13 59 - 22.4% Assumptions of
Chi-square test violated
0.197 0.025 right 9 11 45 52 87 204 - 77.6%
Q13m wrong 1 4 13 19 14 51 - 19.4%
Assumptions of Chi-square test violated
0.259 right 12 11 45 58 86 212 - 80.6%
Q13n wrong 2 6 20 22 32 82 - 31.2%
Assumptions of Chi-square test violated
0.635 right 11 9 38 55 68 181 - 68.8%
Q13o wrong 1 1 4 5 13 24 - 9.1%
Assumptions of Chi-square test violated
0.615 right 12 14 54 72 87 239 - 90.9%
Q13p wrong 11 11 48 64 69 203 - 77.5%
Assumptions of Chi-square test violated
0.192 right 2 4 10 13 30 59 - 22.5%
Table 4.24: Association between years of experience and
knowledge of signs and symptoms of infection.
Q13l was the only statement which had a significant association with years of
experience (p = 0.02). This association was weak (Cramer's V = 0.19) and the
effect size was small.
68
Qualifications
To
tal
Ch
i-sq
r (p
)
X2 n
Cra
mer
's V
Ph
i
Fis
her
's (
p)
EN
Tra
ditio
nal
EN
CN
P
SN
Tra
ditio
nal
SN
Con
vers
ion
SN
Dip
lom
a
SN
BS
c
SN
MS
c
Q13a wrong 4 5 19 30 31 24 8 121 - 45.8%
Assumptions of Chi-square test violated
0.642 right 6 7 29 32 38 28 3 143 - 54.2%
Q13b wrong 5 9 32 38 42 33 7 166 - 62.9%
Assumptions of Chi-square test violated
0.931 right 5 3 16 24 27 19 4 98 - 37.1%
Q13c wrong 9 7 34 46 47 40 8 191 - 72.6%
Assumptions of Chi-square test violated
0.661 right 1 5 14 15 22 12 3 72 - 27.4%
Q13d wrong 8 8 26 35 42 31 6 156 - 59.3%
Assumptions of Chi-square test violated
0.848 right 2 4 22 26 27 21 5 107 - 40.7%
Q13e wrong 6 10 30 34 43 29 4 156 - 59.3%
Assumptions of Chi-square test violated
0.397 right 4 2 18 27 26 23 7 107 - 40.7%
Q13f wrong 2 2 22 25 30 22 5 108 - 40.9%
Assumptions of Chi-square test violated
0.493 right 8 10 26 37 39 30 6 156 - 59.1%
Q13g wrong 1 2 5 11 9 3 3 34 - 12.9%
Assumptions of Chi-square test violated
0.318 right 9 10 43 51 60 49 8 230 - 87.1%
Q13h wrong 3 5 14 29 29 20 6 106 - 40.2%
Assumptions of Chi-square test violated
0.530 right 7 7 34 33 40 32 5 158 - 59.8%
Q13i wrong 6 11 34 41 35 33 6 166 - 62.9%
Assumptions of Chi-square test violated
0.094 right 4 1 14 21 34 19 5 98 - 37.1%
Q13j wrong 3 8 9 16 27 20 5 88 - 33.3% Assumptions of
Chi-square test violated
0.235 0.021 right 7 4 39 46 42 32 6 176 - 66.7%
Q13k wrong 4 3 7 20 14 18 4 70 - 26.5%
Assumptions of Chi-square test violated
0.129 right 6 9 41 42 55 34 7 194 - 73.5%
Q13l wrong 1 3 7 15 17 14 3 60 - 22.7%
Assumptions of Chi-square test violated
0.721 right 9 9 41 47 52 38 8 204 - 77.3%
Q13m wrong 1 3 5 13 13 13 4 52 - 19.7%
Assumptions of Chi-square test violated
0.348 right 9 9 43 49 56 39 7 212 - 80.3%
69
Q13n wrong 3 5 11 24 26 12 2 83 - 31.4%
Assumptions of Chi-square test violated
0.274 right 7 7 37 38 43 40 9 181 - 68.8%
Q13o wrong 2 2 6 5 5 3 1 24 - 9.1%
Assumptions of Chi-square test violated
0.509 right 8 10 42 57 64 49 10 240 - 90.9%
Q13p wrong 6 10 35 46 56 41 10 204 - 77.6%
Assumptions of Chi-square test violated
0.654 right 4 2 13 15 13 11 1 59 - 22.4%
Table 4.25: Association between qualifications and
knowledge of signs and symptoms of infection.
Q13j was the only statement which had a significant association with qualifications
(p = 0.02). This association was moderate (Cramer's V = 0.23) and the effect size
was small. The next section will analyse the questions related to training.
4.8 CPD and Training
Table 4.26 overleaf shows that only 54% of respondents report having had training
about the topic in their undergraduate studies. The majority of those who reported
that no training was given have been qualified for 4 or more years. A Chi-square
test for independence indicated a moderately strong significant association between
Q15 and years of experience (p = 0.01; Cramer's V 0.22). The effect size of this
association is small.
70
Table 4.27: Association between CPD training and years of experience.
The respondents were also asked (Q16) if they ever attended any CPD related to
the topic and if yes or no, to comment on which CPD or why they did not attend.
The data presented in Table 4.27 shows that 90% of respondents never attended
any CPD initiative in relation to the topic. Fisher's Exact Test is reported for Q16
and years of experience. No significant association was found (p = 0.12). Twenty
three reported attending CPD training on the topic, 3 of which at a conference,
Q15: Have you received any training with regards to catheterisation of the urinary bladder or catheter care during your undergrad studies?
NO YES
Count % Count %
Years of experience
<=1 yr 1 7.7% 12 92.3%
2-3 yrs 3 20% 12 80%
4-9 yrs 27 47.4% 30 52.5%
10-15 yrs 36 46.8% 41 53.2%
>=16yrs 52 52% 48 48%
Total 119 45.4% 143 54.6%
Table 4.26: Association between undergraduate training and years of experience.
Q16: Have you ever pursued any continuing education courses related to urethral catheterisation / catheter care?
NO YES
Count % Count %
Years of experience
<=1 yr 12 92.3 1 7.7
2-3 yrs 14 93.3 1 6.7
4-9 yrs 56 98.2 1 1.8
10-15 yrs 68 88.3 9 11.7
>=16yrs 87 87 13 13
Total 237 90.5 25 9.5
71
another 3 during surgical and infection control update courses, and 2 during the
conversion course. This is presented as Table 4.28 followed by Table 4.29 which
presents the comments of those who did not attend.
Question 16 - Replied Yes
Description of CPD
15 One day CPD - local (stopped)
3 Incontinence care/Care of Urostomy conference
3 Infection control/Medical and Surgical update
2 EN to SN conversion course
Table 4.28: Comments of those who attended a CPD on the topic.
Question 16 - Replied No
Why?
48 Not offered / Not available
15 Not released / Staff shortage
11 Not / rarely practiced
8 Not my area of interest
8 No time to attend / Family commitments
3 Recently graduated
1 Not allowed to catheterise
Table 4.29 - Comments of those who did not attend CPD.
When Q15 was cross tabulated (Table 4.30 overleaf) with qualifications it
transpired that although less common, nurses with Diploma and Degree
qualification still reported that most of them did not receive this training in their
undergraduate days (32% and 48% respectively). The same results are obtained
for Q16 (Table 4.31) mostly because there seems to have been only one instance of
CPD training related to the topic which has been mentioned earlier.
72
Table 4.30: Association between undergraduate training and qualifications.
Table 4.31: Association between continuing education and qualifications.
Q15: Have you received any training with regards to catheterisation of the urinary bladder or catheter care during your undergrad studies?
NO YES
Count % Count %
Qualifications
EN Traditional 5 50% 5 50%
EN CNP 7 58.3% 5 41.7%
SN Traditional 26 54.2% 22 45.8%
SN Conversion 32 51.6% 30 48.4%
SN Diploma 22 32.4% 46 67.6%
SN BSc 25 48.1% 27 51.9%
SN MSc 3 27.3% 8 72.7%
Total 120 45.6% 143 54.5%
Fisher's Exact 0.136
Q16: Have you ever pursued any continuing education courses related to urethral catheterisation / catheter care?
NO YES
Count % Count %
Qualifications
EN Traditional 7 70 3 30
EN CNP 10 83.3 2 16.7
SN Traditional 43 89.6 5 10.4
SN Conversion 55 88.7 7 11.3
SN Diploma 64 94.1 4 5.9
SN BSc 50 96.2 2 3.8
SN MSc 9 81.8 2 18.2
Total 238 90.5 25 9.5
Fisher's Exact 0.089
73
When tabulating Q16 with practice setting (Table 4.32 below) a strong significant
association has been indicated (p = 0.001; Cramer's V = 0.33). The effect size was
small.
Table 4.32: Association between continuing education and practice setting.
When asked if they would consider attending educational sessions on the topic,
14% (n = 36) replied that they would not. Table 4.33 shows that of those who did
not, 12 had more than 16 years of experience. No significant association was
indicated (p = 0.09).
Q16: Have you ever pursued any continuing education courses related to urethral catheterisation / catheter care?
NO YES
Count % Count %
Setting
Medical 68 97.1 2 2.9
Surgical & Orthopaedic 74 93.7 5 6.3
Intensive Care 20 95.2 1 4.8
Accident & Emergency 13 100 0 0
MMDNA 1 33.3 2 66.7
Health Centers 56 78.9 15 21.1
Hospice 6 100 0 0
Total 238 90.5 25 9.5
74
Q17: Would you consider attending educational sessions aimed at improving your knowledge of urinary catheterisation, care, and patient education?
NO YES
Years of experience
<=1 yr 1 7.7% 12 92%
2-3 yrs 6 40% 9 60%
4-9 yrs 8 14% 49 86%
10-15 yrs 9 12% 66 88%
>=16yrs 12 12% 87 88%
Total 36 14% 223 86%
Fisher's Exact 0.095
Table 4.33: Association between considering attendance to training and
years of experience.
Table 4.34 below shows a moderate association between qualifications and Q17 (p
= 0.02; Cramer's V = 0.23) whereby the majority who would not attend an
educational session about the topic had a degree in nursing (n = 13; 25%).
Q17: Would you consider attending educational sessions aimed at improving your knowledge of urinary catheterisation, care, and patient education?
NO YES
Qualifications
EN Traditional 3 30% 7 70%
EN CNP 0 0% 10 100%
SN Traditional 7 15% 41 85%
SN Conversion 3 5% 58 95%
SN Diploma 8 12% 60 88%
SN BSc 13 26% 38 75%
SN MSc 2 18% 9 82%
Total 36 14% 223 86%
Fisher's Exact 0.022
Table 4.34: Association between considering attendance to training
and qualifications.
75
Table 4.35 shows no association between practice setting and Q17 (p = 0.07)
whereby the majority of those who answered "No" practice in a Medical ward (n =
17; 25%) and 11 (14%) in a Surgical/Orthopaedic ward.
Q17: Would you consider attending educational sessions aimed at improving your knowledge of
urinary catheterisation, care, and patient education?
NO YES
Setting
Medical 17 25% 52 75%
Surgical & Orthopaedic 11 14% 67 86%
Intensive Care 3 14% 18 86%
Accident & Emergency 1 8% 12 92%
MMDNA 0 0% 3 100%
Health Centers 4 6% 65 94%
Hospice 0 0% 6 100%
Total 36 14% 223 86%
Fisher's Exact 0.071
Table 4.35: Association between considering attendance to training and
practice setting.
Following is Table 4.36 which shows no significant association between gender
and Q17 (p = 0.98) whereby 22 out of the 36 who would not attend training were
females.
76
Q17: Would you consider attending educational sessions aimed at improving your knowledge of urinary catheterisation, care, and
patient education?
NO YES
Count % Count %
Gender Female 22 13.9 136 86.1
Male 14 13.9 87 86.1
Total 36 13.9 223 86.1
Pearson's Chi 0.989
df 1
n 259
Cramer's V 0.001
Phi 0.001
Table 4.36: Association between considering attendance to training and gender.
When cross tabulated, there were 120 respondents (46%) who stated that they had
not received any undergraduate training on the topic. Of these, 118 (98%) had
neither been at the receiving end of any CPD. This can be seen in Table 4.37.
Q16: Have you ever pursued any continuing education courses related to urethral catheterisation / catheter
care? Total
NO YES
Q15: Have you received any training with regards to catheterisation of the urinary
bladder or catheter care during your undergrad studies?
NO 118 2 120
YES 120 23 143
Total 238 25 263
Table 4.37: Cross tabulation of undergraduate training and CPD.
77
Those who reported not receiving undergraduate training (Q15) and never attended
any CPD (Q16) (n = 118) were cross tabulated further with Q17, asking if they
considered attending any CPD on the topic in question (Table 4.38). The greater
majority answered that they would attend while 36 respondents said that no, they
would not consider attending. A Chi square test for independence indicated a
weak significant association between Q17 and Q15 (p = 0.03, Cramer's V = 0.12).
The assumptions for the Chi square test were violated when Q17 was tabulated
with Q16 so Fisher's Exact is reported (p = 0.76). No association was indicated.
Q17: Would you consider attending educational sessions aimed at improving your knowledge of
urinary catheterisation, care, and patient education?
Total NO YES
Replied NO to
Q15: Have you received any training with regards to catheterisation of the urinary bladder or catheter care during your undergrad studies?
22 95 117
Replied NO to
Q16: Have you ever pursued any continuing education courses related to urethral
catheterisation / catheter care?
32 202 234
Total 36 202 236
Table 4.38: Cross tabulation of Q17 with negative answers to Q15 and Q16.
The 36 participants who stated that they never had any undergraduate or CPD
training and would not consider attending consisted of 22 females and 14 males; 12
had 16 or more years of experience; 13 held a Degree in nursing; 17 practiced in a
Medical ward. This can be seen in Tables 4.39 through to 4.42.
78
Negative response only
Total Q15 - Received undergraduate
training? Q16 - Received any
CPD? Q17 - Consider
any CPD?
Gender Female 61 141 22 144
Male 58 96 14 97
Total 119 237 36 241
Table 4.39: Cross tabulation of negative response to Q15, 16, 17 to gender.
Negative response only
Total Q15 - Received
undergraduate training? Q16 - Received
any CPD? Q17 - Consider any
CPD?
Years of Experience
< or = to 1 year 1 12 1 12
2-3 yrs 3 14 6 15
4-9 yrs 27 56 8 56
10-15 yrs 36 68 9 69
> or = to 16yrs 52 87 12 89
Total 119 237 36 241
Table 4.40: Cross tab of negative response to Q15, 16, 17 to years of experience.
Negative response only
Total Q15 - Received undergraduate
training?
Q16 - Received any
CPD?
Q17 - Consider any CPD?
Qualifications
EN Traditional 5 7 3 8
EN CNP 7 10 0 10
SN Traditional 26 43 7 44
SN Conversion 32 55 3 56
SN Diploma 22 64 8 64
SN BSc 25 50 13 51
SN MSc 3 9 2 9
Total 120 238 36 242
Table 4.41: Cross tabulation of negative response to Q15, 16, 17 to qualification.
79
Negative response only
Total Q15 - Received undergraduate
training?
Q16 - Received any
CPD?
Q17 - Consider any CPD?
Practice setting
Medical 47 68 17 69
Surgical & Orthopaedic 34 74 11 76
Adult Intensive Care 14 20 3 20
A&E 1 13 1 13
MMDNA 0 1 0 1
PHC 22 56 4 57
Hospice 2 6 0 6
Total 120 238 36 242
Table 4.42: Cross tab of negative response to Q15, 16, 17 to practice setting.
Table 4.43 illustrates the responses of these participants to Q5 (In your area of
practice, who inserts or changes an indwelling urethral catheter?). It shows that
the greater majority who are not interested in attending this CPD practice in
settings where nurses actually insert urinary catheters.
Negative response only
Total Q15 - Received undergraduate
training?
Q16 - Received any
CPD?
Q17 - Consider any
CPD?
Q5 - Who inserts?
Nurses 107 201 34 205
Doctors 0 2 0 2
We don't insert 12 34 2 34
Total 119 237 36 241
Table 4.43: Cross tabulation of negative response to Q15, 16, 17 to Q5.
80
4.9 Planning and conduction of training
As part of this is a TNA, the respondents were also asked about certification,
recognition of such certification, development and conduction of training, contents,
and assessment methods. The following section presents the analysis of this data.
Respondents were asked (Q18) "Should this training be recognised by
certification? The total responses were 259 of which 241 (91%) would like it to be
certified. Another question (Q19) asked "Would you expect this qualification to be
recognised both locally and abroad?" Out of 265 replies, 201 (76%) stated that
they would like to it be recognised abroad. The largest percentages of those who
do not want this to be recognised and neither wanted recognition to be valid abroad
had more than 10 years of experience while minimal younger nurses opted for
these options. Those who opted the least for recognition were ENs with Certificate
in Nursing Practice (CNP) as qualification (20%), followed by traditional
qualifications. This trend was consistent throughout the qualification pyramid
whereby those with the highest qualification, that of a Master degree, all chose
recognition by certification (100%). Although still the highest percentage, only
91% of those holding a Master degree would like this qualification to be valid
abroad. When tabulating Q18 with the practice setting, the least who opted for
certification were Hospice nurses at 67%. The most who opted for were those at
A&E, Intensive care and MMDNA whereby all the respondents wanted
certification. With regards to this being valid abroad, Hospice were still at the
lowest end (50%) and A&E nurses were alone at the topmost (100%).
The next questions were set to answer the questions related to training, namely
Who? How? Which? These were address through Q20 to Q25. When asked "Who
should develop this training?", Urology Nurses ranked highest at 25% followed by
Faculty of Health Sciences (FHS) staff at 17%. Others scored the least at 1.3%.
This data is presented in Graph 4.2. Graph 4.3 shows the same trend in reply to
81
Q21: "Who should deliver this training?". Urology nurses were chosen by 26%,
FHS staff by 17%, and Others by 1.2%.
Graph 4.2: Choices regards development of training.
Graph 4.3: Choices regards delivery of training.
0
50
100
150
200
250
UN FHS PG NM PDN FN MD U O
0
20
40
60
80
100
120
140
160
180
200
UN FHS PG NM PDN FN MD U O
Key
FHS - Faculty of Health Sciences
UN - Urology Nurses
PG - Post Grad Nurses own field
NM - Nurse Managers
PD - Practice Development Nurses
FN - Foreign Nurse Educators
MD - Doctors
U - Urologists
O - Others
Key
FHS - Faculty of Health Sciences
UN - Urology Nurses
PG - Post Grad Nurses own field
NM - Nurse Managers
PD - Practice Development Nurses
FN - Foreign Nurse Educators
MD - Doctors
U - Urologists
O - Others
82
Another question (Q22) probed on the environment which would be best preferred
by the respondents. The responses most prevalent were On site (38%) followed by
MDH (27%) and FHS practice labs (26%). Other ranked the least at 1.8%. The
options offered under the "Other" heading by five respondents included:
"Somewhere quiet"; "Somewhere hands on"; "Hotels"; "Good parking space".
Graph 4.4: Environment most appropriate for training.
When asked about the mode of delivery, 21% stated that Discussion and Practice
based with minimal lecturing is preferred. The traditional lecture format and the
online delivery were the least popular whilst the most popular option was a mix of
these formats (36%). This is illustrated by Graph 4.5.
0
20
40
60
80
100
120
140
160
180
200
FHS MDH UOM On site Other
Key
FHS - Faculty of Health Sciences practice labs
MDH - Mater Dei Hospital
UOM - University of Malta
Campus
On site - At the respondents' place of work
O - Other
83
Graph 4.5: Preferred mode of delivery.
Graph 4.6: Preferred mode of assessment.
0
20
40
60
80
100
120
140
160
Discussion Traditional Lecture Online Practice with minimal lecturing
A mix of the above
0
20
40
60
80
100
120
Exam MCQs Written assignment
Group presentation
Discussion of practical scenario
Practicals on real patients
None Other
84
The data displayed in Graph 4.6 was collected when participants were asked about
their preferred method of assessment. Practice based discussions of scenarios were
the most preferred (26%) whilst "Other" were the least opted for at 0.4% and
included "Assessment on dummies" and "Literature review". Only 5% preferred no
assessment at all.
The participants were also asked questions about funding. Q26 asked, "If such
training is available, would you be willing to finance your own studies?" Nine
respondents (3.6%) did not answer this question. The majority of the rest chose
not to finance their own studies (n = 163; 64%). Of these, 9% were ENs, 21%
were traditional SNs, 25% were SNs who had pursued the EN to SN conversion
course, 22% were diplomats and 22% were graduates (BSc and MSc). The least
experienced nurses seem to accept more the concept financing one's own CNE
whereas the most experienced held the highest percentage of those who do not
agree to finance their own studies. This data is presented in Table 4.44.
Years of experience
Total < or = to 1 year 2-3 yrs 4-9 yrs 10-15 yrs > or = to 16yrs
Q26
NO 5 13 28 43 73 162
YES 8 2 29 32 22 93
Table 4.44: Cross tabulation of years of experience and
willingness to finance own studies.
Tables 4.45 and 4.46 illustrate the reasons provided justifying why they think they
should or should not finance their own studies.
85
Reason justifying own financing
Number of times cited
CPD is not a choice / I have to invest in my CPD 6
Enhancement of practice 4
Can be claimed by CPD allowances / Paid by DH 37
Table 4.45 - Reasons justifying own financing of CPD.
Reason not to finance
Number of times cited
Not my area of practice 2
Cannot afford it 10
Not appreciated by DH / It is up to DH to keep us updated 4
Not needed for managers 3
I have other commitments / family 4
I am not interested 3
Table 4.46: Reasons justifying why not to finance own CPD.
When asked "How much would you be ready to pay for such a course of studies?"
(Q27) only 123 respondents replied. Table 4.47 shows that the great majority (n =
96; 78%) chose the first option (less than €100 per person [p.p]). The second
option (€100 - €300 p.p) was chosen by twenty five respondents (20%). The third
(€300 - €500 p.p) option was chosen by one female nurse who had 10 - 15 years
experience and a Master degree. Likewise, the fourth (over €500 p.p) option was
also chosen by one female participant with over 16 years of experience holding a
Diploma in Nursing.
Responses
N Percent
Payment options
€100 96 78.0%
€100-€300 25 20.3%
€300-€500 1 0.8%
over €500 1 0.8%
Total 123 100.0%
Table 4.47: Payment options chosen.
86
An open ended question (Q28), "What do you expect of such a programme of
education?" allowed a sense of freedom to the participants and yielded varied
responses which were clustered under two major headings, Theory and Practice.
Graph 4.7: What respondents expect of a CPD course.
Graph 4.8: What respondents expect of a CPD course.
0
5
10
15
20
25
30
35
40
EBG IC TM DC C DQ A&P
0
10
20
30
40
50
60
P CC DC CS M&V Prof B MR TNA
Key
EBG - Evidence Based Guidelines Update
IC - Infection Control - prevention, recognition, treatment
TM - Teaching Methods
DC - Decision to catheterise - Adv & Disadv, risk management, alternatives
C - Complications
DQ - Discussion and Questioning of misconceptions
A&P - review of Anatomy and Physiology
Key
P - Practice under supervision
CC - Choice of catheter and products
DC - Difficult catheterisation
CS - case studies and scenarios
M&V - Materials, venues, and motivated lecturers
Prof - Professionalism
B - Basics
MR - Managerial recognition
TNA - What is shown
lacking by this study
87
The most common barriers to attending continuing education have been listed in
Q29. An option to choose others was available to allow more freedom to the
respondents and a clearer picture. Graph 4.7 illustrates the findings. The three
most common barriers were time, financial cost, and family commitments. The
least was feeling ashamed to attend training. The option to tick "Other" and a
chance to comment on the choice was given with this question. Nineteen
participants commented on their choice. Six comments repeated the choice whilst
thirteen cited release from work as a barrier to attendance.
Graph 4.9: Barriers to attendance
4.10 Themes emerging from the focus interview
Six participants participated in the 45 minute long focus group interview. The
main topics discussed were the lack of knowledge, attendance to training, and
0
20
40
60
80
100
120
140
160
180
200
Financial cost
Time constraints
Family commit.
Travel time No interest I don't need to learn
Ashamed Other
88
reasons for not catheterising. As described in the previous chapter, thematic
analysis was perfomed on the data collected and is prenseted in Table 4.48 below.
Themes emerging
Lack of managerial support
Lack of recognition by managers and doctors
Percieved need for training
Lack of confidence in relation to training and practice
Lack of autonomy
Table 4.48: Themes emerging from the focus group.
The theme 'Lack of managerial support' emerged in relation to both lack of
knowledge and attendance to training. Some were not happy with not being
released for training and also mentioned managers' attitudes towards training.
Some of these were not pro training and their attitudes were quite demotivating.
'Lack of recognition' referred to such managers and the role they play in the
dynamics of the team within any HC. Also, they pointed out that if trained, they
would expect doctors to recognise them as such and involve them in decisions and
allow them to practice more autonomously. This relates directly to the last theme,
'Lack of autonomy'. With regards to 'Percieved need for training', those who work
in clinics where catheterisation is never performed stated that they would prefer
attending CPD in relation to their speciality rather than catheterisation. Two
participants practicing in the treatment rooms stated that there are more common
areas which they deal with and they prefer to focus more on them, like tissue
viability and diabetes issues. 'Lack of confidence' emerged from comments made
in relation to lack of knowledge, reasons for which most do not catheterise. This
last theme also relates to 'Lack of autonomy' which they cited was something some
wished to achieve in relation to doctors deciding what they do. On the other hand
not all agreed upon autonomy. Not all nurses aspire to be autonomous
practitioners and this might also account for the low attendance to training.
Chapter 5
Analysis and Discussion
of the findings
95
5.1 Introduction
Indwelling urinary/urethral catheters are commonly used for multifarious reasons
(CDC, 2012; Bhardwaj, Pickard, & Rees, 2010) and are associated with
complications such as infections, tissue damage, blockage, and discomfort
(Lowthian, 1998). Nurses, as primary users of these devices, have to be competent
in their use so as to avoid serious consequences and acute hospitalisation (Fitter,
1986; Germon, 1987; McConnell, 1987 in McConnell, Cattonar & Manning,
1996). Research based guidelines are periodically revised by internationally
recognised organisations (RCN, 2012; EAUN, 2012; NICE, 2011; ANZUNS,
2006). Notwithstanding this readily available rich supply of evidence based
material several authors report poor levels of knowledge of basic catheter care,
choice of catheter and patient education (Bray & Sanders, 2007; Carson & Culyer,
1996; Henry, 1992). The results of this TNA show that the local situation is no
different. Lack of knowledge has been consistently demonstrated irrespective of
years of experience, gender, practice setting and academic qualifications. The
possible reasons could be that respondents forgot what was taught in their pre
registration education, the lack of post registration training reported locally or just
demotivation. The main results of this study expose the magnitude of the lack of
knowledge on LTCC in areas deemed critical in this regard. Action is needed to
ensure the delivery of safe care and the results shall be used to address these issues
within the national context, something deemed important by Fenech Adami &
Kiger (2005). Some needs have to be addressed through training although as
Wood, Douglas & Priest (2004) pointed out others might call for attitudinal
change, changes in work practices, policy and management.
The onetime data collection yielded a 53% RR. Polit & Hungler (1999) hold that a
questionnaire's RR should be over 60% but Rebar, Gerisch, Macnee & McCabe
(2011) argue that this is not so significant when the participants are members of a
captive group, such as those of this study being all nurses. Various reasons were
identified for this low RR. Respondents could have been discouraged by the large
96
number of items in the tool. Non-respondents might have thought that they know
all they need to know about the topic and were not interested. The findings might
still be generalised as Templeton et al (1997) assert that the low RR needs not
affect the validity of the data. Visser & Traugott (in Werrett, Helm & Carnwell,
2001) demonstrated that lower RRs may be more accurate and certain aspects of
the data remain unaltered even when RRs improve. The least RRs were generated
by areas which were of most interest: MMDNA, PHC, and A&E. The researcher
is mostly known to the nurses within MDH which in turn possibly yielded a higher
response from the wards. On the other hand, at the time of data collection A&E
had just gone through some major staff changes and a large influx of new recruits.
It was a hectic period and the questionnaire might have been seen as something
extra on top of their busy workload. The low response of MMDNA and PHC
might indicate that non respondents perceive that they already have the knowledge
needed. Otherwise they do not give priority to this skill. Not having followed up
the non respondents makes it impossible for one to know this and it would be
erroneous to generalise the lack of knowledge demonstrated by the participants to
all the population.
The convenience sample, also called grab or opportunity sample, chosen for the
focus interview was selected because it was easily available. In addition it
represented the only group which had training on catheterisation but there was
minimal difference in knowledge scores when compared to the others. The nurses
at PHC were those who catheterised the least patients. The disadvantages of this
type of sampling technique is that generalisations cannot be made as it is not
considered to be representative. On the other hand, rather than being
representative, the aim of this focus interview was to ground the quantitative
findings. Time permitting, I would have conducted a series of focus group
interviews and invited respondents so that a mix of gender, years of experience,
setting and qualifications would be present, representing the population at large.
97
5.2 Changing and caring for urethral catheters
The large majority of nurses in HCs do not insert, change or care for urethral
catheters (Refer to Table 4.6 and Graph 4.1). I was intrigued by this finding
considering that the most experienced were more prevalent in HCs (49 of 52
nurses) and one would expect them to feel more confident and have better
knowledge scores. Most of these nurses claimed that they never attended any pre
registration training regards although they scored highest amongst those who
attended a CPD on the topic. Interestingly, only three cited lack of training as a
reason for not catheterising (refer to Table 4.7). Some cited PHC policy which is
officially nonexistent although such comments from nurses who practice within
School Health or Immunization Clinics might be justified. The training that had
been offered to them was discontinued before everyone could attend so I decided
to delve deeper into this matter during the focus interview. It transpired that the
training had been stopped prematurely due to unforeseen circumstances and that it
did not include a practical component. Thus most were still afraid to practice the
skill.
"Jien xorta ma nħossnix komda, avolja kellna l-lecture."
"Despite the lecture we had, I still don't feel comfortable catheterising someone."
PHC Nurse (F2)
"Ma kellniex ċans nipprattikaw"
"We did not have the chance to practice."
PHC Nurse (F6)
This is explained by ARCS theory which states that the confidence level of
learners often correlates with the amount of motivation which one puts into
98
training. Since some nurses did not have time to attend the lecture and others
claimed that there was no practical training involved, it can be safely assumed that
confidence was not built as there was no space to provide positive reinforcement of
achievements through multiple, varied, and challenging experiences, something
advocated by Poulsen et al (2008). Poulsen et al further claim that when learning
requirements are percieved to be out of reach, motivation also decreases.
A routine change of catheter is usually performed by MMDNA nurses and so the
majority also stated that this procedure is not or rarely done at a HC. Also there
seems to be a tendency of patients traveling to MDH rather than to a HC. If one
presents to a HC and is then referred to MDH (as is suggested by F1 and F5
below), the next time round the tendency would be to go immediately to MDH.
This seems to be happening also to other services, for example, if one presents to a
HC with a bone fracture where often, due to various reasons x-ray and plaster
services are not available, the patient is referred to the acute service. The next time
round they will probably present immediately to hospital. Besides increasing the
workload of the acute hospital this factor also hints at a possibility of deskilling
which needs to be addressed if the HCs are to offer realistic support to MDH A&E.
Policy change appears to be needed. The issue of autonomy arose during the focus
interview whereby PHC nurses stated that they are not autonomous and depend on
doctors who most often refer patients to MDH.
"Ħafna drabi t-tobba jaqbdu jirreferu għal-Mater Dei"
"Often times the doctors just refer patients to Mater Dei Hospital"
PHC Nurse (F1)
"Fl-aħħar mill-aħħar li jgħidu huma hux? Jekk jgħidlek li għal Mater Dei tibgħat
jkollok. Ħa mmur neżamina l-pazjent jien imbgħad?"
"Ultimately it's what they say no? ('they' refers to doctors). If s/he tells you to send
the patient to MDH you have to do so. Should I examine the patient myself then?
PHC Nurse (F5)
99
Autonomy takes off from a platform of knowledge and if nurses are really
motivated to learn issues like that mentioned by F5 can be overcome. An
encouraging 94% of PHC respondents stated that they would like to attend
training. On the other hand, a second attempt to deliver training to PHC nurses
weeks after the data collection had a staggering 90% not turning up. The
theoretical framework (ARCS Theory) suggests that this might be due to irrelevant
subject matter, for those who practice within PHC but not in areas where
catheterisation could take place. Dissatisfaction with previous training might also
be cited. This also links to the situation whereby patients are hastily referred to
MDH thus not allowing the nurses to actually practice the newly learnt skill.
According to ARCS theory, this decreases satisfaction. Managerial support, family
commitments and motivation could be other reasons. The shift of nurses from the
acute to the less hectic community setting and their will to keep updated could be
related and one wonders if social desirability was the reason behind the responses
of those 94%. Having said this, Bardsley (2005) asserts that research and evidence
based practice should be part and parcel of everyday clinical practice but the reality
in PHC is that the skill is sparsely performed in this setting. This might be a
reason for nonattendance. Bray, Sanders & Flynn (2010) found that despite
training, publication of policy and provision of guidelines, staff in certain clinical
areas remained reluctant to undertake catheterisation. These findings within the
Maltese context have to be considered in the light of an over burdened A&E
department (Ameen, 2012) desperately needing PHC support. It appears that
changes to policy need to be made.
I have informally discussed the same data with a couple of Hospice nurses. They
do not catheterize patients as their role focuses on counseling, assessment, and care
coordination rather than hands on practice for which they usually refer to
MMDNA. Despite this, all of them would attend a CPD on the topic and one
stated that being knowledgeable and updated meant that they could spot
complications and refer accordingly. If one refers back to ARCS theory, despite
not practicing the skill, these nurses deem such training as relevant to their practice
and so all of them stated that they would attend.
100
"Tajjeb li tagħraf meta hemm problema. Tkun tista tirreferi aħjar."
"It is good to know when a problem arises. It allows you to refer accordingly."
Hospice Nurse
Nurses are the largest group of health professionals worldwide (Wood, Douglas &
Priest, 2004) and so it is expected that they were mostly identified as those who
perform catheter care on a daily basis. Seventeen respondents chose a combination
of nurse, carer and informal carer (family, etc). The latter is assumed to be
untrained. This might be justified in Hospice or Community care but not in
Intensive, Surgical or Medical units. These responses suggest that catheter care in
hospital is often being delegated to untrained persons but data was not collected in
this regard so one can only assume that these untrained persons were not guided or
educated by trained staff. Roe (1989) concluded that the catheter care information
provided by nurses was neither comprehensive nor consistent. This implies that
even if the untrained persons were educated by these respondents, one should
caution against this practice especially when considering that the rate of
nosocomial23
CAUTI is around 40% (AACCN24
, 2013; Gould et al, 2009; Topal et
al, 2005; Kalsi et al, 2003).
5.3 Knowledge deficit
This study shows that overall knowledge of LTCC is poor. A multitude of possible
reasons exists. Those who have undergone pre registration training a long time
ago might have either forgotten or otherwise what they learnt could have changed
over time so their knowledge is today outdated. Locally, those who attended a
related CPD had the same poor scores as those who did not, so much so that 94%
23 Nosocomial - Acquired in hospital
24 AACCN - American Association of Critical Care Nurses
101
of PHC nurses scored poorly overall. Reading might improve knowledge but:
some might be demotivated to read since they feel that they are not autonomous
relating to lack of satisfaction as cited in ARCS theory; not be interested as this is
not part of their everyday practice relating to the pillar of relevance in ARCS
theory; or otherwise their time is being taken up by other commitments. This has
major implications considering that nurses have largely identified themselves as
those who perform LTCC. Although official data is not available the overall
impression is that most traumatic catheterisations are due to an incorrect
catheterisation technique. Nurses' knowledge was one of the main targets of this
work because it's lack contributes to sub optimal patient care. O'Connor (2010:1)
asserts that since the 1900s nurses have started moving away from being "only the
instrument by which the doctor gets his instructions carried out..." hinting at an
increase in autonomy, relevant training and education, confidence and satisfaction
mentioned by Poulsen et al (2008). In congruence, according to the MCNM25
(2002), a professional deemed competent to perform an act should be able to
decide when it is required and carry it out independently.
If knowledge is lacking one cannot be deemed competent to perform the skill or
teach others to perform it. I relation to LTCC, this might impinge on infection
rates. CAUTI, the single most common hospital acquired infection (CDC, 2012) is
a heavy burden on any health care system (Nicolle, 2008; Weinstein, 1999) and on
any patients' biopsychosocial health status. Lack of knowledge imposes severe
limitations on the quality of LTCC education that nurses provide to their clients, if
any. The majority knew about the commonest S&S of infection but severe deficits
were demonstrated (refer to Table 4.19 to 4.25) with regards to other S&S and
prevention of infection. The lack of practical training is not an issue as catheter
care and prevention of CAUTI can be learnt by independent reading. PHC nurses
might opt not to focus on this since they do not care for catheterised patients but
this is not so for MDH, Hospice or MMDNA nurses. This lack of knowledge
25 MCNM - Maltese Council of Nurses and Midwives
102
denotes that these nurses are either not educating about CAUTI or otherwise
passing on the wrong information. No explanation has been found in the literature
although one would be tempted to cite demotivation as a reason for not keeping
abreast with the plethora of guidelines available.
5.4 Pre and post registration training
The majority of those with less than 4 years of experience reported attending pre
registration training whilst 47%-52% of those with over 4 years of experience
stated that they did not. They could have either forgotten the session that they
should have attended over 4 years ago or not placed so much importance on it at
the time. The majority (90%) never attended any related CPD. Out of 62 nurses
who had undergone the EN to SN course only two stated that this training was
provided. These could be nurses whom as preceptor I myself followed during the
said course as I always invite them to attend the undergraduate training I provide
on the topic. There is no way of knowing if this is so or if they are associating
training with an academic discussion they have with their preceptor regarding
catheter care as part of the same course.
The American Nurses Association (2000) describes CPD as a process of
development and maintenance of competence and enhancement of practice.
Studies did present positive perceptions of CPD producing behavioural changes
although Furze & Pearcey (1999) argue that most fail to objectively evaluate if the
change has actually occurred. Pelletier, Donoghue & Duffield (2003) hold that it is
important for those planning a course that they measure its impact. Armstrong &
Adam (2002) found that the knowledge of participants had improved but did not
materialise in a change in practice. The findings of this study show that PHC
nurses who attended the catheterisation CPD admitted that change did not
materialise reason being that there was lack of hands on practice. It is possible that
a TNA was not conducted prior to that training and so the issue of hands on
103
practice was not addressed. It appears that there wasn't any difference between the
levels of knowledge of those who stated that they attended CPD and those who did
not. This was the reason why this TNA gauged the level of knowledge but also
sought insight into the factors which would make training successful. This though,
should not demean the value of post training evaluation. Zaineb (2011) states that
evaluation is invaluable in noting the lack of application of the taught skills and
also identify the causes for such. Through personal communication the PHC
Practice Development Nurse (PDN) confirmed that around a year ago a CPD
course had been running but had to be discontinued before all nurses could attend.
Fifteen out of 71 PHC nurses who participated in this study had attended this CPD
course. Knowing this I expected a better turn out for the second training initiative
mentioned previously (repeated on six separate occasions) of which I was a
participant. This was running just after the questionnaire data was collected and it
was organised by the same PHC PDN. Just over 10% (n = 18) of PHC nurses
attended. Having the focus interview planned for after this training was positive
for me as a researcher. During the focus interview I was able to challenge the low
attendance to the lectures which, this time, were delivered as planned in order to
provide for the large amount of nurses who had not attended the previous CPD. In
hindsight, it would have been interesting to check how many of the fifteen nurses
who had attended the first training instance had been part of the eighteen who
attended the second, if any.
One of Chetcuti's (2008) findings was not amongst those of this study: the
possibility that respondents would not be informed of such training. Organisers
usually promote events by means of an e-circular. If not, some might not be aware
of the training offered and so not attend. Two other major determinants play a
part: that of not being released from work and family commitments. One
understands that release from work is always conditioned by the exigencies of the
service. On the other hand, time off in lieu of that spent in training (when
attending from their free time) is always granted. Family commitments might
impinge on the possibility of distancing oneself for training purposes. Having said
this, when an employee avails him/herself of the time in lieu gained, the employer
104
usually replaces that employee by another who is probably being paid at an
overtime rate.
When considering the financial cost of hospital admissions, it is estimated that a
patient admitted at MDH costs between €260 and €300 every 24 hours. This has to
be seen in the light of a rough estimate of over 1500 catheter changes a year. If a
low 1% of these have to be admitted, this might yield a possibly higher cost than
that paid in overtime rate. Even if replacement is allowed, it is not always possible
to find someone willing to work extra hours and release from work is often times
still impossible (Knight et al, 2006). Atkins (2009) states that such reasons lead
organisations in moving to e-learning although it is not an all round solution.
Atkins asserts that finding appropriate off-the-shelf content is difficult and even so
it would not be indicated for hands on skills training. The respondents themselves
rated e-learning the lowest with regards to methods of delivery. Maybe if training
is delivered on site on multiple occasions attendance might improve and employees
would not have to travel away from the place of work. The logistics of finding a
replacement paid at an overtime rate could also be avoided together with less time
away from work due to travel. Another two barriers identified by this study and by
Longman, Temple-Smith, Gilchrist & Lintzeris (2012) are previous negative
experiences of catheterisation (avoidance) and structural constraints preventing
practice. Both eventually lead to deskilling and further avoidance and might
indicate the need to address them through discussion and policy change. These
both affect confidence levels which, according to ARCS theory, are directly related
to motivation and the effort that one puts forth in order to achieve an objective.
No pre registration training was reported by 120 respondents (46%) of which 118
(98%) had neither been at the receiving end of any CPD. Combined with the lack
of knowledge demonstrated, this suggests that a very common albeit possibly
dangerous skill has been learnt in environments which might not be conducive to
learning, in an episodic and infrequent fashion, from others who possibly share the
same limited knowledge. This combination of factors detracts the knowledge base
105
of practitioners (Lees & Emmerson, 2006). This study aimed to find what factors
would enhance uptake of training. Respondents stated that they expected training
to be delivered by nurses who know how to catheterise well and who are up to
date.
"Li jkunu jafu x'hinuma jagħmlu"
"Who know what they're doing"
Female, 10-15yrs exp, PHC
This might be hinting at a lack of satisfaction with previous training received, in
whatever form it was delivered. Since statistical data of patients admitted to the
acute setting after traumatic catheterisations is not available no definite
conclusions can be drawn. Through my experience and discussions with
colleagues often called in to catheterise 'problematic' patients, it appears that some
can be catheterised without difficulty when using the proper technique. A need for
training also suggested by 86% of the study participants re-emerges. In
resemblance to the results of Cully, Vanden Heuvel & Wooden (2000), 36
respondents who never had any training stated that they would not attend training.
Although these are few, others who stated that they would attend might have
provided a socially desirable response and could ultimately not attend either.
There is no way of knowing how many, if any, would do so. Those who stated this
practice in settings where nurses insert urinary catheters. Their response might
indicate further reading on their own initiative, a belief that the technique is being
done properly, or otherwise that they always managed to insert a catheter without
causing trauma so assuming that they are doing the technique properly. The
majority were females (n = 22) with the most experience (n = 12). Having more
than 16 years of experience might lead them to assume that they have all the
knowledge they need or otherwise refuse training as they perceive that others see
them as the all-knowing and be ashamed of attending CPD.
106
This study also demonstrates that family commitments are the most commonly
cited barriers to attendance, a factor rooted in traditional Maltese family dynamics
and culture where the position of the woman/mother was seen within her
household. Many still view women as the housewife probably due to the
imposition of the Catholic ethic over the Maltese for centuries, hinted at by Abela
(2000). Although Maltese society, according to Abela (2001:6) "is moving away
from the iron-fisted grip that both Church and politics had in the past",
Baldacchino (2003) found that we still lag behind our European counterparts with
regards to flexible work arrangements, child care, and responsibility breaks. This
leads us to expect that family commitments hinder these female nurses from
attending CPD. Considering that the majority of nurses are women any other
initiative might not be taken up as one wishes it to be. This further indicates
towards training delivered on site.
5.5 Development, delivery and certification of training
Barbazette (2006) delineated five crucial questions which one should ask before
organising a training event. These are the following: "Why address the deficit
through training?" This can now be answered since the data shows that training is
indicated to rectify a knowledge deficit; "What is to be covered?" and "Who is to
plan, conduct and attend the training?" can be answered by using the data collected
by this study; "How is the material to be delivered?" is a question that also covers
if there should be a practical component as well. This would involve logistics
planning and the data gathered will prove useful in finding an answer; "When
should training be delivered?" can only be answered when training is approved
although one would also have to consider the time of day when it is best delivered.
Consideration is given to knowing if any other training has been planned, the time
of the year when the majority are on leave and so would not be able to attend,
when locations are mostly available, and when exams/conferences are not in
progress. Answers to these questions have been provided hereunder together with
issues of certification.
107
Three studies (Niehbuhr & Stomborg, 2004; Headley, 2005; Cary, 2001) report
that certification should be supported as it is associated with improved patient
outcomes, motivation and satisfaction. The data of the current study shows that the
great majority of respondents (91%; n = 241) would like to be certified implying
that they are satisfied when acquiring a CPD certificate and/or be motivated further
to improve their professional credentials. Those with less autonomy might see
certification as the path to progress in their nursing career. Less (76%; n = 201)
opted for internationally recognised certification. When interpreted within the
context of years of experience, a substantial amount of those 76% have more than
10 years of experience possibly suggesting that they are at a stage in their lives,
maybe due to family commitments, when they do not plan to practice abroad.
Those who opted the least for recognition were Enrolled and Traditionally
qualified while all Masters qualified nurses chose both options. This could either
indicate that traditional course participants do not value CPD highly or otherwise
that those with higher academic qualifications value certification more. This is
only an assumption and does not mean that any of the groups will benefit more or
less from training, that it will result in a change in practice in one and not the other
group, or that it will increase or decrease participation of any group. Hospice
nurses were the least who opted for certification maybe because they are more
motivated to gain the practical knowledge and gain a lot of satisfaction through
improving their patients' outcomes rather than from gaining certification. One
should note that those employed with NGOs26
like Hospice are not eligible for
CPD reimbursement for which one needs to register by submitting proof of
training. This might decrease the value of certification in their eyes but does not
explain why MMDNA, another NGO, was amongst those who's respondents most
opted for certification. This might be due to internal dynamics which promote the
acquisition of further CPD.
26 NGO - nongovernmental organisation
108
With regards to development of training, Urology nurses scored highest (refer to
Table 4.2). This might indicate social desirability bias if the participants chose this
option because they knew that the researcher practices in Urology. Nearly the
same results were obtained for the delivery of training (refer to Table 4.3) although
this time PDNs scored higher than FHS27
staff possibly because PDNs have
organisation and conduction of CPD as one of their core purposes. Secondly,
nurses probably identified themselves with them more than with nurse academics.
Similar results were obtained by Chetcuti (2008) and Ellis (2003) although Munro
& Crawford (2004) argue that the quality of the education provided depends on the
collaboration between education and practice. This suggests that a mix of those
who scored highest might yield the best results. When investigating the modes of
delivery a mix of methods (36%) scored highest. This is also advocated by Allen
et al (2005). It possibly implies that the traditional lecture format or the online
delivery method (which scored lowest) are not preferred since they provide less
interaction between participants and hands on practice. This finding might shed
light on non attendance to both pre registration and catheterisation CPDs. A low
turnout might have materialised if respondents predicted that the delivery would be
in a traditional lecture format and were discouraged by it. A low 5% of
respondents replied that they would prefer to have no assessment at all suggesting
that there exists awareness amongst participants that certification requires some
form of assessment.
The overall poor knowledge demonstrated was in a way acknowledged when
participants listed what they expect out of a course of training (refer to Tables 4.47
and 4.48). The topics included current guidelines and evidence but also basic
knowledge such as choice of catheter, decision when to catheterise, and also
anatomy and physiology. This implies that they would like to learn the technique
afresh including the relevant anatomy and physiology of the urinary tract. A
number of respondents focused on teaching methods and complications. These
27 FHS -Faculty of Health Sciences, University of Malta
109
were either the few possessing most knowledge who would like to focus on other
skills; or who are unaware of their lack of knowledge and deciding to focus more
on other things; or otherwise would want both basics and other topics. A fully
comprehensive CPD programme is being suggested. It might prove lengthy and
costly but these results, combined with statistics of avoidable admissions and
procedures and their combined expenses might as well justify it. This suggests that
a lot of consideration must be devoted to the planning phase of such training for it
to be viable.
5.6 Barriers
This study did not delve directly into the factors which would enhance
participation in a CPD course although a very good indication is provided by the
barriers to attendance. Sussman (2002) divides the barriers in three main
categories, situational28
, institutional29
and dispositional30
, all of which have been
identified by the respondents of this study. The most common barriers outlined in
the literature are: lack of information about CPD (Chetcuti, 2008), shortage of staff
(Dean, 2011), lack of availability, lack of managerial support, family commitments
and personal constraints (Spielhofer et al, 2010; Furze & Pearcey, 1999; Saliba,
1999). The cuts to funding are another major barrier at the detriment of education
(Dean, 2011; Pascoe et al, 2007). This is directly related to release from work
whereby if a replacement is not found, then one will not be released.
The majority of participants stated that they would prefer not to finance their own
studies (n = 163; 64%), a finding prone to non response bias since a lot did not
28 Situational barriers arise from one's own situation at the time and include financial constraints,
family commitments, lack of childcare, and health problems. 29
Institutional constraints arise from the institution and include course fees, times when the
sessions are delivered, course availability, location of training, etc. 30
Dispositional barriers are the attitudes and perceptions towards training held by the person.
110
answer this question. They either think that such training should be paid for by the
MHEC or maybe that it was overpriced. If so they might have opted not to reply
so as not to suggest a future price tag should training be offered later on in the hope
of it being offered for less or for free. If one assumes that the 9 respondents who
practice in an NGO were amongst the 163 respondents and removes them, the
large remaining percentage is employed by the MHEC. The remaining 154 enjoy a
yearly CPD grant (€700) through which the fee could be claimed. This suggests
that respondents are either not availing themselves of the yearly grants, have
assumed that it would not be covered by the CPD allowance, are allocating their
allowances to other CPD initiatives of more interest to them, or prefer to allocate
them to computer system upgrades, tablets or smart phones, which are also covered
by the scheme with the premise of them being used for CPD but which can
ultimately be used by all the family. The least experienced nurses seem to accept
more the concept of financing their own CPD whereas the most experienced
disagree. Since their launch, CPD courses have been run by the Department of
Nursing, FHS which also runs both undergraduate and postgraduate courses. It
could therefore be that the younger generation has been exposed more the concept
of CNE. This exposure to a possibly different professional culture which seems
more inclined towards CPD/CNE than that of 10-15 years ago could be the reason
for younger nurses choosing to finance their own CPD. Two respondents who
opted not to finance their own studies cited reasons for their choice suggesting that
they expect to be trained to offer a service.
"Not appreciated by the DH31
"
Male, EN to SN Course, 10-15 yrs exp.
"It is up to the DH to keep us updated"
Male, Traditional SN, >16 yrs exp.
31 DH standing for the Department of Health, today known as the MHEC.
111
In relation, Ellis' (2003) and Sheperd's (1995) findings cite indifference at
managerial level as a demotivating factor. This is also congruent with Keller's
(1979) [ARCS theory] argument about extrinsic rewards to promote satisfaction
and motivation. Keller holds that positive reinforcement and motivational
feedback are crucial although these seem to be lacking by middle managers. One
argues that if CPD was not appreciated by higher management then there would
have been no effort in setting up the remuneration scheme in the first place. This
seems to be indicating towards middle managers who, according to Gould et al
(2001) are key players in promoting standards of patient care, in motivating
employees and in keeping them satisfied. This suggests that in keeping updated,
personal satisfaction from attending CPD can be drawn (Pennington, 2011)
although this seems to be sparsely cited in the literature (Doyle, 2006). Griscti &
Jacono (2006:452) suggest that policies should demand certification in order to
encourage nurses to "give up their isolation and move toward lifelong learning".
As reflected in Chetcuti's (2008) small scale local study results mandatory CPD
will invariably improve participation but is in opposition to the principles of adult
education whereby if the individuals do not feel the need to learn (Jarvis, 2003) it
might prove of minimal benefit and ultimately result in a waste of resources. The
results of this study might be an eye opener and possibly aid in the planning of a
CPD course, if and when it is launched.
The great majority would consider paying 'less than €100 per person' for training.
This possibly indicates that they want to pay the least possible or that respondents
are not fully aware of the costs of such courses. A quick online search shows that
most advertised online32
cost €50 - €300 per person excluding travel and living
expenses. Once an expert travels to deliver on site training a minimum number of
participants is imposed and the fees rise as much as eightfold. Most courses are
32 See courses available at:
http://www.blackburn.ac.uk/course/the-management-of-urinary-catheterisation-for-adults/
http://www.kcl.ac.uk/teares/nmvc/external/prospectus/study_info.php?code=KSCCC_
http://pepractice.co.uk/course_urinary_catherterisation.html
http://bucks.ac.uk/courses/course/st035
112
valid for a period of two years after which one has to re-certify. A female with
over 10 years experience who holds a Master's qualification chose the highest cost
category. It is possible that after having paid the much higher fees of a Master's
tuition her perception of how much money one should invest in personal
development became very different from those of the others. This does not explain
why the other Master's qualified nurses did not choose the same option although
personal opinions, practice setting, family commitments and financial status at the
time of the study might bear on the decision. Also, they might have read for a
Master's degree with the University of Malta at a time when they were still being
offered for free, possibly not appreciating their cost.
5.7 Strengths and limitations of the study
A strength is in the fact that the researcher is an experienced Urology nurse who
has insight into the practical problems. In this regard, the researcher also acted as a
tool of data collection especially during discussions with different professionals
who provided various perspectives of the issues discussed. Using an anonymous
questionnaire allowed for less socially desirable responses.
The questionnaire also provided open ended questions to allow more freedom to
the respondents. These questions provided data which would otherwise not be
available if one used only quantitative questions whilst avoiding researcher bias,
which could have been present in interviews.
This study is the first of its kind locally and has provided grounding to the
perception that knowledge of LTCC was lacking. It also indicates towards
achievable corrective measures. The researcher, due to the nature of his academic
training and professional status can use the findings to address the problem.
113
The first limitation identified was within the design. As stated in page 14, one of
the main purposes of a NA is the identification of gaps between current and desired
practice. Although priority was given to testing knowledge, an observational
element could have been introduced to substantiate the argument that the lack of
knowledge is causing a deficit in practice.
Another limitation is related to the sampling technique. The researcher wished for
systematic random sampling but due to data protection reasons the option of a
stratified random sample had been chosen. The major limitation of this study is the
relatively low RR. If it had to be repeated one could sample all the areas where
nurses employed with the MHEC practice. Some of the interventions to improve
RR could have been adopted including a more attractive questionnaire design.
Reliability testing was not done extensively. The test-retest was omitted due to the
possibility of contaminating the sample. A pilot study was conducted on Urology
nurses who might have had better knowledge and understood questions better.
This was not checked with the data of the respondents.
It is also not possible to know if non respondents had the same knowledge deficit
as respondents. If more time was available, maybe one would have thought of this
before and found a way so as to contact a sample of non respondents in this regard.
This is a disadvantage of using questionnaires.
Although the study investigated barriers to attending a prospective CPD course on
the topic it did not delve into factors which could enhance participation. This
might be an issue even though barriers might be overcome through careful
planning. To this end, if more focus groups were planned the possibility to gain
more insight into the responses would have materialised. This was not done due to
time limitations.
114
5.9 Conclusion
This chapter discussed the findings of this study in the light of the literature
available within the context of the local situation. The overall findings provide a
good snapshot of the current knowledge of the participants which seems to be quite
poor. The learning needs are varied and include knowledge of the hands on skills
and general infection control. Considering both the amount of patients living with
a LTC and the complications which can develop this lack of knowledge can be
interpreted as dangerous. The next chapter will conclude and offer realistic
recommendations for practice, education, research, and management.
Chapter 6
Conclusion
115
6.1 Conclusion
Urinary catheters are commonly used. Saint et al (2000) estimated that 15%-25%
of hospitalised patients are catheterised and up to 10% of those in long term care
live with a LTC (Sorbye et al, 2005). The ageing world population discussed in
Chapter 1 predisposes to an increase of LTC use. In decreasing the need for
hospitalisations related to LTC problems, nurses, as the end users of these devices,
have to be knowledgeable in caring for the patients who need them.
A cross-sectional design has been adopted to obtain a snapshot of the knowledge
of the population. It was conducted by means of a questionnaire followed by a
focus interview, a mixed method approach, where the strengths of one method
make up for the limitations of another. Due to limitations imposed by data
protection, a stratified random sample of nurses was recruited.
This study sought to identify the learning needs of nurses who care for patients
with LTCs. It investigated knowledge related to the insertion technique, control
and prevention of trauma and infection, and perceptions about related CPD
training. The sample consisted of 496 nurses of which 265 (53%) replied to a
onetime data collection. These nurses practiced in the Community, PHC and in
acute settings. A 29 item questionnaire comprising open and closed ended
questions yielding both quantitative and qualitative data was followed by a focus
interview with a group of PHC nurses. This provided grounding to the data of the
questionnaire. Some statistical tests have been carried out and the qualitative data
has been thematically analysed.
116
This research revealed an overall poor level of knowledge irrespective of pre or
post registration qualifications, years in service, current place of work, or gender.
Some indications have been provided for corrective actions. A very good insight
has been provided into the perceptions about training, barriers to attendance,
planning, delivery and certification of a course, data which might prove invaluable
when planning training. Some recommendations have been offered in view of the
findings, the literature, and the current local situation.
6.2 Recommendations
In view of the findings of this study and the fact that a CPD course in relation to
catheterisation and catheter care is not available, the following recommendations
have been made.
6.2.1 Further research
It is recommended to:
Collect statistics of possibly avoidable admissions or procedures and their
related expenses which are brought about by the use of incorrect/outdated
techniques or by outdated knowledge. This data is difficult to collect but
would be invaluable in justifying the cost of training.
Continue investigating this topic in the form of:
an observational study which can correlate its results to the ones of this
current study
an action research design to allow for planning, conduction,
implementation and evaluation of training.
117
Achieve more depth and grounding, covering areas such as the elderly
setting, the private sector, and Gozo.
Conduct pre and post training data collection if training is approved to
allow evaluation of training and retention of knowledge over time.
6.2.2 Education
It is recommended to:
Address preregistration training on the topic differently to the current
method, moving away from the traditional lecture format towards more
hands on tutorials comprising a smaller number of students. This will
allow individualised attention and a bigger chance of practicing the skill
than when in groups of 15 students or more.
Provide a CPD course specific to catheterisation and catheter care which:
o Covers the topics discussed comprehensively
o Is formulated by Urology nurses, PDNs and Academics
o Is delivered by Urology nurses using mixed approaches
o Allows hands on training
o Includes theoretical discussions delivered on site
o Is assessed using mixed methods of assessment
o Is certified
o Provides time off in lieu of that spent in training and if it is against a
fee, this should be reimbursed by the CPD grant scheme.
6.2.3 Management and Practice
It is recommended to:
118
Concentrate on a joint effort between managers and practitioners whereby
the nurse involved in an incident is identified.
Adopt a no blame attitude and carry out a root cause analysis every time a
traumatic catheterisation is identified.
Address the needs indicated by the analysis.
Draft policies to provide a framework within which managers,
'investigators', trainers, and nurses are able to work in tandem to address
these issues.
Promote CPD attendance, especially by middle managers.
References
119
Abdullah, B. F. (2008). Guidelines for CPD programme for Nurses/Midwives.
Unpublished manuscript.
Abela, A. A. (2000). Values of women and men in the Maltese islands, a comparative
European perspective. (1st ed.). Valletta: Commission for the Advancement of
Women, Ministry for Social Policy.
Abela, J. S. (2001, Tuesday 8th March). Women in Malta: Just how emancipated are
they?. The Malta Independent, pp. 6.
Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U., Wein, A. (2002).
The standardization of terminology of lower urinary tract function: Report from the
standardization sub-committee of the international continence society. Neurourology
and Urodynamics, 21, 167.
Akhtar-Danesh, N., Valaitis, R. K., Schofield, R., Underwood, J., Martin-Misener, R.,
Baumann, A., & Kolotylo, C. (2010). A questionnaire for assessing community
health nurses’ learning needs. Western Journal of Nursing Research, 32(8), 1055-
1072. doi:10.1177/0193945910373600
Al-Habdan, I., Sadat-Ali, M., Corea, J. R., Al-Othman, A., Kamal, B. A., & Shriyan, D.
S. (2003). Assessment of nosocomial urinary tract infections in orthopaedic patients:
A prospective and comparative study using two different catheters. International
Surgery, 88(3), 152.
120
Allen, M., Jacobs, S. K., Levy, J., Pierce, S., Pravikoff, D., & Tanner, A. (2005).
Continuing education as a catalyst for inter-professional collaboration. Medical
Reference Services Quarterly, 24(3), 93.
Allepuz-Palau, A., Rossello-Urgell, J., Vaque-Rafart, J., Hermosill-Perez, E., Arribas-
Llorente, J. L., Sanchez-Paya, J., & Lizan-Garcia, M. (2004). Evolution of closed
urinary drainage systems use and associated factors in Spanish hospitals. Journal of
Hospital Infections, 57(4), 332-338.
Ameen, J. (2012, March 14th). New policy at emergency department: Patients with minor
complaints sent to health centers. Times of Malta.
American Association of Critical Care Nurses. (2013). Catheter-associated urinary tract
infections. Retrieved 04/09, 2013, from
http://www.aacn.org/wd/practice/content/practicealerts/cathassocuti-
nov11.pcms?menu=
American Nurses Association. (2000). Scope and standards of practice for nursing
professional development. U.S.A: American Nurses Publishing.
Anderson, D. M. (2002). Mosby's medical, nursing, and allied health dictionary. (6th
ed.). United Kingdom: Mosby.
Anthony, S., & Jack, S. (2009). Qualitative case study methodology in nursing research:
An integrative review. Journal of Advanced Nursing, 65(6), 1171.
doi:10.1111/j.1365-2648.2009.04998.x
121
Arain, M., Campbell, M. J., Cooper, C. L., & Lancaster, G. A. (2010). What is a pilot or
feasibility study? A review of current practice and editorial policy. BMC Medical
Research Methodology, 10(67)
Armstrong, D., & Adam, J. (2002). The impact of postgraduate critical care course on
nursing practice. Nurse Education in Practice, 2, 169.
Atkins, J. (2009). What are the current barriers to training and learning provision in the
UK? Retrieved 14/03, 2013, from http://www.bcs.org/content/conBlogPost/1489
Australian and New Zealand Urological Nurses Society. (2006). Catheter care
guidelines. Retrieved 09/09, 2011, from
http://www.anzuns.org/ANZUNS_catheterisation_document.pdf
Baharein, K., & Noor, M. (2008). Case study: A strategic research methodology.
American Journal of Applied Sciences, 5(11), 1602.
Baldacchino, G. (2003). Factors affecting Women’s formal participation in the Malta
labour market: Results of a research project. Unpublished manuscript.
Barbazette, J. (2006). In Taff R. (Ed.), Training needs assessment. methods, tools, and
techniques. (1st ed.). USA: Pfeiffer.
Bardsley, A. (2005). Use of lubricant gels in urinary catheterisation. Nursing Standard,
20(8), 41.
122
Barratt, H., & Kirwan, M. (2009). Cross-sectional studies. design, application, strengths
& weaknesses of cross-sectional studies. Retrieved 12/12, 2012, from
http://www.healthknowledge.org.uk/public-health-textbook/research-methods/1a-
epidemiology/cs-as-is/cross-sectional-studies
Bhardwaj, R., Pickard, R., & Rees, J. (2010). Documented adherence to standards and
guidelines: An audit. British Journal of Nursing, 19(18 Supplement).
Borg Xuereb, R. (2006). CPD annual report. Institute of Health Care, University of
Malta, Malta. Unpublished manuscript.
Bowling, A. (2002). Research methods in health investigating health and health services
(2nd ed.). London: Open University Press.
Boyd, H. H. (2005). Quick tips: How to get a respectable response rate. Retrieved 03/16,
2013, from http://www.uwex.edu/ces/pdande/resources/pdf/Tipsheet1.pdf
Bray, L., Sanders, C., & Flynn, A. (2010). Paediatric catheterisation: Exploring and
understanding children's nurses' perceptions and practice in an acute setting. Journal
of Clinical Nursing, 19, 3235.
Bray, L., & Sanders, C. (2007). Urethral catheter audit. Paediatric Nursing, 19(3), 14-16.
Brown, J. (2002). Training needs assessment: A must for developing an effective training
program. Public Personnel Management, 31(4), 569-569.
123
Bryman, A. (2006). Integrating quantitative and qualitative research: How is it done?
Qualitative Research, 6(1), 97-113.
Buchan, J., & Calman, L. (2005). The global shortage of nursing: An overview of issues
and actions. Geneva: International Council of Nurses.
Burke-Johnson, R., & Onwuegbuzie, A. J. (2004). Mixed method research: A research
paradigm whose time has come. Educational Researcher, 33(7), 14.
Burnard, P. (1991). A method of analyzing interview transcripts in qualitative research.
Nurse Education Today, 11, 461-466.
Calleja, E. (2012). Indwelling urethral catheters in adults. Journal of the Malta College of
Pharmacy Practice, 18, 33-35.
Calman, K. C. (2008). A review of continuing professional development in general
practice. United Kingdom: Department of Health.
Carson, M., & Culyer, L. (1996). Catheter care. Primary Health Care, 6(6), 17-19.
Caruana, J. (2012). Update: Nurses complain conditions at emergency dept still
unacceptable. The Times of Malta
Cary, A. (2001). Certified registered nurses: Results of the study of the certified
workforce. American Journal of Nursing, 101(1), 44.
Casey, D., & Houghton, C. (2010). Clarifying case study research: Examples from
practice. Nurse Researcher, 17(3), 41.
124
Cekada, T. L. (2010). Training needs assessment. Professional Safety, 55(3), 28-33.
Centers for Disease Control and Prevention. (2010). Increasing questionnaire response
rates. Retrieved 03/16, 2013, from
http://www.cdc.gov/healthyyouth/evaluation/pdf/brief21.pdf
Centers for Disease Control and Prevention. (2012). Catheter associated urinary tract
infections (CAUTI). Retrieved 09/09, 2012, from
http://www.cdc.gov/HAI/ca_uti/uti.html
Chang, W., Tseng, I., Hsiao, F., & Wang, M. (2003). Continuing education needs and
barriers for public health nurses in aboriginal townships in Taitung, Taiwan. Journal
of Nursing Research (Taiwan Nurses Association), 11(4), 295-302.
Chetcuti, S. (2008). Continuous professional development: A&E nurses' views and
expectations. Unpublished manuscript.
Chiesa, M., & Hobbs, S. (2008). Making sense of social research: How useful is the
Hawthorne effect? European Journal of Social Psychology, 38(1), 67-74.
doi:10.1002/ejsp.401
Cluett, E.R., & Bluff, R. (2000). Principles and practice of research in midwifery.
London: Bailliere Tindall.
Coggon, D., Rose, G. & Berker, D. J. P. (2012). Epidemiology for the uninitiated.
Retrieved 12/12, 2012, from http://www.bmj.com/about-bmj/resources
readers/publications/epidemiology-uninitiated
125
Cohen, S. I. (1985). A cost-benefit analysis of industrial training. Economics of
Education Review, 4(4), 327-339.
Colgan, R., Nicolle, L. E., McGloone, A., & Hooton, T. (2006). Asymptomatic
bacteriuria in adults. American Family Physician 74(6):985-990.
Commission of European Communities. (2001). Memorandum on lifelong learning.
Brussels: Commission of European Communities.
Cormack, D. F. S. (2000). The research process in nursing (4th ed.). London: Blackwell
Science.
Council of Nurses and Midwives. (2002). The scope of professional practice.
Unpublished manuscript.
Cowie, A. P. (Ed.). (1990). Oxford advanced learner's dictionary (5th ed.). Great Britain:
Oxford University Press.
Cully, M., Vanden Heuvel, A., & Wooden, M. (2000). Participation in, and barriers to,
training: The experience of older adults. Australasian Journal on Ageing, 19(4),
172.
Davies, P., Houghton, A. M., Morgan, L., Saunders, M., Jayousi, D., Marsden, R. &
Whytock, S. (2006). Focus groups. Retrieved 01/11, 2008, from
http://www.lancs.ac.uk/fass/events/capacitybuilding/docs/7E%20Evaluation%20Met
hods%20-%20Focus%20Groups%20-%20V1.pdf
126
de Courcy-Ireland, K. (1993). An issue of sensitivity: Use of analgesic gel in
catheterising women. Professional Nurse, 8(11), 738-740.
Dean, E. (2011). Nurses miss out of essential training due to staff shortages. Nursing
Standard, 25(18), 8.
Denzin, N. (2009). The research act: A theoretical introduction to sociological methods.
USA: Mc-Graw Hill.
Department of Economics within IOWA University. (2007). Interpreting tables.
Retrieved 01/12, 2013, from
http://www2.econ.iastate.edu/classes/crp274/swenson/CRP272/Interpreting%20table
s%20and%20chi%20square.pdf
Devine, A. L. (2003). Female catheterisation: What nurses need to know! Accident &
Emergency Nursing, 11(2), 91.
Docherty, A., & Sandhu, H. (2006). Student-perceived barriers and facilitators to e-
learning in continuing professional development in primary care. Education for
Primary Care, 17, 343.
Doyle, C. (2006). Methods of continuing professional education preferred by Irish
paediatric nurses. Journal for Specialists in Paediatric Nursing, 11(2), 90.
Drey, N., Gould, D., & Allan, T. (2009). The relationship between continuing
professional education and commitment to nursing. Nurse Education Today, 29(7),
740-745. doi:10.1016/j.nedt.2009.03.008
127
Edwards, P., Roberts, I., Clarke, M., DiGuiseppi, C., Pratap, S., Wentz, R., & Kwan, I.
(2002). Increasing response rates to postal questionnaires: Systematic review. British
Medical Journal, 324, 16.03.2013.
Ellis, B. (2003). Illuminative case study design: A new approach to the evaluation of
continuing professional development. Nurse Researcher, 10(3), 48.
Fenech Adami, M., & Kiger, A. (2005). A study of continuing nurse education in Malta:
The importance of national context. Nurse Education Today, 25, 78.
Fernandes-Taylor, S., Hyun2, J. K., Reeder, R. N., & Harris, A. H. S. (2011). Common
statistical and research design problems in manuscripts submitted to high-impact
medical journals. BMC Research Notes, 4, 304. doi:10.1186/1756-0500-4-304
Fleming, A. A., Day, J., & Glanfield, L. (2000). Registered nurse management of urinary
catheters in a rehabilitation and long-term care hospital. International Journal of
Nursing Practice, 6(5), 237-246. doi:10.1046/j.1440-172X.2000.00216.x
Forbes, A., While, A., & Ullman, R. (2006). Learning needs analysis: The development
of a tool to support the on-going professional development of multiple sclerosis
specialist nurses. Nurse Education Today, 26(1), 78-86.
Frankfort-Nachimas, C., & Nachimas, D. (1996). Research methods in the social sciences
(5th ed.). London: Arnold.
Furze, G., & Pearcey, P. (1999). Continuing education in nursing: A review of the
literature. Journal of Advanced Nursing, 29(2), 355.
128
Gallagher, L. (2006). Continuing education in nursing: A concept analysis. Nurse
Education Today, 27, 466. doi:10.1016/j.nedt.2006.08.007
Galloway, A. (1997). Questionnaire design & analysis. Retrieved 03/21, 2007, from
http://www.tardis.ed.ac.uk./~kate/qmcweb/qcont.htm
Geng, V., Cobussen-Boekhorst, H., Farrell, J., Gea-Sanchez, M., Pearce, I.,
Schwennesen, T., . . . Vandewinkel, C. (2012). In Geng V., Cobussen-Boekhorst H.,
Farrell J., Gea-Sanchez M., Pearce I., Schwennesen T., Vandewinkel C.(Eds.),
Evidence based guidelines for best practice in urological health care.
catheterisation. indwelling catheters in adults: Urethral and suprapubic. (1st ed.).
The Netherlands: European Association of Urology Nurses.
Gerrish, K., & & Lacey, A. (2010). The research process in nursing (6th ed.). United
Kingdom: Wiley-Blackwell.
Gibbs, G. R. (2010). Analyzing qualitative data (1st ed.). London: Sage.
Gibson, F. K., & Hawkins, B. W. (2004). Interviews versus questionnaires.
Questionnaires (1st ed.). London: Sage Publications.
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A. & Healthcare
Infection Control Practices Advisory Committee (HICPAC). (2009). Guideline for
prevention of catheter-associated urinary tract infections. Retrieved 12/03, 2012,
from http://www.cdc.gov/hicpac/cauti/001_cauti.html
129
Gould, D., Kelly, D., Goldstone, L., & Maidwell, A. (2001). The changing training needs
of clinical nurse managers: Exploring issues for continuing professional
development. Journal of Advanced Nursing, 34(1), 7.
Gould, D., Kelly, D., & White, I. (2004). Training needs analysis: An evaluation
framework. Nursing Standard, 18(20), 33-36.
Grant, J. S., & Davis, L. L. (1997). Focus on quantitative methods. selection and use of
content experts for instrumental development. Research in Nursing and Health, 20,
269.
Grant, J. (2002). Learning needs assessment: Assessing the need. BMJ (Clinical Research
Ed.), 324(7330), 156-159.
Green, A., Westwood, O., Smith, P., Pensiton-Bird, F., & Holloway, D. (2009). Provision
of continued professional development for non-medical prescribers within a south of
England strategic health authority: A report on a training needs analysis. Journal of
Nursing Management, 17(5), 603-614. doi:10.1111/j.1365-2834.2008.00892.x
Green, R., Gorzka, P., & Kodish, S. (2005). Achieving excellence in practice: A model
for continuing education for nurse practitioners. Journal of the American Academy of
Nurse Practitioners, 17(11), 452.
Greenbaum, T. L. (1998). The handbook for focus group research (2nd ed.). London:
Sage Publications.
130
Greenwald, A. G., Carnot, C. G., Beach, R., & Young, B. (1987). Increasing voting
behavior by asking people if they intended to vote. Journal of Applied Psychology,
72, 315.
Griscti, O., & Jacono, J. (2006). Effectiveness of continuing education programmes in
nursing: Literature review. Journal of Advanced Nursing, 55(4), 449.
Gujral, Kirkwood, Hinchliffe, & Gujral. (1999). Suprapubic catheterization: A suitable
procedure for clinical nurse specialists in selected patients. BJU International, 83(9),
954-956. doi:10.1046/j.1464-410X.1999.00051.x
Hagen, S., Sinclair, L., & Cross, S. (2010). Washout policies in long-term indwelling
urinary catheterisation in adults. Cochrane Database Systematic Review, 17(3)
doi:CD004012
Halcomb, E., Meadey, E., & Streeter, S. (2009). Professional development needs of
general practice nurses. Contemporary Nurse, 32(1), 201.
Halloway, I., & Wheeler, S. (2011). Qualitative research in nursing and healthcare (3rd
ed.). UK: Wiley-Blackwell.
Hartley, J., Davies, L., & Burnhill, P. (1977). Alternatives in typographic design of
questionnaires. Journal of Occupational Psychology, 50, 299.
Harvey-Cielto et al (n.d). Instructional design. Retrieved 14/01, 2013, from
http://www.slideshare.net/ChristinaSookdeo/motivational-theories-12696671
131
Hayter, M. (1999). Burnout and AIDS care-related factors in HIV community clinical
nurse specialists in the north of England. Journal of Advanced Nursing, 29(4), 984.
Hazelett, S. E., Tsai, M., Gareri, M., & Allen, K. (2006). The association between
indwelling urinary catheter use in the elderly and urinary tract infection in acute
care. BMC Geriatrics, 6, 15-15.
Headley, C. M. (2006). Setting the stage for professional development. Nephrology
Nursing Journal, 33(5), 517.
Henry, M. (1992). Catheter confusion. Nursing Times, 88(42), 65-72.
Hicks, C., & Hennessy, D. (1997). The use of a customized training needs analysis tool
for nurse practitioner development. Journal of Advanced Nursing, 26(2), 389-398.
doi:10.1046/j.1365-2648.1997.1997026389.x
Holloway, I., & Wheeler, S. (2011). Qualitative research in nursing and healthcare. (3rd
ed.). United Kingdom: Wiley-Blackwell.
Holton, EF III. (2000). Large-scale performance-driven training needs assessment. Public
Personnel Management, 29(2), 249-249.
Inu, T. S. (1996). The virtue of qualitative and quantitative Research . Annals of Internal
Medicine, 125(9), 730.
132
Iqbal, M. Z., & Khan, R. A. (2011). The growing concept and uses of training needs
assessment. A review with proposed model. Journal of European Industrial
Training, 35(5), 439-466. doi:10.1108/03090591111138017
Jacobson, H. E., Mas, F. S., Hsu, C. E., Turley, J. P., Miller, J., & Kim, M. (2010). Self-
assessed emergency readiness and training needs of nurses in rural Texas. Public
Health Nursing, 27(1), 41.
Jarvis, P. (2010). Adult education and lifelong learning (4th ed.). USA: Routledge.
Jarvis, P. (1996). Adult and continuing education. London: Routledge.
Jarvis, P., Holford, J., & Griffin, C. (2003). The theory and practice of learning. United
Kingdom: Kogan Page.
Jenner, E. A. (1998). A case study analysis of nurses' roles, education and training needs
association with patient-focused care. Journal of Advanced Nursing, 27(1087).
Jick, T. D. (1979). Mixing qualitative and quantitative methods: Triangulation in action.
Administrative Science Quarterly, 24(4), 602.
Johansson, R. M., & Christensson, L. (2010). Urinary retention in older patients in
connection with hip fracture surgery. Journal of Clinical Nursing, 19, 2110.
doi:10.1111/j.1365-2702.2010.03261.x
133
Johnson, J. R., Kuskowski, M. A., & Wilt, T. J. (2006). Systematic review:
Antimicrobial urinary catheters to prevent catheter-associated urinary tract infection
in hospitalized patients. Annals of Internal Medicine, 144(2), 116.
Johnson, D., Russell, R., Lockatell, V., Zulty, J., & Warren, J. (1993). Urethral
obstruction of 6 hours or less causes bacteruria, bacteraemia, and pyelonephritis in
mice challenged with "neuropathogenic" Escherichia coli. Infection and Immunity,
61(8), 3422-3428.
Jones, J., & Lowe, T. (2003). The education and training needs of qualified mental health
nurses working in acute adult mental health services. Nurse Education Today, 23(8),
610-619.
Kalsi, J., Arya, M., Wilson, P., & Mundy, A. (2003). Hospital-acquired urinary tract
infection. International Journal of Clinical Practice, 57(5), 388.
Keller, J. M. (1979). Motivation and instructional design: A theoretical perspective.
Journal of Instructional Development, 2(4), 26-34.
Khawcharoenporn, T., Vasoo, S., Ward, E., & Singh, K. (2011). Abnormal urinalysis
finding triggered antibiotic prescription for asymptomatic bacteriuria in the ED.
American Journal of Emergency Medicine, 29(7), 25.03.2013-828.
Knight, C. S., Badros, K. K., Madden, C. A., Drewer, N., & Makuchal, P. (2006). Sports
medicine and school nurses: A growing need for further education and appropriate
resources. Journal of School Health, 76(1), 8.
134
Lees, L., & Emmerson, K. (2006). Identifying discharge practice training needs. Nursing
Standard, 20(29), 47.
Leigh, D., Watkins, R., Platt, W. A., & Kaufman, R. (2000). Alternate models of needs
assessment: selecting the right one for your organization. Human Resource
Development Quarterly, 11(1), 87.
Leon, A. C., Davis, L. L., & Kraemer, H. C. (2011). The role and interpretation of pilot
studies in clinical research. Journal of Psychiatric Research, 45, 626.
Litosseliti, L. (2007). Using focus groups in research. London: Continuum.
Longman, C., Temple-Smith, M., Gilchrist, G., & Lintzeris, N. (2012). Reluctant to train,
reluctant to prescribe: Barriers to general practitioner prescribing of opioid
substitution therapy. Australian Journal of Primary Health, 18(4), 28/03/2013.
Lowthian, P. (1998). The dangers of long-term catheter drainage. British Journal of
Nursing, 7(7), 366-368.
Madigan, E., & Neff, D. F. (2003). Care of patients with long-term indwelling urinary
catheters. Online Journal of Issues in Nursing, 8(3), 130-141.
Mangnall, J. (2012). OptiLube active. the role of lubricants in urinary catheterisation.
British Journal of Community Nursing, 17(9), 414.
Marklew, A. (2004). Literature review urinary catheter care in the intensive care unit.
Nursing in Critical Care, 9(1), 21-27. doi:10.1111/j.1362-1017.2004.0048.x
135
Mateo, M. A., & Kirchoff, K. T. (1991). Conducting and using nursing research in the
clinical setting. London: Williams and Wilkins.
Matsuda, M. (2008). Editorial comment: Globalization and health care policy. Nursing
Ethics, 15(4), 429-430. doi:10.1177/0969733008090512
McConnell, E. A., Cattonar, M., & Manning, J. (1996). Australian registered nurse
medical device education: A comparison of simple vs. complex devices. Journal of
Advanced Nursing, 23(2), 322-328. doi:10.1111/1365-2648.ep8542357
McGrath, R. G., & MacMillan, I. C. (1995). Defining and developing competence: A
strategic process paradigm. Strategic Management Journal, 16(4), 251-275.
McNulty, C., Bowen, J., Foy, C., Gunn, K., Freeman, E., Tompkins, D., . . . Smith, G. E.
(2006). Urinary catheterization in care homes for older people: Self-reported
questionnaire audit of catheter management by care home staff. Journal of Hospital
Infection, 62(1), 29-36.
Miles, G., & Schroeder, J. (2009). An evidence-based approach to urinary catheter
changes. British Journal of Community Nursing, 14(5), 182-187.
Miller, J. A., & Osinski, D. M. (2002). Training needs assessment. Unpublished
manuscript.
Morgan, D. L. (1998). Practical strategies for combining qualitative and quantitative
methods: Applications to health research. Qualitative Health Research, 8, 362.
doi:10.1177/104973239800800307
136
Morse, J. M. (1996). Critical issues in qualitative research methods. London: Sage
Publications.
Munro, K., & Crawford, A. (2004). Developing and accrediting a CPD framework.
Nursing Standard, 19(8), 40.
Nash, M. (2005). Physical care skills: A training needs analysis of inpatient and
community mental health nurses. Mental Health Practice, 9(4), 20-23.
National Cancer Institute. (2012). End-of-life care for people who have cancer. Retrieved
02/14, 2013, from http://www.cancer.gov/cancertopics/factsheet/Support/end-of-life-
care
National Council for the Professional Development of Nursing and Midwifery. (2004).
Report on the continuing professional development of staff nurses and staff
midwives. National Council for the Professional Development of Nursing and
Midwifery.
National Health Service. (1999). Continuing professional development. quality in the new
NHS. National Institute for Health and Clinical Excellence. (2012). Infection:
Prevention and control of healthcare-associated infections in primary and
community care. Retrieved 04/01, 2012, from
http://www.nice.org.uk/guidance/CG139
Neuman, W. L. (Ed.). (2000). Social research methods. qualitative and quantitative
approaches. (4th ed.). London: Allyn and Bacon.
137
NHS Great Yarmouth and Waveney. (2006). Policy for catheter management.
Unpublished manuscript.
Nicolle, L. E. (2008). The prevention of hospital-acquired urinary tract infection. Clinical
Infectious Diseases, 46, 251.
Niebuhr, B., & Stomborg, M. (2004). Survey of nurse managers: Perceptions of the value
of speciality nursing certification. Nursing Management, 36(5), 36.
Nursing and Midwifery Council. (2002). Code of professional conduct. Unpublished
manuscript.
Nursing and Midwifery Council. (2010). Lack of competence. Retrieved 06/11, 2011,
from http://www.nmc-uk.org/Employers-and-managers/Fitness-to-practise/Lack-of
competence/
O'Connor, S. J. (2010). Great expectations in hard times: Some thoughts on the nature of
continuing professional development and continuing medical education. European
Journal of Cancer Care, 19, 1. doi:10.1111/j.1365-2354.2009.01172.x
Ogier, M. (1998). Reading research (2nd ed.). London: Bailliere Tindall.
O'Kell, S. (1986). A literature search into the continuing education undertaken in nursing.
Nurse Education Today, 6(4), 152-157.
138
Olsen, C., & St.George, D. M. M. (2004). Cross-sectional study design and data analysis.
Retrieved 12/12, 2012, from
http://www.collegeboard.com/prod_downloads/yes/4297_MODULE_05.pdf
Onwuegbuzie, A. J. (2000). Annual meeting of the association for the advancement of
educational research. Expanding the Framework of Internal and External Validity in
Quatitattive Research, Ponte Vedra, Florida.
Oulton, J. A. (2006). The global nursing shortage: An overview of issues and actions.
Policy, Politics & Nursing Practice, 7(3), 34S-39.
Pallant, J. (2007). SPSS survival manual (3rd ed.). England: Open University Press.
Parahoo, K. (2006). Nursing research principles, process and issues (2nd ed.). United
Kingdom: Palgrave Macmillan.
Pascoe, T., Hutchinson, R., Foley, E., Watts, I., Whitecross, L., & Snowdon, T. (2007).
The educational needs of nurses working in Australian general practices. Australian
Journal of Advanced Nursing, 24(3), 33.
Pelletier, D., Donoghue, J., & Duffield, C. (2003). Australian nurses' perception of
impact of their postgraduate studies on their patient care activities. Nurse Education
Today, 23, 434.
Pellowe, C. (2009). Using evidence-based guidelines to reduce catheter related urinary
tract infections in England. Journal of Infection Prevention, 10(2), 44-48.
139
Pennington, H. (2011). Using a training needs analysis framework in career development.
Nursing Management, 18(2), 32.
Personal Communication. (2011). Average catheter changes per annum by MMDNA.
Malta: CommCare Unit.
Pfisterer, M., Johnson, T. M., Jenetzky, E., Hauer, K., & Oster, P. (2007). Geriatric
patients’ preferences for treatment of urinary incontinence: A study of hospitalized,
cognitively competent adults aged 80 and older. Journal of the American Geriatrics
Society, 55, 2016.
Plager, K. A., & Razaonandrianina, J. O. (2009). Madagascar nursing needs assessment:
Education and development of the profession. International Nursing Review, 56, 58.
Pouslen, A., Lam, K., Cisneros, S., & Trust, T. (2008). ARCS model of motivational
design. Retrieved 14/01, 2013, from
http://www.torreytrust.com/images/ITH_Trust.pdf
Polit, D. F., & Hungler, B. P. (1999). Nursing research. principles and methods (6th
ed.). Philadelphia: Lippincott.
Polit, D. F., Tatano, C., & Hungler, B. P. (2001). Essentials of nursing research.
methods, appraisal and utilization (5th ed.). Philadelphia: Lippincott Williams &
Wilkins.
Pratt, R., & Pellowe, C. (2010). Good practice in management of patients with urethral
catheters. Nursing Older People, 22(8), 25-29.
140
Pulkkinen, J. (2003). An analysis of the communication structures in the research on
information and communication technology integration in education in the years
2000–2001. Retrieved 12/12, 2012, from Myös verkkojulkaisuna.
http://herkules.oulu.fi/isbn9514272463/
Punch, K. F. (2005). Introduction to social research. quantitative and qualitative
approaches (2nd ed.). London: Sage Publications.
Quan, K. (2012). Moving to another department. Retrieved 03/12, 2013, from
http://www.netplaces.com/new-nurse/setting-future-career-goals/moving-to-another-
department.htm
Rattray, J., & Jones, M. C. (2007). Essential elements of questionnaire design and
development. Journal of Clinical Nursing, 16, 234.
Rebar, C. R., Gersch, C. J., Macnee, C. L., & McCabe, S. (Eds.). (2011). Understanding
nursing research. using research in evidence-based practice. (3rd ed.). London:
Lippincott Williams & Wilkins.
Reddy, Y. R. K. (1979). Cost benefit analysis of training - an appraisal. Long Range
Planning, 12(6), 50-55.
Rew, M. Use of catheter maintenance solutions for long-term catheter care. British
Journal of Nursing, 8(11), 708-714.
Robson, C. (2002). Real world research: A resource for social scientists and practitioner
researchers (2nd ed.). London: Blackwell.
141
Roe, B. H. (1989). Study of information given by nurses for catheter care to patients and
their carers. Journal of Advanced Nursing, 14, 203-210.
Roe, B. H., & Brocklehurst, J. C. (1987). Study of patients with indwelling catheters.
Journal of Advanced Nursing, 12, 713-719.
Rowley, J. (2002). Using case studies in research. Management Research News, 25(1),
16.
Royal College of Nurses. (2012). Catheter care: RCN guidance for nurses. Retrieved
11/14, 2012, from
http://www.rcn.org.uk/__data/assets/pdf_file/0018/157410/003237.pdf
Runciman, W. B. (2002). Qualitative versus quantitative research – balancing cost, yield
and feasibility. Quality and Safety in Health Care, 11, 146.
Saint, S., Wiese, J., Amory, J. K., Bernstein, M. L., Patel, U. D., Zemencuk, J. K., . . .
Hofer, T. P. (2000). Are physicians aware of which of their patients have indwelling
urinary catheters? The American Journal of Medicine, 109(6), 476-480.
Saint, S., & Wiese, J. (2000). Are physicians aware of which of their patients have
indwelling urinary catheters? American Journal of Medicine, 109(6), 476.
Salas, E., & Cannon-Bowers, J. A. (2001). The science of training: A decade of progress.
Annual Review of Psychology, 52, 471-479.
142
Sanchez, M. E. (1992). Effects of questionnaire design on the quality of survey data.
Public Opinion Quarterly, 56, 206.
Saxer, S., de Bie, R. A., Dassen, T., & Halfens, R. J. G. (2008). Nurses' knowledge and
practice about urinary incontinence in nursing home care. Nurse Education Today,
28, 926.
Seale, C. (1999). The quality of qualitative research. London: Sage Publications.
Seloilwe, E. S. (2005). Globalization and nursing Wiley-Blackwell. doi:10.1111/j.1365-
2648.2005.03430.x
Sewell, M. (2012). The use of qualitative interviews in evaluation. Retrieved 03/07, 2007,
from http://ag.arizona.edu/fcs/cyfernet/cyfar/Intervu5.htm
Sheperd, J. C. (1995). Findings of a training needs analysis for qualified nurse
practitioners. Journal of Advanced Nursing, 22, 66.
Silverman, D. (Ed.). (2010). Interpreting qualitative data (3rd ed.). London: Sage.
Skees, J. (2010). Continuing education: A bridge to excellence in critical care nursing.
Critical Care Nursing Quarterly, 33(2), 104-116.
doi:10.1097/CNQ.0b013e3181d913a1
Sørbye, L., Finne-Soveri, H., Ljunggren, G., Topinkova, E., & Bernabei, R. (2005).
Indwelling catheter use in home care: Elderly, aged 65+, in 11 different countries in
Europe. Age & Ageing, 34(4), 377-381.
143
Sperling, H., Lummen, G., & Rubben, H. (2005). Use of lubricants in urology.
Indications and results. Der Urologe, 44(6), 662.
Spielhofer, T., Golden, S., Evans, K., Marshall, H., Mundy, E., Pomati, M., & Styles, B.
(2010). Barriers to participation in education and training. (No. 1). UK: National
Foundation for Educational Research. doi:978-1-84775-709-8
Sproull, N. L. (1988). Handbook of research methods: A guide for practitioners and
students in the social sciences. London: The Scarecrow Press Ltd.
Staniland, K. (2011). Staff support in continuing professional development. Nursing
Management, 18(1), 33.
StatPac Statistics Manual. Statistics. Retrieved 01/12, 2013, from
http://statpac.com/manual/statistics.htm
Stickler, D. J., & Chawla, J. C. (1987). The role of antiseptics in the management of
patients with long-term indwelling bladder catheters. The Journal of Hospital
Infection, 10(3), 219.
Sussman, D. (2002). Barriers to job-related training. Perspectives, 5-12.
The Foundation Programme Malta. (2011). Our hospitals. Retrieved 02/09, 2012, from
http://www.fpdoctors.info/index.php?page=our-hospitals
Theriault, R., Ward-Smith, P., & Soper, C. (2012). Leakage associated with urinary
catheter usage: A design challenge. Urologic Nursing, 32(6), 307.
144
Topal, J., Conklin, S., Camp, K., Morris, V., Balcezak, T., & Herbert, P. (2005).
Prevention of nosocomial catheter-associated urinary tract infections through
computerized feedback to physicians and a nurse-directed protocol. American
Journal of Medical Quality, 20(3), 121.
United Kingdom Central Council. (1986). Project 2000. (No. 1). London: UKCC.
United Kingdom Central Council for Nursing, Midwifery, and Health Visiting. (1986).
Project 2000:The new preparation for practice. UKCC. (Project 2000)
United Nations. (2002). World population ageing: 1950-2050. Retrieved 11/11, 2012,
from http://www.un.org/esa/population/publications/worldageing19502050/
University of Stirling. (2008). Policy on development and delivery of continuous
professional development. Retrieved 07/28, 2011, from
http://www.research.stir.ac.uk/documents/CPDpolicyUpdatedJan2011.pdf
University of Toronto. (2010). Measures of association: Nominal data--phi and Cramer's
V Retrieved 01/12, 2013, from http://homes.chass.utoronto.ca/~josephf/pol242/LM-
3A#Measures%20of%20Association:%20Phi%20and%20Cramers%20V
Weaver, B. (2009). Assumptions/Restrictions for chi-square tests on contingency tables.
Retrieved 01/12, 2013, from
https://sites.google.com/a/lakeheadu.ca/bweaver/Home/statistics/notes/chisqr_assum
ptions
145
Weinreich, N. K. (2006). Integrating quantitative and qualitative methods in social
marketing research. Retrieved 03/11, 2007, from http://wwwsocial-
marketing.com/research.html
Weinstein, J. W., Mazon, D., Pantelick, E., Reagan-Cirincione, P., Dembry, L. M., &
Hierholzer, W. J. (1999). A decade of prevalence surveys in a tertiary-care center:
Trends in nosocomial infection rates, device utilization, and patient acuity. Infection
Control & Hospital Epidemiology, 20(8), 543.
Werrett, J. A., Helm, R. H., & Carnwell, R. (2001). The primary and secondary care
interface: The educational needs of nursing staff for the provision of seamless care.
Journal of Advanced Nursing, 34(5), 629-638. doi:10.1046/j.1365-
2648.2001.01792.x
While, A., Ullman, R., & Forbes, A. (2007). Development and validation of a learning
needs assessment scale: A continuing professional education tool for multiple
sclerosis specialist nurses. Journal of Clinical Nursing, 16, 1099.
Whittaker, K. A., Davies, S., Thomson, A. M., & Shepherd, B. (1997). A survey of
community placements for educational programmes in nursing and midwifery. Nurse
Education Today, 17(6), 463-472.
Wilde, M. H. (1997). Long-term indwelling urinary catheter care: Conceptualizing the
research base. Journal of Advanced Nursing, 25, 1252.
146
Williams, R. (2012). Categorical data analysis Retrieved 01/12, 2012, from
http://www3.nd.edu/~rwilliam/stats1/x51.pdf
Williams, A., Taylor, K., Bates, C., Tincello, D. G., & Richmond, D. H. (2003).
Knowledge of female bladder care among medical staff, nurses and midwives:
Results of a questionnaire survey. BJU International, 91(3), 208-210.
doi:10.1046/j.1464-410X.2003.03080.x
Wilson, M. (2011). Addressing the problems of long term urethral catheterization: Part 1.
British Journal of Nursing, 20(22), 1418.
Wisker, G. (2001). The postgraduate research handbook. New York: Palgrave.
Wolters, R., Grol, R., Schermer, T., Akkermans, R., Hermens, R., & Wensing, M. (2006).
Improving initial management of lower urinary tract symptoms in primary care:
Costs and patient outcomes. Scandinavian Journal of Urology & Nephrology, 40(4),
300-306. doi:10.1080/00365590600641657
Wood, I., Douglas, J., & Priest, H. (2004). Education and training for acute care delivery:
A needs analysis. British Association of Critical Care Nurses: Nursing in Critical
Care, 9(4), 159.
World Health Organization. (2012). 10 facts on ageing and the life course. Retrieved
11/11, 2012, from http://www.who.int/features/factfiles/ageing/en/index.html
World Health Organization. (2007). Everybody's business: Strengthening health systems
to improve health outcomes. WHO's framework for action. Geneva, Switzerland:
147
WHO. Retrieved 11/11, 2012 from
http://www.who.int/healthsystems/strategy/everybodys_business.pdf
Yatani, K. (2012). Chi-square, fisher's exact, and McNemar's test Retrieved 01/12, 2013,
from http://yatani.jp/HCIstats/ChiSquare#Fisher
Yi-Tsun, C., Ming-Hsien, L., Hsiu-Yun, L., Shinn-Jang, H., & Liang-Kung, C. (2009).
Potentially inappropriate urinary catheter indwelling among long-term care facilities
residents. Journal of Evaluation in Clinical Practice, 15, 592. doi:10.1111/j.1365-
2753.2008.01055.x
Zaineb, A. (2011). Importance of training evaluation for training effectiveness
importance of training evaluation for training effectiveness... read more:
Blog.commlabindia.com/elearning/training-evaluation. Retrieved 04/15, 2013, from
http://blog.commlabindia.com/elearning/training-evaluation
Appendix 1
The questionnaire
148
Dear participant, thank you for accepting to participate in this study. There are 3 sections to this questionnaire. It
would be best if you do not consult with anyone when you fill this tool up. Also, please fill in all questions
accordingly.
Section A - Demographics
1. Gender
Male □ Female □
2. How many years have you been qualified as a nurse?
Less than or equal to 1 year □
2-3 years □
4-9 years □
10-15 years □
More than or equal to 16 years □
3. What type of nursing qualifications do you possess?
EN - Traditional □
EN - Certificate in Nursing Practice □
SN - Traditional □
SN - EN to SN Conversion □
SN - Diploma in Nursing Studies □
SN - Degree in Nursing Studies □
SN - Master's Degree □
SN - Doctoral Degree □ Other:_________________________________________
4. In which setting do you currently practice?
Acute Medical □
Acute Surgical - Including Orthopaedics □
Intensive care - ITU, CICU, Theatres □
Accident and Emergency □
Rehabilitation - KGRH □
Community - Domiciliary – MMDNA or Commcare □
Community - Elderly - Homes □
Community - Health Centres □
Other – Mental, Hospice, etc □ Please state: _______________________
149
Section B
Section B1 - Indwelling long term catheterisation - (a urinary catheter which stays in situ` for more than 28 days).
5. In your area of practice, who inserts or changes an indwelling urethral catheter? (tick one option only)
Qualified nurses □
Medical doctors □
Carers or Nursing aides □
We do not insert or change urethral catheters □ If you ticked this answer, can you specify why?
_____________________________________________________________________________________________
6. Please read the statements below in relation to long term catheterisation and tick accordingly:
Agree Disagree I don't know
Is the bladder management of choice for neurological conditions □ □ □
Is definitely the best option for incontinent patients □ □ □
Insertion is done aseptically □ □ □
Insertion can be done safely as a clean technique □ □ □
The biggest size is the best option □ □ □
A 12Fr sized catheter is usually the best option for both sexes □ □ □
Antibiotics should be administered before changing a urethral catheter □ □ □
Antibiotics should be administered after removing a urethral catheter □ □ □
There is no need for antibiotic cover for removal or change of catheter □ □ □
7. The lubricant of choice for urinary catheter insertion is (tick as appropriate):
Male patients - A water based gel with anaesthetic (ex: Instillagel) □
Male patients - A water based without anaesthetic (ex: KY jelly/Aquagel) □
Female patients - A water based gel with anaesthetic (ex: Instillagel) □
Female patients - A water based without anaesthetic (ex: KY jelly/Aquagel) □
Any one option is good enough □
I don't know □
150
8. To maximise its effect, the lubricant anaesthetic has to be:
Inserted directly into the urethra □
Applied over the catheter □
Left into the urethral for 2-4 minutes □
All of the above apply □
None of the above apply □
I don't know □
9. The position of the penis during male urethral catheterisation should be:
Flat down at the level of the legs - parallel □
Slightly elevated above the level of the legs □
45 to 90 degrees at an angle perpendicular to the body □
All of the above are just fine □
I don't know □
Section B2 - Catheter care
10. Which of the following are potential entry points for infection in a patient with an indwelling urinary catheter?
(tick as appropriate)
Urine bag valve - bag emptying port □
Sample port □
Connection between bag tubing and catheter □
Surface of the catheter in contact with the meatus □
The balloon inflation port □
All of the above □
I don't know □
151
11. Within your institution / organisation, who performs catheter care on a daily basis? (can tick more than one
option)
Qualified nurses □
Qualified carers / nursing aides □
Informal carers (family / others) □
Medical officers □
Nurse managers □
Infection control nurse □
Continence nurse □
Practice development nurse □
All of the above □
Others □
If others, please state who: _______________________________________________________________________
12. In relation to long term catheterised patients, please state if the statements below are true or false: (tick the right
choice)
True False Don't know
Reflux of urine from the bag to the bladder can cause infection □ □ □
A urine bag hanging lower than 40cms below the bladder causes trauma □ □ □
The drainage bag should be emptied every 6-8 hours or when two thirds full □ □ □
The drainage bags should be changed at 7 day intervals □ □ □
Daily washing of the drainage bag with a disinfectant is advisable □ □ □
The catheter should be strapped to the thigh to prevent pulling □ □ □
Regular bladder washouts are important to reduce the chance of infections □ □ □
Blockage and encrustations are common complications of long term catheters □ □ □
Long term antibiotics are advisable when having a long term catheter in situ` □ □ □
Antibiotic creams (ex: Fucidin) applied to the urethral orifice prevent infection □ □ □
After 10 days with a catheter, bacteruria develops □ □ □
Bacteruria without signs and symptoms of UTI should be treated with antibiotics □ □ □
152
13. Below is a list of signs and symptoms. Which of these are attributable to UTI? (tick as appropriate)
True False Don't know
Frequent urethral spasms □ □ □
Leaks of urine in between catheter and meatus □ □ □
Low urine output - Oliguria □ □ □
High urine output - Polyuria □ □ □
Altered mental status □ □ □
Headaches □ □ □
Foul smelling urine □ □ □
Swelling of the lower extremities □ □ □
Dark coloured urine □ □ □
Burning sensation without other symptoms □ □ □
Blood stained urine - Haematuria □ □ □
Presence of pus in the urine - Pyuria □ □ □
Cloudy urine □ □ □
Chest pain □ □ □
Fever of 38 degrees Celsius or more □ □ □
Purple discoloration of the urine bag □ □ □
14. Which of the following would you advise to a person living with a long term catheter in order to reduce their
chance of acquiring a symptomatic infection? (tick as appropriate)
Minimal disconnections of the system - catheter to drainage bag □
Daily meatal cleansing with soap and water □
Regular antiseptic bladder washouts □
Regular flushing of the urine bag with an antiseptic □
Keeping the bag below bladder level □
Antibiotic cover prior to catheter change □
Long term cover with antibiotics □
Daily intake of 300mls of Cranberry juice □
Daily fluid intake of 2-3ltrs - unless contraindicated ex: renal failure □
Application of ointments to the meatus, round the catheter □
153
Section C - Continuing education - This section is concerned mainly with your own professional development.
15. Have you received any training with regards to catheterisation of the urinary bladder or catheter care during your
undergraduate studies?
Yes □ No □
16. Have you ever pursued any continuing education courses related to urethral catheterisation / catheter care?
Yes □ No □
If you answered yes to Question 16, please specify which courses and with which institutions (local or foreign).
Also please state if you pursued the courses via distance education by mail, distance education online, travelled to
study etc:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
If you answered no to Question 16, can you explain why?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
17. Would you consider attending educational sessions aimed at improving your knowledge of urinary
catheterisation, care, and patient education?
Yes □ No □
18. Should this training be recognised by certification?
Yes □ No □
19. Would you expect the qualification to be recognised both locally and abroad?
Yes □ No □
154
20. In your opinion, who should be involved in developing this training? (Tick as appropriate)
Educators from the Faculty of Health Sciences (former Institute of Health Care) □
Nurses with post graduate qualifications in your own area □
Nurses from the acute setting - Urology department □
Nurse managers □
Practice Development Nurses □
Foreign Nurse Educators □
Medical doctors □
Urologists □
Others □
If others, please state who:
_____________________________________________________________________________________________
21. In your opinion, who should be involved in delivering this training? (Tick as appropriate)
Educators from the Faculty of Health Sciences (former Institute of Health Care) □
Nurses with post graduate qualifications in your own area □
Nurses from the acute setting - Urology department □
Nurse managers □
Practice Development Nurses □
Foreign Nurse Educators □
Medical doctors □
Urologists □
Others □
If others, please state who:
_____________________________________________________________________________________________
22. In your opinion, which environment would be most appropriate for this training to be delivered?
Faculty of Health Sciences - lecture rooms and practice labs □
Mater Dei Hospital lecture rooms □
University Campus □
On site - wards, offices, departments □
Other □
If other please state where: _______________________________________________________________________
155
23. In your opinion, should this educational session include theory AND also a practical component?
Yes □ No □
Give reasons for your answer: ____________________________________________________________________
_____________________________________________________________________________________________
24. Should this education and training be available, which mode of delivery would you prefer for the theoretical
part? (tick as appropriate)
Discussion based sessions □
Traditional lecture format □
Online education □
Practice based (hands on with minimal lecturing) □
A mix of the above □
25. In your opinion, which type of assessment would be most appropriate?
Exam - Essay type □
Exam - Multiple choice questions □
Written assignment □
Group presentations □
Practical scenarios – based on discussion between participants □
Practical scenarios - clinical assessment on real patients □
None □
Other □
If other, please state which: _______________________________________________________________________
26. If such training is available, would you be willing to finance your own studies?
Yes □ No □
Give reasons for your answer: ____________________________________________________________________
_____________________________________________________________________________________________
156
27. How much would you be ready to pay for such a course of studies? (tick as appropriate)
< €100 per person □
€100 - €300 per person □
€300 - €500 per person □
Over €500 per person □
28. What would you expect out of such a programme of education? Please list both theoretical and practical
expectations with regards to content.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
29. What would be possible barriers which would not allow you to participate in such an educational activity? (you
can tick more than one).
Financial cost □
Time constraints □
Family commitments □
Travel time □
Lack of interest in nursing education □
I don't think I need to learn more about this topic □
After all these years in service I am ashamed to attend any continuing education sessions □
Other □
If other, please state which:_______________________________________________________________________
Thank you for taking the time to participate. Should you require any additional information or would like to discuss
queries or offer suggestions, please do not hesitate to contact me on [email protected].
Regards,
Kevin J Holmes
Urology Outreach
25457083
Appendix 2
Focus Interview
Schedule
157
PHC Nurses were found to be those who least insert or change urinary catheters and various
reasons have been given:
Not / rarely done at Health Centre 10
We refer to MMDNA 6
Not in job description / Not in our specialization 4
PHC Policy 3
Not trained 3
Needs expertise 1
Only a small minority cited lack of training as a reason.
It also transpired that there is lack of knowledge of both the skill of insertion and care for a
urinary catheter.
1. What are your views about this lack of knowledge?
2. What are the views of the participants about the reasons for not catheterising?
I am aware that the training you had been offered had been discontinued before all could attend.
Lack of knowledge/training might be one of the main reasons for not catheterising in PHC.
3. If this is so, how do you explain the low attendance for this current training which has
been delivered as planned? Why do you think was there such a low attendance?
Appendix 3
Letter of Information
Pilot study
Date:
Dear colleague,
I am currently reading for an M.A. degree in Adult Education (Staff Training and Development) with the
Faculty of Education, University of Malta. In part fulfilment of this course of studies I will undertake a
research study which will be focusing on the learning needs of nurses working with patients requiring
long term urinary catheter care. The study has been approved the University Research Ethics Board.
The first part of the study involves collection of data by means of a questionnaire. You, as a nurse in
Urology have been chosen to participate in the pilot study. If you agree to participate, you are kindly
requested to fill in the attached questionnaire and time yourself in doing so. Please write the time it took
you to fill it up on the questionnaire itself. Please also make a note of any working which is unclear,
ambiguous or offensive. I am not seeking your knowledge on the topic but would like to know if the tool
is appropriate for delivery to generalist nurses.
Participation is voluntary and therefore, you are not obliged to partake in filling out the questionnaire. I
will be the only one to have access to the data collected and will use it to improve the tool used for the
proper data collection. I will treat the data with strict anonymity.
When duly filled in, please insert the questionnaire in the brown envelope provided, seal it and leave it
with your nurse in charge. The questionnaires will be destroyed as soon as the questionnaire is refined.
This study will be available at the library of the University of Malta. Should you have any queries or
suggestions, please do not hesitate to contact me. Your help and time are greatly appreciated.
Sincerely yours,
______________________ ______________________
Kevin J Holmes MSc. Nurs. Dr. Michelle Camilleri PhD.
Staff Nurse Dissertation supervisor
Mob:********
Ward: 25457090/1
email: [email protected]
Appendix 4
Letter of information
Questionnaire
Date:
Dear colleague,
I am currently reading for an M.A. degree in Adult Education (Staff Training and Development) with the
Faculty of Education, University of Malta. In part fulfilment of this course of studies I will undertake a
research study which will be focusing on the learning needs of nurses working with patients requiring
long term urinary catheter care. The study has been approved the University Research Ethics Board.
The first part of the study involves collection of data by means of a questionnaire. You have been chosen
at random to participate in the study. If you agree to participate, you are kindly requested to fill in the
attached questionnaire which will take you approximately 20 minutes to complete.
The return of the filled questionnaire will be treated as your consent to participate in the study.
Participation is voluntary and therefore, you are not obliged to partake in filling out the questionnaire. I
will be the only one to have access to the data collected and will treat it with strict anonymity.
When duly filled in, please insert the questionnaire in the brown envelope provided, seal it and leave it
with your nurse in charge by the DATE. The questionnaires will be destroyed as soon as the study is
finished. The results of this study will be available at the library of the University of Malta. Should you
have any queries or suggestions, please do not hesitate to contact me. Your help and time are greatly
appreciated.
Sincerely yours,
______________________ ______________________
Kevin J Holmes MSc. Nurs. Dr. Michelle Camilleri PhD.
Staff Nurse Dissertation supervisor
Mob:********
Ward: 25457090/1
email: [email protected]
Appendix 5
Letter of information
Focus Group
Date:
Dear colleague,
I am currently reading for an M.A. degree in Adult Education (Staff Training and Development) with the Faculty of
Education, University of Malta. In part fulfilment of this course of studies I will undertake a research study which
will be focusing on the learning needs of nurses working with patients requiring long term urinary catheter care.
The study has been approved the University Research Ethics Board. Together with fellow colleagues I am cordially
inviting you to participate in a focus group interview regarding the topic. The session will take approximately 40 to
60 minutes. Refreshments and a snack will be provided. Needless to say that your participation is voluntary and of
utmost importance.
I would like you to understand that every effort will be made to guarantee confidentiality. The session will be held
on DATE AND TIME at VENUE. I would prefer to use a digital recorder which will facilitate transcription. I will
be the only one to have access to the recordings and transcripts which will be destroyed after analysis. If you have
any objection to this please let me know in advance. Some verbatim quotes might be used in the write up but every
measure will be taken for your identity never to be compromised. The signed copy of this letter shall be collected
prior to the session and sealed in an envelope. Nobody will have access to your identities and the letters will also be
destroyed upon completion of the study. The results of this study will be available at the library of the University of
Malta. Should you have any queries or suggestions, please do not hesitate to contact me. Your help and time are
greatly appreciated.
Yours truly,
______________________ ______________________
Kevin J Holmes MSc. Nurs. Dr. Michelle Camilleri PhD.
Staff Nurse Dissertation supervisor
Mob:********
Ward: 25457090/1
email: [email protected]
I the undersigned have read the above letter and accept to take part in this interview. I understand what the study
entails, that confidentiality will be respected, and that I can decide to withdraw my participation anytime during the
study without it incurring any penalty on me. I have also been provided with a copy of this letter for my own
records.
Signature ___________________ Name in full ___________________
Appendix 6
FREC and UREC
Approvals
Appendix 7
Approval by the
Director of Nursing,
Mater Dei Hospital
Appendix 8
Approval by the
Director of
Elderly and Community Care
Appendix 9
Approval by the
Data Controller,
Primary Health Care
