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RESEARCH

Does nurse self-testing affect catheter choice?

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Self-testing of intermittent catheters by continence nurses could form part of intermittent catheter evaluation and give them better insight into patients’ experiences

Abstract

Background: Involving patients in decision making about their care requires expert knowledge and understanding of patients’ perspectives. Knowledge comes from several sources and experience; however, the self-testing of products by health professionals who teach clean intermittent self-catheterisation (CISC) has not been investigated.

Aim: This study aimed to assess the impact of self-testing on catheter evaluation by continence nurses.

Methods: Sixteen continence nurses self-tested two catheters and completed a questionnaire on their opinions about the catheter, routine self-testing and whether the study would make them change their usual practice.

Results: Almost half of the participants found self-testing intermittent catheters a useful experience and some of those who did not routinely self-test said they would do so in future.

Conclusion: Self-testing intermittent catheters can provide useful knowledge to those who teach CISC.

Citation: Rigby D et al (2014) Does nurse self-testing affect catheter choice? Nursing Times; 110: 18, 15-17.

Authors: Deborah Rigby was senior research nurse; Colette Grant was research nurse; Adele Long was Bio-Med director; all at Bristol Urological Institute, North Bristol Trust at the time the research was conducted

Introduction

Although it is not a new concept, there has been increasing emphasis on patient-centred care within nursing in the health service. This approach is reflected in the Department of Health (2010) policy guidance Equity and Excellence: Liberating the NHS, in which the tenet of “no decision about me without me” is expressed.

There are many ways to put this philosophy into practice and measure its effects. Effectiveness of the nurse-patient relationship that results in balanced joint decision making depends on a number of factors (Millard et al, 2006), and the role of the nurse in enabling patient empowerment is complex (Piper, 2010; Oudshoorn, 2005).

Little research has explored the extent to which nurses (or other health professionals) will go to understand the perspective of their patients and achieve the level of empathy that enables patient engagement.

This is touched on in an online discussion on Research Gate, which asked: “Do surgeons change their attitudes towards new patients after they themselves have gone through a major intervention, recovery and return to surgical practice?” Responses were mixed, but most suggested that surgeons do have more empathy once they have also been a patient.

In the continence field, advice from the Royal College of Nursing on best practice in catheter care suggests that nurses educate patients so they can “make informed health choices and decisions” (Addison et al, 2012). Urinary catheterisation is the mainstay for the management of urine retention and is also used to reduce symptoms of urinary incontinence; clean intermittent self-catheterisation (CISC) is considered the gold standard and is preferable to indwelling catheterisation for patients who can perform it.

However, CISC can cause urethral trauma, irritation, stricture and recurrent urinary tract infections (UTIs) in some users, and its introduction demands emotional and psychological adjustment (Ramm and Kane, 2011). A negative experience can be stressful (Winder, 2002), give rise to poor adherence (Addison, 2001) and sometimes result in complete abandonment of this method of bladder drainage (Shaw and Logan, 2013). For this reason, selecting the most appropriate intermittent catheter (IC) is essential.

When training patients to perform CISC, continence nurses must be able to select the most appropriate catheter for the individual, while engaging them in the decision-making process. With the increased popularity of CISC, there has been a proliferation in the range of catheters available, from the basic PVC Nelaton catheter to those that are pre-lubricated, have a hydrophilic coating, no-touch sleeves and discreet packaging. This variety of product makes the choice of catheter for first-time users increasingly complex.

Our study was divided into two parts. In part one (not described in detail in this article), we aimed to identify which criteria nurses who teach CISC considered important in the choice of IC for first-time users. We sent out 470 questionnaires and received 217 (46%) replies from health professionals. Most nurses said that catheter design was the most important factor to be taken into consideration when choosing an IC.

As the number of catheter brands increases, market competition focuses increasingly on marketing strategies and added benefits, rather than simply on meeting legal performance and safety standards. CNs need to be aware that their choices should be based on patient suitability, design and ease of use, and be supported by research evidence or clinical experience. They should not be influenced by marketing claims.

The debate on the relative values of theoretical versus practical knowledge is extensive but most practical knowledge is limited to teaching the procedure to patients rather than personal use of the devices. Most CNs will not have personal practical knowledge of using all brands of ICs, even though they recommend using them and teach CISC.

Part two of our study, reported below, investigated whether the intimate know-ledge of self-testing a catheter would influence CNs’ decision-making process and catheter selection.

Aim

The aim of the study was to investigate the impact of self-testing by continence nurses on IC selection.

Method

The study was conducted in the UK during 2010-11. Ethical approval was obtained from the Southmead Research Ethics Committee. Research and development (R&D) approvals were required from each NHS or primary care trust where participants worked.

Participants were health professionals who had a nursing qualification and were involved in teaching CISC. They were identified from professional organisations such as the Association for Continence Advice, the RCN Continence Care Forum and the British Association of Urological Nurses. Most had already participated in part 1 of the study on catheter choice.

Potential participants (n=41) were sent an information leaflet describing the study and asked to sign and return a consent form. Those who consented (n=20) were sent the following:

  • A study instruction leaflet;
  • A pregnancy testing kit (to eliminate the possibility of being pregnant before entering the study, which was an exclusion criterion);
  • A urine testing kit (to eliminate the possibility of having a UTI before entering the study);
  • Two test ICs with the manufacturers’ instructions for use;
  • An evaluation questionnaire.

Participants had to self-test two leading catheter brands, one week apart. A crossover (non-blinded) design was adopted with half the study group using catheter 1 first and the other half using catheter 2 first. Participants were assigned to the two groups by alternate allocation to each group on receipt of the signed consent form. On completion of the testing, they were asked to return the evaluation questionnaire, which asked for their opinions on:

  • Catheter design;
  • Ease of use, including hydration, lubrication, comfort on insertion and removal;
  • Feelings of urgency after removing the catheter;
  • Clarity of product information.

Participants were also asked whether they self-tested ICs as part of their usual practice and, if not, whether testing them in this study had changed the way they viewed their selection.

The study also collected data on participants’ opinions of the catheters used. This information is not disclosed in this article. The aspect we were interested in was whether trying the catheters influenced decision-making.

Results

A total of 24 NHS organisations were approached, of which 18 agreed to take part in the study. Forty-one nurses who teach CISC volunteered to take part; 20 gave informed consent and 16 completed the study. The large drop-out was mainly due to the process of obtaining R&D approvals from every NHS organisation, each of which had only one or two CNs eligible to participate.

In general, both catheter brands were well received, with some participants preferring catheter 1 and others catheter 2. There were no statistically significant differences in evaluation based on whether the catheter was tested first or second.

Free text comments primarily related to ease of use, patient information and catheter comfort. Nearly a third of the participants (n=5) said they routinely self-tested new catheters as part of their professional evaluation of them. Seven (44%) did not think that self-testing would change how they evaluated ICs, while another seven (44%) agreed or agreed strongly that doing so would change their practice (Fig 1). Of the seven participants who neither agreed nor disagreed, two already self-tested; it is reasonable to assume they believed it to be beneficial and their opinion was not changed by the study. Only two (12%) participants disagreed that self-testing would make a difference, both of whom did not routinely self-test ICs (Fig 1).

Of those who did not already routinely self-test, four (36%) said they would change their practice. Five (31% of all participants) nurses already self-tested as part of their routine practice. The proportion of nurses in this study who would self-test increased from 31% to 56% after trying self-testing.

Discussion

Although there is literature stressing the importance of health professionals being well informed about new devices (Hamilton, 2007), there is little on the use of personal testing as part of professional practice.

By self-testing ICs, CNs shift their role and perspective from those of professional practitioner to those of user. Reflective practice encourages understanding and empathy with the patient, while role play is used to mimic patient experience. By self-testing ICs, nurses are going beyond role play to help them understand their patients’ experience.

The criteria for choosing an IC in this study appear to be personal, with little reference to research evidence, company reputation, availability or cost. Attention was focused on practicalities, such as manufacturer’s instructions for use, comfort (a major aspect of catheter design) and ease of use (packaging).

These criteria were identified by CNs as having the highest levels of (theoretical) importance in part one of this study, which suggests that the criteria that CNs theoretically prioritise in choosing an IC are those that are most important to patients.

To have shared the experience of self-catheterisation, albeit in a limited way, arguably offers CNs a greater capacity to empathise with their patients. Self-testing also permits the CN to personally test the claims made by manufacturers and therefore gain a greater knowledge of the product.

Around a third of participants said they already self-tested ICs to evaluate them. It should be noted, however, that some CNs who decided to participate may be biased towards self-testing so the proportion of self-testers in this study may not be a reflection of the numbers who self-test in the population as a whole.

Several participants who had not routinely tried new ICs on themselves agreed it would change their practice and said they intended to apply self-testing in the future. This implies CNs felt that testing ICs gave them valuable additional information about the IC that they could not achieve through other more conventionally accepted means, such as visual assessment, feedback or research evidence. Potentially, this could result in an improvement in the experience of first-time IC users and have a positive effect on future adherence.

The self-testing of products is a contentious issue in clinical training and practice. The risk of UTIs to IC users is less than eight cases per 1,000 days catheterised (de Ridder et al, 2005). For healthy CNs, who are knowledgeable on IC technique, testing catheters occasionally therefore carries a very low risk - yet it is not an approved practice. The perception of risk associated with IC use was a factor for a number of NHS and primary care trusts refusing to give R&D approval, which prevented their staff from participating. Others took a more pragmatic approach and allowed the CNs to make the decision themselves.

This study highlights that the personal testing of ICs is already widely employed by CNs who advise and instruct patients on IC use. Self-testing can offer valuable information to the CN and should be considered as an approved optional approach to IC care.

Conclusion

Self-testing of ICs was undertaken by CNs. Of those who did not self-test before this study, one-third said they would do so in the future. The remainder neither agreed nor disagreed, or disagreed, that self-testing would alter the way in which they evaluate ICs.

The contribution of self-testing as part of clinical practice or training and as a way of increasing product knowledge is worthy of further investigation.

Key points

  • Little is known about the role of the self-testing of products by health professionals
  • Some continence nurses self-test intermittent catheters before recommending them
  • Self-testing can add to continence nurses’ knowledge of intermittent catheters and catheterisation
  • The risk of harm associated with self-testing is low among experienced teachers of the technique
  • Self-testing should be considered an optional but useful part of intermittent catheter care
  • 5 Comments

Readers' comments (5)

  • I am in my final year as a student nurse. I had a two week elective placement and I asked to go onto a womens health/general surgical ward. On my placement there was a patient who had bladder damage during a routine procedure and had to ISC. I volunteered to show the lady how to do it. I had no formal training at University or on the wards but I did have experience myself. I too had bladder damage after a Radical Hysterectomy in 2013 and had to learn how to ISC myself, on the ward where I was I had a great nurse who physically sat with me and a mirror and after hours of trying I succeded in ISC. Speaking to the patient and letting that person know that I had dealt with this situation and knew a few good points that would be very useful, was so rewarding. I knew that as the catheter is retracted that the urethra spasms and shuts tightly around the catheter, this is must what cause the infection, grazing etc. The patient was so grateful and gave brilliant feedback to my mentor and the ward manager. I think experience of the situation helped me understand how my anatomy reacted thus helping me to inform patients of how theirs may act. I had tried many different ISC single uses and knew what was the best on the market and recommended etc. On the other hand if I had not had the procedure done to me I would be reluctant to "try it" out for the sake of patients as it is an uncomfortable, embarrassing procedure. I do hope to specialise in womens health one day.

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  • I'm all for sharing experiences with patients, but I would not be willing to self test IC's for example. After all, Midwives do not have to experience childbirth themselves in order to be a safe, caring Practitioner do they?
    Supporting patients to help themselves is always a priority. Becoming 'guinea pigs' ourselves is not.

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  • Linda | 29-Apr-2014 6:40 pm

    totally agree. there are unnecessary risks involved.

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  • Are you people crazy? I think if valuable research dollars are being spent on this nonsense it's no wonder British nurses are fed up

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  • Whilst self-testing an intermittent catheter once may help those who teach patients ISC understand the properties of a new catheter design better it does not replicate the needs of individual patients who may need to carry out ISC in all lifestyle situations 4-7 times a day for life often overcoming multiple impairments. It is essential that those helping a patient find the best catheter for them do have knowledge of the coatings, flexibility, features that may enable a no touch technique, etc and do not assume that they are all more or less the same. There are some who teach ISC who have never tried to carry it out in normal lifestyle settings. It is not always as easy as some make out especially when carried out multiple times a day. Washing hands in a dirty sink with dirty taps, only non drinking water to fill catheter packets with water for those that do not come ready to use or enclosed with sachets of sterile solution. Toilet cubicles that come with poor light.
    ISC carried out by those with good technique with out other impairments in an ideal situation will take twice at least twice as long as a normal pee. Innovative catheter design will allow ISC users to catheterise more easily and quicker in lifestyle settings without fear of embarrassment. There is no one perfect catheter design that meets all users needs. Anything that helps those who teach patients understand the difficulties that ISC users experience is appreciated, even experienced users cannot fully appreciate the problems that users of the opposite sex, or those who live with different impairments or lifestyle circumstances face.
    How many users fail to master ISC, or give up on it as a method of bladder emptying management simply because they were not given the opportunity to experiment with different catheters. Getting used to handling a new catheter and its packaging can take time, and definitely more than one catheterisation.
    After 2 decades as an ISC user I still remember the first 2 traumatic weeks being taught. A different catheter made all the difference in getting home. Further innovation in catheter design gave me my life back.
    It is vital that those who teach ISC understand the individual features of the 30 plus styles that are currently on the Drug Tariff so that they can direct users to ones that will meet their individual needs.
    Limited local formularies limited choices do not meet the needs of all ISC users and their many impairments.

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