How Registered Nurses can Help Prevent Urinary Tract Infections Background and Context

Concepts, models and theories

Today, catheter-associated urinary tract infections (CAUTIs) remain one of the primary causes of nosocomial infections in the United States. Despite increasingly aggressive efforts to reduce the prevalence of CAUTIs, current estimates indicate that as many as half of all hospitalized patients receiving indwelling catheters do not have the corresponding documentation concerning the application of evidence-based criteria for this clinical decision (Weldon, 2013). The most recent guidelines from the Healthcare Infection Control Practices Advisory Committee stress the need to infection prevention by limiting both the use of catheters wherever possible as well as the duration of use in order to decrease the number of nosocomial urinary tract infections (UTIs) (Welden, 2013).

The U.S. Centers for Disease Control (CDC) likewise emphasizes the need for the improved use of indwelling catheters and estimates that acute care hospitals experienced 93,000 UTIs in 2011 alone (Catheter-associated urinary tract infection, 2018). In addition, UTIs have been found to be responsible for more than 12% of all types of infections at acute care hospitals, and almost all of these infections are the result of indwelling catheters (Catheter-associated urinary tract infection, 2018). These alarming rates are all the more troubling given the frequency of indwelling catheter use in various acute care settings today.

Moreover, an estimated 12% to 16% of adult inpatients will have an indwelling catheter used on them during their hospital stay, but every day these devices are used causes an increased risk of between 3% and 7% of developing a CAUTI (Catheter-associated urinary tract infection, 2018). In addition, long-term care facility residents likewise suffer from inordinately high rates of CAUTIs (Keeping nursing home residents safe, 2018). Since the American population is aging rapidly, it is reasonable to posit that these rates will continue to worsen unless steps are taken today to improve the manner in which registered nurses are educated concerning evidence-based guidelines for indwelling catheter insertion and maintenance.

Relevance to nursing practice

Catheter associated urinary tracts infections are relevant to nursing practice because the CDC emphasizes that CAUTIs can result in a wide array of complications for hospitalized patients, including: prostatitis, epididymitis, and orchitis in males, and cystitis, pyelonephritis, gram-negative bacteremia, endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis (Catheter-associated urinary tract infection, 2018). These complications translate into elevated patient discomfort, longer hospitalizations, as well as higher mortality rates. In fact, the CDC estimates that in excess of 13,000 deaths are related to UTIs each year (Catheter-associated urinary tract infection, 2018).

Taken together, it is clear that greater focus needs to be placed on identifying optimal approaches to educate registered acute care nurses concerning these issues as well as current evidence-based approaches to indwelling catheter use.

Local background and context

The focus of this study will be on an inpatient acute care setting in a tertiary heath care in the United States that has historically experienced CAUTI rates in line with the national averages.

Role of the DNP student

In their capacity as research-focused professionals, prospective DNP students are especially well situated to assume a leadership role in developing educational strategies to provide nursing staff members with the information and tools they need to reduce CAUTIs in their health care facilities (LaVeck, 2017).

Theoretical Framework

The conceptual framework to guide this project was Malcolm Knowles's (1970, 1980, 1982) adult learning theory and “Novice to Expert” by Patricia E. Benner. This theoretical framework is especially appropriate for the purposes of this study since it includes both the manner in which adults learn most effectively as well as the importance of gaining hands-on experience as part of the learning process. As originally propounded by Knowles (1970), andragogy, or the methods used for teaching adults, is based on several key assumptions concerning the characteristics of adult learners as they mature that differ from assumptions about traditional pedagogy and child learners as follows:

Their self-concept moves from one of being a dependant personality toward one of being a self-directing human being;

· They accumulate a growing reservoir of experience that becomes an increasing resource for learning;

· Their readiness to learn becomes oriented increasingly to the developmental tasks of their social roles; and,

· Their time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem-centeredness (Knowles, 1970, p. 55).

Knowles’ (1980) subsequently developed this theoretical model based on four fundamental assumptions concerning how adults tend to learn and how they develop as a result.

• Concept of learner: Their self-concept moves from one of being a dependant person to one who is self-directed;

• Role of learners' experience: As individuals grow, they accumulate a reservoir of experience that becomes an increasingly rich resource for learning;

• Readiness to learn: Learners see education as a process for developing increased competence to achieve their full potential in life; and,

• Orientation to learning: As real life problems occur some learning situations require immediate attention (pp. 43-44).

Besides inculcating an organizational culture that places a high priority of achieving optimal clinical outcomes using evidence-based strategies (Trevellini, 2015), nurse educators must also ensure that the manner in which they approach the staff education process is consistent with the basic tenets of andragogy described by Knowles (1970, 1980) and expanded upon by Brenner (1982).

Based on the four fundamental assumptions described in study’s theoretical framework, Knowles (1980) subsequently recommended that adult educators seek to achieve the following for optimal learning opportunities:

1. Set a cooperative climate for learning in the...

Assess the learner’s specific needs and interests;
3. Develop learning objectives based on the learner’s needs, interests, and skill levels;

4. Design sequential activities to achieve the objectives;

5. Work collaboratively with the learner to select methods, materials, and resources for instruction; and,

6. Evaluate the quality of the learning experience and make adjustments, as needed, while assessing needs for further learning (Adult learning theories, 2011).

These recommendations are highly congruent with Benner’s (1982) views on adult education. From Benner’s perspective, experiential learning opportunities are an integral component of gaining the knowledge and expertise needs by registered nurses today. In this regard, Benner advises that, “Experience, in addition to formal education preparation, is required to develop this competency since it is impossible to learn ways of being and coping with an illness solely by concept or theorem” (p. 406). This observation does not mean, of course, that registered nurses practicing in acute care must personally experience every disease or illness condition they treat in order to fully understand its implications for others and how best to intervene, but it does mean that gaining hands-on experience and having opportunities for empirical observations concerning patient responses and clinical outcomes in an essential part of the adult learning process. As Benner concludes in this regard, “A deep understanding of the situation is required before one acquires a repertoire of ways of being and coping with a particular illness experience” (p. 406).

These assumptions are also highly consistent with the guidance provided by Benner (1982) concerning the manner in which most effectively adults learn which are discussed further in the staff education section that follows further below.

Definition of Terms Common in Critical Care Nurses on Preventing Catheter Associated Urinary Tract Infections

Unless otherwise indicated, the following definitions were taken from the CDC’s most recent guideline (2017, pp. 6-7) concerning the prevention of CAUTIs:

ANA: This acronym refers to the American Nurses Association (Gelinas, 2015).

APIC: This acronym means that Association for Professionals in Infection Control and Epidemiology (APIC), (Smith, 2015).

ASB: This acronym means asymptomatic bacteria.

CAUTI: This acronym means catheter-associated urinary tract infection.

CCU: This acronym means critical care unit.

CIC: This acronym refers to clean intermittent catheterization..

CDC: This acronym refers to the U.S. Centers for Disease Control.

CFU: This acronym means colony-forming units.

DNP: This acronym means doctorate of nursing practice (LaVeck, 2017).

HAI: This acronym means healthcare-associated infections (Keeping nursing home residents safe, 2018).

HICPAC This acronym refers to the Healthcare Infection Control Practices Advisory Committee.

LOS: This acronym means length of stay.

MDR: This acronym refers to multi-drug resistance.

PVR: This acronym means post-void residual (Streamlined evidence-based RN tool kit for catheter associated urinary tract infection prevention, 2015).

SUTI: This acronym means symptomatic urinary tract infection.

UTI: This acronym refers to a urinary tract infection.

Relevance to Critical Care Nurses on Preventing Catheter-Associated Urinary Tract Infections to Nursing Practice

Registered nurses practicing in acute care settings are on the front lines of preventing CAUTIs, but their effectiveness in achieving improved clinical outcomes is frequently hampered by limited organizational resources, a suboptimal organizational culture and a lack of knowledge concerning current evidence-based indications for urinary catheter insertion and maintenance (Smith, 2015). For example, according to one registered nurse, “Because RNs play a major role in reducing CAUTI rates to help prevent harm and save lives, it's crucial we focus on CAUTI reduction and prevention—now” (Gelinas, 2015, p. 6).

Indeed, given their high incidence rate and potential for causing increased lengths of stay, patient discomfort, associated complications and even death, it is clear that greater focus needs to be placed on helping acute care nurses become more proficient in preventing CAUTIs using evidence-based guidelines. In this regard, Smith (2015) emphasizes that, “Nurses at all levels can influence patient outcomes in a positive way. By focusing on evidence-based prevention strategies and promoting a culture of safety and accountability, (registered nurses can) reduce urinary-catheter device days” (p. 46). Fortunately, there are some current evidence-based guidelines available for this purpose, including the national initiatives discussed further below.

National Initiatives to Address and Prevent CAUTIs

Current national initiatives concerning indications for urinary catheter insertion and maintenance to reduce the incidence of CAUTIs include guidelines from the HICPAC as well as the Association for Professionals in Infection Control and Epidemiology (APIC) (Smith, 2015). A summary of the most recent recommendations from the HICPAC’s guidelines concerning appropriate indications for indwelling catheter use are set forth in Table 1 below.

Table 1

Summary of HCPAC guidelines concerning indwelling catheter use

Area of recommendation

Description

Appropriate indications for indwelling catheter use

• Patient has acute urinary retention or bladder outlet obstruction.

• Need for accurate measurements of urinary output in critically ill patients.

• Perioperative use for selected surgical procedures:

o Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract.

o Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU).

o Patients anticipated to receive large-volume infusions or diuretics during surgery.

• Need for intraoperative monitoring of urinary output.

• To assist in healing of open sacral or perineal wounds in incontinent patients.

• Patient requires prolonged immobilization (e.g., potentially unstable thoracic or…