Intermittent Catheterization Education Toolkit and Competency Checklist

Background: Patients with neurogenic bladder have dysfunction to the bladder wall and urethral sphincter causing the loss of bladder function and the need for some form of bladder management. Intermittent catheterization is the gold standard of treatment but has poor compliance. Purpose: This scholarly project implemented an intermittent self-catheterization (ISC) toolkit to increase confidence in self-catheterization resources and increase confidence in employee and patient abilities, and knowledge of long-term benefits and needed resources. Methods/Measures: This project was completed on an inpatient rehabilitation unit in a teaching hospital located in Salt Lake City, Utah. Current knowledge, teaching practices and available resources of ISC were assessed through a pre- and post-survey. The ISC toolkit comprised a competency checklist and educational resources developed using survey responses and current evidence to increase employee ability and confidence. The self-catheterization toolkit was implemented after a series of educational videos delivered to staff over several weeks. Staff were instructed on how to deliver effective and comprehensive self-catheterization teaching. Results: No statistically significant differences were noted in pre-survey to post-survey responses in nursing knowledge, teaching practices and available resources. Trends after introduction of the toolkit showed limited improvement to staff confidence in resources available, abilities to adjust teaching and understanding of patient barriers. However, trends noted a decrease in staff confidence in level of involvement in teaching self-catheterization, in ability to discuss with the team, and confidence that early education sets the patient up for success. Conclusions: The implementation of the self-catheterization toolkit showed increased staff confidence in resources to teach self-catheterization. Areas of decreased confidence are thought to be related to initial overconfidence of nursing staff. As nursing gains experience teaching ISC efforts should be evaluated and reinforced as needed. The toolkit is feasible to use within other units of the hospital as well as for patients who are struggling with adherence to ISC.

Running head: INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT Intermittent Catheterization Education Toolkit and Competency Checklist Nicole Lynch University of Utah 1 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 2 Abstract Background: Patients with neurogenic bladder have dysfunction to the bladder wall and urethral sphincter causing the loss of bladder function and the need for some form of bladder management. Intermittent catheterization is the gold standard of treatment but has poor compliance. Purpose: This scholarly project implemented an intermittent self-catheterization (ISC) toolkit to increase confidence in self-catheterization resources and increase confidence in employee and patient abilities, and knowledge of long-term benefits and needed resources. Methods/Measures: This project was completed on an inpatient rehabilitation unit in a teaching hospital located in Salt Lake City, Utah. Current knowledge, teaching practices and available resources of ISC were assessed through a pre- and post-survey. The ISC toolkit comprised a competency checklist and educational resources developed using survey responses and current evidence to increase employee ability and confidence. The self-catheterization toolkit was implemented after a series of educational videos delivered to staff over several weeks. Staff were instructed on how to deliver effective and comprehensive self-catheterization teaching. Results: No statistically significant differences were noted in pre-survey to post-survey responses in nursing knowledge, teaching practices and available resources. Trends after introduction of the toolkit showed limited improvement to staff confidence in resources available, abilities to adjust teaching and understanding of patient barriers. However, trends noted a decrease in staff confidence in level of involvement in teaching self-catheterization, in ability to discuss with the team, and confidence that early education sets the patient up for success. Conclusions: The implementation of the self-catheterization toolkit showed increased staff confidence in resources to teach self-catheterization. Areas of decreased confidence are thought INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 3 to be related to initial overconfidence of nursing staff. As nursing gains experience teaching ISC efforts should be evaluated and reinforced as needed. The toolkit is feasible to use within other units of the hospital as well as for patients who are struggling with adherence to ISC. INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 4 Implementation of an Intermittent Catheterization Education Toolkit and Competency Checklist Introduction Problem Description On the Inpatient Medical Rehabilitation Unit (IMRU) at the University of Utah Hospital, there is no collaboration or process for nursing to evaluate the ability of the spinal cord injury patient with neurogenic bladder to self-catheterize. No standard education is done by nursing, and no education is provided on the importance of long-term benefits of catheterization in a patient learning to self-catheterize. Further, despite being solely responsible for sterile intermittent catheterization of patients, nursing does not provide the necessary education for patients to learn this task and information. Nationally nurses are teaching this skill to patients, but the practice in this urban teaching hospital is to have occupational therapy teach patients to self-catheterize. When the nervous system is impaired or injured patients can develop neurogenic bladder, making micturition difficult. The urinary system uses the parasympathetic, sympathetic, somatic and limited central nervous system innervation to the lower urinary tract (Hasudungan, 2014; Wilson, 2015). Patients with neurogenic bladder have a dysfunction to the detrusor muscle in the bladder wall and urethral sphincter causing a loss of bladder sensation with subsequent loss of bladder function (Rabadi & Aston, 2014). The causes of neurogenic bladder are related to neurological difficulties such as spinal cord injury (SCI), multiple sclerosis, Parkinson's, stroke, autonomic neuropathy (diabetes mellitus, pernicious anemia), and viral disease (polio) (Wilson, 2015). These neurologic diseases can affect the patient's ability to void by disturbing the nerve function necessary to store urine, eliminate urine, or completely empty the bladder (Biazilo et al., 2017). INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 5 Available Knowledge Each year 15-53 per million new individuals are diagnosed with SCI in western countries (Pavese et al., 2016). In the U.S. specifically, 250,000 people are living with SCI (Taweel & Seyam, 2015). Of these, 80% exhibit at least some degree of bladder dysfunction (Taweel & Seyam, 2015). Intermittent self-catheterization (ISC) is the gold standard treatment for patients with SCI and bladder dysfunction (Afsar, Yemisci, Cosar, & Cetin, 2013; Bardsley, 2014; Bardsley, 2015; Cassaani, 2014; Hagen & Rekand, 2014; Kriz &Relichova, 2014; Leach, 2018; Lopes & Lima, 2014; ; Sheldon, 2013; Twaeel & Seyam, 2015; Wilson. 2015; Zlatev, Shem & Elliot, 2016). Intermittent self-catheterization is a method of draining urine from the bladder by inserting a catheter into the urethra past the sphincter into the bladder. Once the urine is drained the catheter is removed. This process is vital to bladder and kidney health (O'Neill, 2015). In fact, historically patients with SCI have had a mortality rate of 40% due to urinary complications. With the introduction of ISC, the mortality rate due to urinary complications has decreased to 13% (Pavese et al., 2016). Intermittent self-catheterization allows for the lowest urinary complications of any method and has several benefits to other methods. Self-cathing has shown decreased urinary tract infection (UTI) rates, kidney stones, pain, incontinence and urethral trauma. It has also shown improved independence, less need for medical personal, preserved dignity because patients can urinate privately and discretely, reduced equipment and less obvious/wearable equipment, improved social relationships, decreased sexual barriers, preserved bladder elasticity as the bladder is able to both fill and empty, and improved quality of life shown in multiple studies with validated questionnaires. INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 6 Despite being the gold standard of treatment, ISC has poor patient adherence rates. Retrospective reviews report ISC compliance rates ranging from 34% 81% (Seth, Hasalam, & Panicker, 2014). Up to 58% of patients discontinued usage of ISC at one year (Seth, Hasalam, & Panicker, 2014). Several studies have looked at why this would be the case. Patients state urinary complications as a primary reason for discontinued use, including UTI, nephrolithiasis, discomfort, and incontinence (Afsar et al., 2013; Cassani, 2014). Further studies have found that when there is inconsistent or poor teaching, poor confidence, and poor psychological coping there is worsened compliance (Engkasan, Ng, & Low, 2014; Girotti, MacCornick, Perisse, Batezini, & Almeida, 2011; Seth, Haslam, & Panicker, 2014; Logan, Shaw, Webber, Samuel, & Broome, 2008; Shaw & Logan, 2013). Subsequently these studies found where there is consistent teaching by knowledgeable providers with appropriate explanations and guidance, adherence is higher and complications are fewer. Rationale The Integrated Theory of Health Behavior Change (ITHBC) suggests that health behavior is changed through the constructs of enriched knowledge and beliefs, improved skills and abilities and enhanced social facilitation (Ryan, 2009). This theory centers on the idea that changing health behaviors is difficult and complex whether in the context of chronic conditions, health promotion or learning new behaviors. In other theories such as the health belief model, health promotion model, and theory of reasoned action, the focus is on initiation of behavior, but this does not always equate to long-term change (Ryan, 2009). Integrated Theory of Health Behavior Change builds upon theories of health behavior change, self-regulation theories, social support theories, and self-management of chronic illness research to express new understanding that yields both distal and proximal change (Ryan, 2009). This theory notes, as have previous INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 7 theories, that desire, motivation, self-reflection, and social influence will determine a patient's willingness to make and sustain changes (Ryan, 2009). In summary, as patients have better knowledge, beliefs, and support from health care providers, they in turn have greater confidence in the intervention, which leads to engagement in behaviors and improved health status over time (Ryan, 2009). As patients on IMRU learn to self-catheterize using the competency checklist and education toolkit, they will have enhanced knowledge and beliefs, increased skills and ability and improved support leading to a decreased complication rate with self-catheterization and greater longer-term adherence to gold standard treatment for neurogenic bladder. Specific Aims The purpose of this scholarly project was to implement a self-catheterization competency checklist with an education toolkit for nursing staff to utilize while educating neurogenic bladder patients on inpatient rehab to increase confidence in self-catheterization abilities and knowledge of long-term benefits. This was accomplished through assessment of current needs and resources available to patients for self-catheterization evaluation and training, development and implementation of a self-catheterization toolkit, and evaluation of overall effectiveness of the toolkit and teaching materials in patients with neurogenic bladder. Methods Context Data was collected from nurses working on an inpatient rehabilitation unit in a teaching hospital located in Salt Lake City. This unit admits a diverse set of patients from across the western United States, with most patients from suburban and urban areas in Utah. This unit has a range of one to five patients each month who are age 18 or older and who have both a neurogenic bladder and the fine motor ability to self-catheterize with or without assistive INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 8 devices. This rehabilitation unit is a 38-bed unit with four attending doctors and approximately 45 nurses. Interventions The unit was assessed to identify the current needs and resources available to patients for self-catheterization evaluation and training. To assess the needs and resources of the unit, the staff on this rehab unit were surveyed on their knowledge of teaching self-catheterization and the resources they felt were available to teach a patient to self-catheterize. A self-catheterization toolkit for this inpatient rehab unit was developed using survey responses. The catheterization toolkit included a competency checklist and educational resources for patient use. These were comprehensive documents constructed from current evidence. The educational resources consisted of material the patient can use to foster the knowledge and ability to self-catheterize. The education toolkit was reviewed prior to completion by a spinal cord injury patient experienced in self-catheterization to deliver feedback regarding relevance and usability. The checklist consisted of steps for the patient to pass off demonstrating their knowledge and abilities in self-catheterization The self-catheterization toolkit was implemented on the rehab unit with a series of short videos. These videos contained explanations on the importance of effective teaching by nursing staff, and how to use both the self-catheterization competency checklist and education toolkit. The videos also reviewed different techniques patients can use to effectively learn self-cathing, different adaptive equipment patients can use to self-catheterize, ways to prevent complications, and advantages and disadvantages of several bladder management methods. Staff who viewed these trainings were tracked and patients' ability to complete the competency checklist was noted to track improved patient education and compliance. Staff were instructed on how to use the INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 9 toolkit with their patients in order to deliver effective and comprehensive self-catheterization teaching. Study of the Intervention Prior to initiating the catheterization toolkit, a pre-survey was sent to nursing staff to evaluate comfort level of teaching self-catheterization, and self-identification of ability to explain aspects around bladder management programs. Specifically, the survey evaluated the ability to explain advantages and disadvantages of self-catheterization, preferred bladder management methods, and barriers to bladder management programs. Further questions assessed perceived resources, support and ability to communicate as an interdisciplinary team. Answers were evaluated to create educational material regarding self-catheterization education and resources for the staff. The educational material was distributed over a month-long period in order to review important points discussed in previous material and to incorporate longterm learning. Staff continued to have access to the educational material as needed. The overall effectiveness of the toolkit and educational resources were evaluated by delivering a survey to nursing staff after the educational videos. The post-survey solicited information regarding ability and confidence in teaching self-catheterization. The post-survey responses were compared to pre-survey responses. A one-month follow-up survey was also completed to evaluate staff utilization and intent to utilize the self-catheterization toolkit. Both surveys were double blinded. Survey participants created a code to anonymously match pre- and post-survey results. Measures The self-catheterization toolkit was comprised of a competency checklist and educational resources given to the patient. Both the checklist and educational resources were created after INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 10 research of current best practice regarding self-catheterization. These tools were created to aid nursing staff to teach patients with thorough knowledge of best practice. Four video segments were developed to educate nursing staff on different bladder management methods, how to use the competency checklist and educational resources, and how to put these tools into practice. Nursing staff were surveyed before and after development of the toolkit to evaluate improved knowledge and confidence in teaching self-catheterization. REDCap was used to ensure accuracy and anonymity of survey data collection. More than 80% of nursing staff participated in the survey and reviewed the educational material. Analysis A quantitative survey was delivered to nursing staff prior to education and implementation of the educational tool kit and competency checklist, and compared to a onemonth post-survey. Descriptive statistics were used to evaluate demographic and outcome data. Change statistics were used to evaluate pre-program implementation to post-program implementation in staff confidence and perceived ability of staff to deliver the education. The Mann-Whitney U test was used to measure the change between pre-intervention and postintervention scores. The bivariate Pearson Correlation measures were used to determine strength of linear relationships between questions. Data were analyzed using the SPSS program (Statistical Package for Social Science), version 25.0 (IBM Corp., 2017). Ethical Considerations This study was determined to be exempt from human subject review by the University of Utah Institutional Review Board. Results INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 11 Pre-intervention data were collected from 39 participants. Each participant was a staff member on the inpatient rehabilitation floor. While some demographic information is discussed here, see Appendices A and B for additional demographic data. Of the staff surveyed, the majority of the participants were white (34, 87.2%) and female (31, 79.5%), while age and educational level were more varied. The majority of staff were between ages 25-44, with a slightly larger amount who indicated they were 25-34 (12, 30.8%) than indicated they were 3544 (11, 28.2%). Educational level of staff members was almost equally split with a slightly larger percentage indicating they had a bachelor's degree (18, 46.2%) than associate degree (17, 43.6%). Staff were to make a specific identification code to be used in the both the pre- and postintervention surveys. Errors in the survey created a large possibility that codes were changed in the pre-survey and post-survey process, resulting in a lack of confidence to match pre-survey to post-survey codes. The survey design was dependent on codes to match demographic data as this was only required on the pre-survey. In the post-intervention survey staff were asked how many years they had worked on the inpatient rehabilitation unit. A majority had worked there for less than 5 years, with the highest percentage indicating they had worked 1 to 2 years in the unit (13, 34.2%). Pre- to Post- Data Trends On analysis of pre- to post-survey data no statistically significant trends were noted (See Appendix C). However, analysis showed two predominant themes. Nursing staff had limited improvement in feeling confident of having the needed resources. Nursing staff also had limited decrease in feelings of involvement in teaching ISC and confidence to discuss a patient's ISC with the interdisciplinary team and explain advantages of each bladder program to the patient. INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 12 It is noted that the management team, consisting of the manager, assistant manager and educator, changed during the duration of this project. It is assumed that staff engagement and involvement in projects on the unit were lower during this time of change in management personnel. A new manager and assistant manager were hired after completion of this project. Confidence in resources. Nursing staff indicated feeling they had improved support. This is manifest by increased confidence in questions such as "I understand patient barriers in performance and adherence of intermittent self-catheterization," "I can adjust the education I provide based on a patient's emotional state," "I can adjust the education I provide based on a patient's physical abilities," and "I feel I have the resources I need to teach self-catheterization." This increase in support is directly related to the objective to develop a self-catheterization toolkit including development of a competency checklist and an educational toolkit. Further evidence of this is indicated by 82% (S.D. = 0.389) of staff who indicated they were using or intended to use the self-catheterization competency checklist and toolkit for applicable patients. To further support this, staff who stated they had the resources they needed had positive correlation with increased confidence in many other questions including: staff feeling they should be involved in intermittent selfcatheterization teaching (p= 0.007, r=0.422), confidence in current involvement (p= 0.000, r=0.569), ability to explain advantages (p= 0.004, r=0.449)and disadvantages (p= 0.008, r=0.417), talking to the interdisciplinary team (p= 0.009, r=0.416) and confidence in intermittent self-catheterization as the preferred method (p= 0.003, r=0.468). Decreased feeling of involvement. It was assumed that staff would feel more confident in teaching all aspects of intermittent self-catheterization after viewing the series of educational videos. However, staff indicated INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 13 decreased confidence in questions of feeling highly involved in teaching, teaching why intermittent self-catheterization is the preferred method, and the ability to discuss with the interdisciplinary team. One possible reason for the decreased confidence in these questions is that nursing staff gained some insight to their current involvement and teaching methods. Prior to education and additional resources it is possible that nursing staff were over confident in their teaching skills. As they learned more about teaching intermittent self-catheterization, they realized points where they lacked confidence and needed further repetition in teaching patients to gain confidence leading to decreased confidence in post-survey responses. Another possibility for decreased confidence in talking to the interdisciplinary team could indicate team dynamics and resistance for nursing to assume primary control in this responsibility from occupational therapy staff. It was also assumed that after viewing the educational materials employees would find increased confidence that teaching a patient early on about anatomy and likelihood of selfcatheterization would equate to successful home ISC. Further investigation is needed to identify why this outcome was different than expected. Correlations There were several statistically significant correlations between questions. Specific correlation findings are found in Appendices D and E. In general, respondents who indicated intent to use resources and felt they should be more involved had higher confidence in many other questions of the survey. Of note, there were statistically significant correlations between higher levels of education and confidence in discussing with the interdisciplinary team (p=0.042, r=0.327) and staff feeling they had the resources they needed (p=0.025, r=0.0360). There was also positive INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 14 correlation in the number of years staff have worked on IMRU and feeling involved in intermittent self-catheterization teaching (P= 0.002, r=0.484). Staff who stated intent to use given resources indicated higher confidence in feeling they should be involved in the intermittent self-catheterization teaching process (p=0.011, r=0.403). Staff who stated intent to use also had more confidence in their ability to explain why ISC is the preferred method (p=0.006, r= 0.431). It was also noted that staff who felt they should be involved were correlated with higher confidence in understanding patient barriers (p= 0.018, r=0.378), explaining advantages (p= 0.007, r=0.426) and disadvantages (p= 0.002, r=0.474), confidence that ISC is the preferred method (p= 0.001, r=0.520), confidence in speaking with the interdisciplinary team (p= 0.021, r=0.367), adjusting teaching to both physical (p= 0.014, r=0.392) and emotional states (p= 0.005, r=0.438) of the patient, and confidence that early teaching sets the patient up for future success (p= 0.012, r=0.397). Discussion Summary Initial phases of this project assessed staff on an inpatient medical rehab unit to determine current confidence in teaching abilities and available resources. A self-catheterization toolkit was developed that included a competency checklist and educational materials to assist patient understanding. Information on how to use these resources and how to best teach and adjust techniques for different situations was delivered through a video series required of staff. As data was analyzed trends indicated that staff felt more confident in their ability to adjust teaching to different situations and felt more confident in the resources available. This trend directly relates to project objectives to develop evidence-based resources for staff to use to teach patients. INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 15 Unanticipated findings were decreases in confidence in involvement in teaching selfcatheterization, and ability to discuss teaching with the interdisciplinary team. Interpretation The results of this project align with findings with other studies. This project agrees with Bardsley (2014), who states that good patient education around catheterization technique is essential. Although Bardsley does not specify what parts should be emphasized, she notes education should be followed up with written and visual information (2014). Leach (2018) also indicated in her research that patients should have both written and verbal instructions for better patient understanding. This project also found that increased resources available for staff can produce higher confidence in teaching patients, and that education should be supplemented with written and visual information. This project agrees with findings of Sheldon (2013) who looked at the role of the nurse in patient education, particularly with intermittent self-catheterization. He emphasized that there is no guide to teaching this, and as a result many nurses rely on things such as personal experiences and policies at unique practice settings, which can lead to inconsistencies in teaching. The results of this project saw trends of decreases in confidence in ability to explain. It is theorized that in the pre-survey staff relied on personal experiences but did not think of explaining benefits of continuation of therapy and importance of compliance, which resulted in inconsistencies in teaching methods and instructions. This project disagreed with findings by Biaziolo et al. (2017), who found self-confidence originates from repeated experiences and is related to success and continuity of treatment. Gonzalez & Sole (2014) found similar benefit in repeated experiences relating to higher ability to master skill. The material in this project focused on use of resources to help teach patients and INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 16 suggested that nurses use these resources and teaching methods early in patients' stay. However, the nursing staff felt a decrease in confidence that early teaching equates to further success at home. Limitations Limitations identified during this project included a double-barreled question on intent to use both the competency checklist and education checklist. Splitting this up would have helped to analyze in more depth which tools were deemed effective. Further, staff on the unit are required to check a weekly staff education tool. This is tracked by unit management. In order to get maximum response a link to the survey was delivered through this medium. Using the survey link in this way caused the need for staff to develop a unique identifier based off their employee ID number. The survey gave errors during the first survey, which caused some staff to omit this answer and some to change their answer. The differences in unique identifiers made it necessary to analyze the data with nonparametric statistical testing, thus yielding less-specific results. Using the survey link to get maximum response also potentiated poor attention when viewing the video. Unofficial feedback from staff indicated the material was viewed in a busy environment where focus was divided, and staff were interrupted. This caused staff difficulty in hearing material and ability to give their full attention. Future attempts to educate staff on this unit should allow for full focus such as in a skills day or through an in-service. Additionally, the setup of this project did not include patient surveys to measure their confidence in teaching administered during the hospital stay. This information would have been valuable for the project to understand whether staff confidence in teaching and resources yielded increases in patient confidence. INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 17 Due to time limits on the project, it is possible that not all the nurses had the opportunity to use the new teaching resources with patients. Lastly it was realized that no education was given to therapy staff regarding nursing's use of new tools. Teaching ISC is multidisciplinary approach and more focus should have been placed in addressing it this way to avoid confusion in the interdisciplinary team. Conclusion After implementing a self-catheterization toolkit it appears promising that staff feel more confident that they have the needed resources to teach self-catheterization. This results in increased staff confidence to adjusting teaching for patient scenarios regarding both physical and emotional barriers. As staff are more confident in their ability to teach with confidence in the resources available and the ability to adjust their teaching, it is theorized that patients will go home with greater confidence and better ISC technique. Greater confidence, techniques and educational material to support what the patient learned while on an inpatient unit will decrease complications seen in primary care and increase adherence to ISC. The increased confidence in adequate resources should continue to help employees in other inpatient units of this hospital as well as in outpatient rehabilitation as a resource for patients who are nonadherent or having complications with self-catheterization. IMRU is consulted often for resources and best practices to assist patients who are learning to ISC. There is applicability in introducing these tools to other settings to increase staff confidence in resources they are using. Further evaluation should be performed on this unit to solidify confidence in teaching ISC in areas where staff had decreases in confidence. This project highlights a suspected overconfidence in teaching ISC prior to education provided. As nurses learned more about teaching intermittent self-catheterization, they realized INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 18 points where they lacked confidence and need further repetition to become comfortable teaching patients. As nursing staff gain repetition and experience in teaching ISC their confidence and abilities should continue to be supported, evaluated and reinforced as necessary. This project did not show statistically significant changes to pre- and post-educational survey responses, and further assessment should be taken to evaluate usefulness and practicality of the toolkit. Acknowledgements I would like to acknowledge my project chair Dr. Amanda Al-Khudairi for her patience, assistance and guidance in this project. I would also like to thank Eli Jacob for his assistance and statistical advice on this project. I would also like to thank content experts Danielle Houseman and Alissa Brown for their endless support on this project. Funding This project did not receive any funding for the completion of this project. INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 19 References Afsar, S. I., Yemisci, O. U., Cosar, S. N., & Cetin, N. (2013). 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Neurogenic bladder in spinal cord injury patients. Research and Reports in Urology, 7, 85-89. doi:10.2147/rru.s29644 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 22 Wilson, M. (2015). Clean intermittent self-catheterisation: Working with patients. British Journal of Nursing, 24(2), 76-85. doi:10.12968/bjon.2015.24.2.76 Zlatev, D. V., Shem, K., & Elliott, C. S. (2016). How many spinal cord injury patients can catheterize their own bladder? The epidemiology of upper extremity function as it affects bladder management. Spinal Cord, 54(4), 287-291. doi:10.1038/sc.2015.169 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 23 Appendix A Demographic Information of Survey Participants (Presurvey Data) Table A1 Statistics Indicate the number of years Highest level of Age range N education Race Ethnicity worked on IMRU 39 39 39 39 39 38 Mean 2.87 1.79 1.69 1.38 1.38 2.21 Std. Error of Mean .205 .066 .117 .179 .179 .173 Median 3.00 2.00 2.00 1.00 1.00 2.00 Std. Deviation 1.281 .409 .731 1.115 1.115 1.069 Variance 1.641 .167 .534 1.243 1.243 1.144 Skewness .489 -1.520 .986 2.888 2.888 .815 Std. Error of Skewness .378 .378 .378 .378 .378 .383 Range 5 1 3 4 4 4 Minimum 1 1 1 1 1 1 Maximum 6 2 4 5 5 5 25 2.00 2.00 1.00 1.00 1.00 1.00 50 3.00 2.00 2.00 1.00 1.00 2.00 75 4.00 2.00 2.00 1.00 1.00 3.00 Percentiles Valid Gender you have Table A2 Age range Cumulative Frequency Valid Missing Total Percent Valid Percent Percent 18-24 5 6.3 12.8 12.8 25-34 12 15.2 30.8 43.6 35-44 11 13.9 28.2 71.8 45-54 6 7.6 15.4 87.2 55-64 4 5.1 10.3 97.4 Prefer not to answer 1 1.3 2.6 100.0 Total 39 49.4 100.0 System 40 50.6 79 100.0 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 24 Figure A1 Table A3 Gender Cumulative Frequency Valid Missing Total Figure A2 Male Percent Valid Percent Percent 8 10.1 20.5 20.5 Female 31 39.2 79.5 100.0 Total 39 49.4 100.0 System 40 50.6 79 100.0 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 25 Table A4 Highest level of education Cumulative Frequency Valid Missing Percent Valid Percent Percent Associates Degree 17 21.5 43.6 43.6 Bachelors Degree 18 22.8 46.2 89.7 Masters Degree or greater 3 3.8 7.7 97.4 Prefer not to answer 1 1.3 2.6 100.0 Total 39 49.4 100.0 System 40 50.6 79 100.0 Total Figure A3 Table A5 Race Cumulative Frequency Valid Missing Total White Percent Valid Percent Percent 34 43.0 87.2 87.2 Hispanic/Latino 1 1.3 2.6 89.7 Black/African American 1 1.3 2.6 92.3 Asian 3 3.8 7.7 100.0 Total 39 49.4 100.0 System 40 50.6 79 100.0 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 26 Table A6 Ethnicity Cumulative Frequency Valid Missing Total White Percent Valid Percent Percent 34 43.0 87.2 87.2 Hispanic/Latino 1 1.3 2.6 89.7 Black/African American 1 1.3 2.6 92.3 Asian 3 3.8 7.7 100.0 Total 39 49.4 100.0 System 40 50.6 79 100.0 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 27 Appendix B Descriptive statistics on numbers of years worked on rehabilitation (post survey data) Table B1 Indicate the number of years you have worked on IMRU Cumulative Frequency Valid Missing Total Figure B1 Percent Valid Percent Percent Less than 1 year 11 13.9 28.9 28.9 1-2 years 13 16.5 34.2 63.2 3-5 years 11 13.9 28.9 92.1 6-10 years 1 1.3 2.6 94.7 Greater than 10 years 2 2.5 5.3 100.0 Total 38 48.1 100.0 System 41 51.9 79 100.0 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT Appendix C Presurvey comparison to Postsurvey comparison Man Whitney U test Table C1 28 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT Table C2 29 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT Appendix D Pearson Bivariate Comparisons Presurvey Table D1 Age range Pearson Correlation Sig. (2tailed) N 30 Correlations Age range 1 Highest level of Gender education -0.001 0.294 Race 0.164 I should be highly involved in teaching patients selfcatheterizat Ethnicity ion 0.164 -0.021 I feel I am currently highly involved in teaching patients selfcatheterizat ion 0.126 I can explain advantages of different bladder manageme nt programs 0.192 I can explain disadvanta ges of different bladder manageme nt programs 0.280 I am confident educating patients with bladder dysfunction on why intermittent catheterizat ion is the preferred method 0.158 I understand patient barriers in performanc e and adherence of selfcatheterizat ion 0.303 I can adjust I can adjust I feel I have the the the education I education I resources I provide provide based on a based on a need to teach selfpatients patients emotional physical catheterizat ion state abilities 0.248 0.314 0.210 Starting the selfSelfcatheterizat ion process catheterizat ion can with prevent patients in future the hospital sets the urinary and health patient up for future complicatio ns success -0.068 -0.105 .405* I can discuss a patients ability to selfcatheterize with the interdiscipli nary team 0.994 0.069 0.317 0.317 0.900 0.445 0.241 0.085 0.337 0.061 0.127 0.052 0.200 0.011 0.683 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 Pearson Correlation Sig. (2tailed) N -0.001 1 -0.041 -0.053 -0.053 -0.012 -0.089 -0.002 -0.081 0.058 -0.068 -0.078 -0.265 -0.165 -0.221 -0.064 -0.255 0.806 0.747 0.747 0.943 0.590 0.991 0.624 0.725 0.682 0.638 0.103 0.314 0.176 0.701 0.117 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 Pearson Correlation Sig. (2tailed) N 0.294 -0.041 1 0.084 0.084 0.249 0.045 0.260 0.166 0.146 0.104 0.174 0.171 .360 .327 * 0.101 -0.196 0.069 0.806 0.609 0.609 0.126 0.787 0.110 0.311 0.374 0.529 0.289 0.298 0.025 0.042 0.542 0.232 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 Pearson Correlation Sig. (2tailed) N 0.164 -0.053 0.084 1 1.000** -0.056 -0.165 -0.055 0.005 -0.128 0.136 0.114 0.103 0.043 0.068 0.031 -0.066 0.317 0.747 0.609 0.000 0.737 0.315 0.740 0.974 0.437 0.408 0.489 0.534 0.793 0.680 0.851 0.690 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 Pearson Correlation Sig. (2tailed) N 0.164 -0.053 0.084 1.000** 1 -0.056 -0.165 -0.055 0.005 -0.128 0.136 0.114 0.103 0.043 0.068 0.031 -0.066 0.317 0.747 0.609 0.000 0.737 0.315 0.740 0.974 0.437 0.408 0.489 0.534 0.793 0.680 0.851 0.690 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 I should be highly involved in teaching patients Pearson Correlation Sig. (2tailed) N -0.021 -0.012 0.249 -0.056 -0.056 1 .509** .408** .447** .430** .395** .461** .411** .444** .341** .417** 0.163 0.900 0.943 0.126 0.737 0.737 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.002 0.000 0.155 39 39 39 39 39 78 78 78 78 78 78 78 78 78 78 78 78 I feel I am currently highly involved in teaching Pearson Correlation Sig. (2tailed) N 0.126 -0.089 0.045 -0.165 -0.165 .509** 1 .406** .357** .377** .476 ** .325** .371** .501 .454 ** 0.111 0.078 0.445 0.590 0.787 0.315 0.315 0.000 0.000 0.001 0.001 0.000 0.004 0.001 0.000 0.000 0.333 0.497 39 39 39 39 39 78 78 78 78 78 78 78 78 78 78 78 78 I can explain advantages of different bladder Pearson Correlation Sig. (2tailed) N 0.192 -0.002 0.260 -0.055 -0.055 .408** .406** 1 .853** .639** .488** .493** .512** .305** .439** .401** .265* 0.241 0.991 0.110 0.740 0.740 0.000 0.000 0.019 39 39 39 39 39 78 78 I can explain disadvanta ges of different Pearson Correlation Sig. (2tailed) N 0.280 -0.081 0.166 0.005 0.005 .447** .357 .853 0.085 0.624 0.311 0.974 0.974 0.000 0.001 0.000 39 39 39 39 39 78 78 78 I am confident educating patients with Pearson Correlation Sig. (2tailed) N 0.158 0.058 0.146 -0.128 -0.128 .430 .377 ** .639** .604 0.337 0.725 0.374 0.437 0.437 0.000 0.001 0.000 0.000 39 39 39 39 39 78 78 78 78 78 I understand patient barriers in performanc I candadjust Pearson Correlation Sig. (2tailed) N 0.303 -0.068 0.104 0.136 0.136 .395** .476** .488** .518** .449** 0.061 0.682 0.529 0.408 0.408 0.000 0.000 0.000 0.000 0.000 39 39 39 39 39 78 78 78 78 78 78 Pearson Correlation Sig. (2tailed) N 0.248 -0.078 0.174 0.114 0.114 .461** .325** .493** .527** .569** .492** 0.127 0.638 0.289 0.489 0.489 0.000 0.004 0.000 0.000 0.000 0.000 39 39 39 39 39 78 78 78 78 78 78 78 Pearson Correlation Sig. (2tailed) N 0.314 -0.265 0.171 0.103 0.103 .411** .371** .512** .441** .411** .593** .711** 0.052 0.103 0.298 0.534 0.534 0.000 0.001 0.000 0.000 0.000 0.000 0.000 39 39 39 39 39 78 78 78 78 78 78 78 78 the resources I need to teach self- Pearson Correlation Sig. (2tailed) N 0.210 -0.165 .360* 0.043 0.043 .444** .501** .305** .393** .281* .300** .282* .369** 0.200 0.314 0.025 0.793 0.793 0.000 0.000 0.007 0.000 0.013 0.008 0.012 0.001 39 39 39 39 39 78 78 78 78 78 78 78 78 78 I can discuss a patients ability to self- Pearson Correlation Sig. (2tailed) N .405* -0.221 .327* 0.068 0.068 .341** .454** .439** .376** .373** .354** .378** .577** .466** 0.011 0.176 0.042 0.680 0.680 0.002 0.000 0.000 0.001 0.001 0.001 0.001 0.000 0.000 39 39 39 39 39 78 78 78 78 78 78 78 78 78 78 78 78 Starting the selfcatheterizat ion process with Pearson Correlation Sig. (2tailed) N -0.068 -0.064 0.101 0.031 0.031 .417** 0.111 .401** .383** .385** .295** .390** .353** 0.203 .342** 1 .385** 0.683 0.701 0.542 0.851 0.851 0.000 0.333 0.000 0.001 0.001 0.009 0.000 0.002 0.075 0.002 39 39 39 39 39 78 78 78 78 78 78 78 78 78 78 78 78 Selfcatheterizat ion can prevent future Pearson Correlation Sig. (2tailed) N -0.105 -0.255 -0.196 -0.066 -0.066 0.163 0.078 .265* .259* .315** .250 * .243* .266* 0.171 0.121 .385** 1 0.523 0.117 0.232 0.690 0.690 0.155 0.497 0.019 0.022 0.005 0.027 0.032 0.019 0.136 0.291 0.001 39 39 39 39 39 78 78 78 78 78 78 78 78 78 78 78 Gender Highest level of education Race Ethnicity the education I provide based on a i adjust I can the education I provide based on a i I have I feel 0.994 *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). ** ** * ** 0.523 0.000 0.000 0.000 0.000 0.000 0.007 0.000 0.000 78 78 78 78 78 78 78 78 78 78 ** 1 .604** .518** .527** .441** .393 ** .376** .383** .259* 0.022 0.000 0.000 0.000 0.000 0.000 0.001 0.001 78 78 78 78 78 78 78 78 78 ** 1 .449** .569 .411 ** .281* .373** .385** .315** 0.000 0.000 0.000 0.013 0.001 0.001 0.005 78 78 78 78 78 78 78 1 .492** .593** .300** .354** .295** .250* 0.000 0.000 0.008 0.001 0.009 0.027 78 78 78 78 78 78 1 .711** .282* .378** .390** .243* 0.000 0.012 0.001 0.000 0.032 78 78 78 78 78 1 .369** .577** .353** .266* 0.001 0.000 0.002 0.019 78 78 78 78 1 .466** 0.203 0.171 0.000 0.075 0.136 78 78 78 1 .342** 0.121 0.002 0.291 ** 0.001 78 INTERMITTENT CATHETERIZATION EDUCATION TOOLKIT 31 Appendix E Pearson Bivariate Comparisons Postsurvey Table E1 I should be highly involved in teaching patients Pearson Correlation Sig. (2tailed) N I feel I am currently highly involved in teaching Pearson Correlation Sig. (2tailed) N I can explain advantages of different bladder Pearson Correlation Sig. (2tailed) N I can explain disadvanta ges of different dd Iblam Pearson Correlation Sig. (2tailed) N confident educating patients with Pearson Correlation Sig. (2tailed) N I am confident educating patients I feel I am with I should be currently I can bladder highly explain highly I can dysfunction disadvanta involved in involved in explain on why ges of teaching teaching advantages intermittent patients patients of different different selfbladder catheterizat intermittent intermittent bladder manageme manageme ion is the selfselfnt nt catheterizat catheterizat preferred programs programs ion ion method ** ** ** ** 1 .494 .426 .474 .520 0.001 0.007 0.002 0.001 I understand patient barriers in performanc e and adherence of intermittent selfcatheterizat ion Indicate the number of years you have worked on IMRU * 0.097 .378 0.018 0.561 Starting the intermittent selfcatheterizat ion process with patients in the hospital sets the patient up for future success .438** .392 .422 .367 Intermittent selfcatheterizat ion can prevent future urinary and health complicatio ns * 0.303 .397 0.005 0.014 0.007 0.021 0.012 I feel I have I can adjust I can adjust the the the resources I education I education I need to provide provide teach based on a based on a intermittent patients patients selfemotional physical catheterizat state abilities ion * ** I can discuss a patients ability to intermittentl y selfcatheterize with the interdiscipli nary team * 0.060 I am using/inten d to use the intermittent selfcatheterizat ion competenc y checklist and educational handout when applicable to my patients * .403 0.011 39 39 39 39 39 39 38 39 39 39 39 39 39 39 .494** 1 .406 * .406* .479** .400* .484** .365* 0.230 .596** .409** 0.017 0.170 0.301 0.063 0.001 39 ** 0.010 0.010 0.002 0.012 0.002 0.022 0.159 0.000 0.010 0.920 0.300 39 39 39 39 39 38 39 39 39 39 39 39 39 * 1 .920 ** .623** .503** 0.120 .402* .508** .449** .515** .432 ** .453** 0.199 0.000 0.000 0.001 0.473 0.011 0.001 0.004 0.001 0.006 0.004 0.224 .426 .406 0.007 0.010 39 39 39 39 39 39 38 39 39 39 39 39 39 39 .474** .406* .920** 1 .698** .503 ** 0.089 .402* .401* .417** .369* .432** .453** 0.199 0.002 0.010 0.000 0.000 0.001 0.594 0.011 0.011 0.008 0.021 0.006 0.004 0.224 39 39 39 39 39 39 38 39 39 39 39 39 39 .520** .479** .623** .698** 1 .552** 0.162 .552** .492 .468 .461 .404 .480 .431 0.001 0.002 0.000 0.000 0.000 0.330 0.000 0.001 0.003 0.003 0.011 0.002 0.006 ** 39 ** 39 39 39 39 39 38 39 39 39 .503** .503 ** .552** 1 0.201 .487** .598 .328 .405 .390 .345 * 0.182 0.018 0.012 0.001 0.001 0.000 0.227 0.002 0.000 0.041 0.010 0.014 0.031 0.269 39 39 39 39 39 39 38 39 39 39 39 39 39 39 Pearson Correlation Sig. (2tailed) N 0.097 .484** 0.120 0.089 0.162 0.201 1 0.095 0.024 0.192 0.226 -0.033 0.009 0.095 0.561 0.002 0.473 0.594 0.330 0.227 0.571 0.887 0.249 0.173 0.844 0.958 0.571 38 38 38 38 38 38 38 38 38 38 38 38 38 38 Pearson the Correlation education I Sig. (2tailed) provide based on a N i I can adjust Pearson .438** .365* .402* .402* .552** .487** 0.095 1 .801 ** 0.249 .451** .484** .482** 0.287 0.005 0.022 0.011 0.011 0.000 0.002 0.571 0.000 0.127 0.004 0.002 0.002 0.076 number of years you have worked on IMRU I can adjust the education I provide based on a i I have I feel Correlation Sig. (2tailed) N Pearson the Correlation resources I Sig. (2tailed) need to N teach I can discuss a patients ability to intermittentl Pearson Correlation Sig. (2tailed) N Starting the intermittent selfcatheterizat ion process ih Intermittent Pearson Correlation Sig. (2tailed) N Pearson selfCorrelation catheterizat Sig. (2tailed) ion can N prevent fI am Pearson using/inten d to use the intermittent Correlation Sig. (2tailed) N * * * 39 39 39 39 39 39 38 39 39 39 39 39 .392 * 0.230 .508** .401 * .492** .598 ** 0.024 .801** 1 0.237 .653 .454 .436 ** 0.264 0.014 0.159 0.001 0.011 0.001 0.000 0.887 0.000 0.146 0.000 0.004 0.006 0.104 39 39 39 39 39 39 38 39 39 39 39 39 39 39 .422 ** .596** .449** .417 .468 .328 * 0.192 0.249 0.237 1 .416 ** 0.201 0.248 0.253 0.007 0.000 0.004 0.008 0.003 0.041 0.249 0.127 0.146 0.009 0.220 0.127 0.121 39 39 38 39 .369 .461 .405 * 0.226 .451** .653 .416 0.021 0.010 0.001 0.021 0.003 0.010 0.173 0.004 0.000 0.009 39 39 39 39 39 39 38 39 39 39 39 .397* 0.017 .432** .432** .404* .390* -0.033 .484** .454** 0.201 0.311 0.012 0.920 0.006 0.006 0.011 0.014 0.844 0.002 0.004 0.220 0.054 39 39 39 39 39 39 38 39 39 39 39 39 39 39 0.303 0.170 .453** .453** .480 ** .345* 0.009 .482 ** .436** 0.248 .387 * .557** 1 0.159 0.060 0.300 0.004 0.004 0.002 0.031 0.958 0.002 0.006 0.127 0.015 0.000 39 39 39 39 39 39 38 39 39 39 39 39 39 39 .403* 0.301 0.199 0.199 .431 ** 0.182 0.095 0.287 0.264 0.253 0.270 0.144 0.159 1 0.011 0.063 0.224 0.224 0.006 0.269 0.571 0.076 0.104 0.121 0.097 0.382 0.334 39 39 39 39 39 39 38 39 39 39 39 39 39 **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed). * 39 ** 39 ** .515 ** 39 39 .409 ** 39 ** ** .367 * 39 ** 39 39 ** .400* ** 39 * 39 Pearson Correlation Sig. (2tailed) N 39 ** .378* I understand patient barriers in performanc d the Indicate 39 ** ** 39 39 39 39 39 ** 1 0.311 .387* 0.270 0.054 0.015 0.097 39 39 39 1 .557** 0.144 0.000 0.382 0.334 39