How Registered Nurses Can Prevent Catheter-Associated UTIs

Background and Clinical Significance of CAUTIs

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 their prevalence, current estimates indicate that as many as half of all hospitalized patients receiving indwelling catheters do not have corresponding documentation reflecting 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 for infection prevention by limiting both the use of catheters wherever possible and the duration of use, in order to decrease the number of nosocomial urinary tract infections (UTIs) (Weldon, 2013).

The U.S. Centers for Disease Control (CDC) likewise emphasizes the need for 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 during their hospital stay, but every day these devices are in use increases the risk of developing a CAUTI by between 3% and 7% (Catheter-associated urinary tract infection, 2018). 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 to improve the manner in which registered nurses are educated concerning evidence-based guidelines for indwelling catheter insertion and maintenance.

CAUTIs are directly relevant to nursing practice because the CDC emphasizes that they 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, and higher mortality rates. 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 educating registered acute care nurses concerning current evidence-based practices for indwelling catheter use.

The focus of this study is an inpatient acute care setting in a tertiary health care facility in the United States that has historically experienced CAUTI rates in line with national averages. 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).

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

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:

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

Theoretical Framework for Nursing Education

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

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 required 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 that registered nurses practicing in acute care must personally experience every disease or illness condition they treat in order to fully understand its implications. Rather, it means that gaining hands-on experience and having opportunities for empirical observation concerning patient responses and clinical outcomes is an essential part of the adult learning process. As Benner concludes, "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 adults learn most effectively, which is discussed further in the staff education section below.

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: American Nurses Association (Gelinas, 2015).

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

ASB: Asymptomatic bacteriuria.

CAUTI: Catheter-associated urinary tract infection.

CCU: Critical care unit.

CIC: Clean intermittent catheterization.

CDC: U.S. Centers for Disease Control.

CFU: Colony-forming units.

DNP: Doctorate of nursing practice (LaVeck, 2017).

Relevance to Acute Care Nursing Practice

SUTI: Symptomatic urinary tract infection.

UTI: Urinary tract infection.

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). As one registered nurse has stated, "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).

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 current evidence-based guidelines available for this purpose, including the national initiatives discussed below.