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UROLOGIC NURSING / January-February 2020 / Volume 40 Number 1 7

Urinary

Sophia Viner, DNP, ANP-BC, is an Adult Nurse Practitioner, and a DNP Student, the University of Massachusetts Lowell, Lowell, MA.

Ramraj Gautam, PhD, is an Associate Teaching Professor, University of Massachusetts Lowell, Lowell, MA.

Urinary Tract Infection Knowledge of Long-Term Care Nursing Staff: The Effect of an Educational Intervention Sophia Viner, DNP, ANP-BC; and Ramraj Gautam, PhD

Data from the Centers for Disease Control and Prevention (CDC) (2018) identify the urinary system as the most common site of health care-associated infections among residents of long-term care facili- ties. Urinary tract infection (UTI) is the second most common infection among residents of long-term care facilities (Genao & Buhr, 2012). Results from a retrospective review using national emergency department (ED) data by Caterino and associates (2012) determined that roughly 5,000,000 ED visits among those aged 65 years and over were for UTI diagnosis and treatment. Communication barriers, chronic genitourinary symptoms, and other health comorbidities of the long-term care facility popula- tion make the identification of a UTI challenging (Genao & Buhr, 2012). Jeon and colleagues (2018) determined that a delay in identification, diagnosis, and treatment result in preventable hospital admis- sions and mortality. Thus, early recognition and ini-

U r o l o g I C N U r s I N g

Research

© 2020 Society of Urologic Nurses and Associates Viner, S., & Gautam, R. (2020). Urinary tract infection knowl-

edge of long-term care nursing staff: The effect of an educational intervention. Urologic Nursing, 40(1), 7-10, 21. https://doi.org/10.7257/1053-816X.2020.40.1.7

Providing an educational intervention for long-term care facility nursing staff improves knowledge and prevention of urinary tract infections.

Key Words Urinary tract infection, educational intervention, long- term care facility, nursing staff, longitudinal data collection.

tiation of appropriate treatment is paramount. Imple - mentation of an educational program for nursing staff on early recognition and treatment of UTI can promote quality of care and reduce hospital readmis- sion.

Background/Purpose Long-term care facilities provide post-acute care

to individuals who do not require acute care but are unable to care for themselves at home (Horney et al., 2017). It is estimated that 4 million Americans are admitted to long-term care facilities annually, with these facilities providing care to nearly 1 million Americans daily (CDC, 2019). Specific health risks, specifically a UTI, are associated with residing in a long-term care facility. This risk has been correlated to a weakening of one’s immune system, which is expected with aging, and the tendency to have mul- tiple health-related comorbidities (High et al., 2009). For females, decreased levels of estrogen, expected in post-menopause, increases the risk for developing a UTI (Grover et al., 2009). For males, UTI preva- lence increases because of age-associated benign prostatic hypertrophy and associated urinary reten- tion (Girard et al., 2017).

Juthani-Mehta and associates (2005) posit that an uncertainty surrounds the diagnosis of UTI because there are no universally accepted criteria for the diagnosis, treatment, or surveillance of this con- dition among residents of long-term care facilities. In non-acute care health settings, consensus is absent between the diagnosis of UTI and asymptomatic bac- teriuria. A diagnosis of UTI is dependent upon the growth of bacteria in a urine culture, yet in the absence of clinical symptoms, treatment may be unwarranted (Benton & Nixon-Lewis, 2007).

1.3 contact hours

Instructions for CNE Contact Hours UNJ 2001

Continuing nursing education (CNE) contact hours can be earned for completing the learning activity associated with this

article. Instructions are available at suna.org/library Deadline for submission: February 28, 2022

8 UROLOGIC NURSING / January-February 2020 / Volume 40 Number 1

Bacteriuria represents colonization of the bladder by organisms acquired from flora of the gut and peri- urethral area. Treatment of asymptomatic bacteri- uria is not recommended, and is associated with antibiotic overuse and an increase in rates of antibi- otic resistance (Juthani-Mehta et al., 2005). Adults over 65 years of age do not often present with the typical symptoms of a UTI, such as fever, urinary burning, or frequency. A UTI among this population may present with nonspecific symptoms, such as decreased appetite, poor oral intake, decreased physical activity, and/or increased agitation (Jump et al., 2012). Nonspecific symptoms, such as mental status changes and behavioral changes, are often attributable to UTIs in this population.

Early identification of UTI and timely initiation of appropriate treatment are important in successful management of the infection. Early intervention sta- bilizes conditions and established approaches to care to initiate best management of conditions can occur (Rantz et al., 2014). All members of the health care team play an important role in providing qual- ity care to patients in skilled and long-term care facilities. Nursing staff education on prevention and early identification of UTI can reduce incidence of an infection among older adults. The purpose of this research was to determine if an educational inter- vention improved UTI knowledge among nursing staff employed in a long-term care facility.

Literature Review The Preferred Reporting Items for Systematic

Review and Meta-Analysis (PRISMA) report was used to identify relevant articles for this review. Limiting publications to the years of 2005-2017; available in English; published in peer-reviewed journals; the search engines of CINAHL, Medline, and Ovid; and the key words of urinary tract infec-

tion, knowledge, nursing staff, and education, 120 articles were initially identified. These articles were further limited based on the presence of UTI, data collected in long-term care facilities, the provision of an educational intervention, full-text availability, and documented health outcomes. Once this refine- ment was completed, 22 articles remained; all were included in the review and used to develop the planned educational intervention. The activities of this research were guided by the article that devel- oped, implemented, and evaluated a UTI-specific educational intervention for long-term care facility nursing staff (Freeman-Jobson et al., 2016).

Guided by reports from the CDC (2018), the uniqueness of assessing and identifying UTI in resi- dents of long-term care facilities, and a paucity of research describing nurses’ ability to identify this health condition, a research study was formulated. The purpose of the study was to determine the impact an educational program had on UTI-specific knowledge among nursing staff employed at either study site. Results of the study may be used to ensure that any educational program is evidence- based and addresses the specific knowledge gaps of the nursing staff.

Study Methodology Using a longitudinal study design, a knowledge

quiz was administered prior to and after the educa- tional program. In addition, demographic data were collected and used only to describe the study popu- lation.

Study knowledge quiz. The questionnaire was composed of 11 items: 9 multiple choice and 2 dichotomous items. The content of the question- naire assessed knowledge in management and pre- vention of UTIs. Responses were anonymous, and the questionnaire required 5 to 7 minutes to com-

Research

research summary Introduction

Urinary tract infections (UTIs) occur frequently among residents of long-term care facilities. Early identification of this health condition leads to prompt treatment, which pre- vents complications.

Objectives To determine if an educational intervention improved

UTI knowledge among nursing staff employed in a long-term care facility.

Methods Using a longitudinal study design and a previously

developed questionnaire, data were collected prior to and after a UTI-specific educational intervention. Data were received from 21 participants, all nursing staff who were direct care providers in a long-term health care facility.

Results Using paired sample t test, knowledge and prevention

of UTI scores improved. While not statistically significant, these data reflect a benefit from the educational intervention.

Conclusions Reviewing clinical indicators for, assessment variables,

and benefits of early diagnosis and treatment may improve the ability to decrease hospital admissions and mortality from this health condition.

Level of Evidence: III-B Source: Johns Hopkins Hospital/Johns Hopkins University (2016).

UROLOGIC NURSING / January-February 2020 / Volume 40 Number 1 9

plete. The questionnaire was administered prior to and after the study intervention. This provided a forum to determine the effect of the intervention.

Study educational program. The educational program was presented orally and guided by PowerPoint slides. An educational content was adopted, with permission from Freeman-Jobson and colleagues (2016). Learning objectives of the pro- gram were: • Define UTI. • Describe characteristics of symptomatic UTI. • Discuss risk factors for UTI. • Describe key factors required for the treatment of

UTI. • Describe physical changes associated with UTI. • Describe the laboratory testing for UTI. • Discuss characteristics of asymptomatic bacteri-

uria and identify the difference between asymp- tomatic bacteriuria and UTI.

The educational program was in the form of a PowerPoint presentation, discussion, and questions. A modified version of the study questionnaire was used with permission from Freeman-Jobson and col- leagues (2016) to measure participants’ pre- and post-knowledge of UTI. Project activities included completing the pre-intervention survey and provid- ing a demographic description, participating in the educational presentation, and completing the post- intervention survey. The post-intervention survey was conducted immediately after an educational program.

Institutional Review Board (IRB) approval was secured from the academic institution of the researcher. Guided by 45 CRR44.101(2), the activi- ties associated with this study were deemed to align with exempt status. Thus, identifying information was not collected, and consent was implied upon submission of study materials. The administrator at each study site agreed to allow the study to occur during worktime. That, together with the ability to provide continuing education contact hours, when appropriate, increased study participation rates.

Study Sites Two long-term care facilities served as study

sites. Each facility was located just outside a major Eastern metropolis in the United States and were dedicated to post-hospital care. Each facility has 40 post-acute short-term care rehabilitation areas and 80 long-term care beds. The educational interven- tion was provided in a staff conference room, which is located within the patient care area and has a door. This prevented disruption during the session and allowed staff to concentrate on the activity. Data from a retrospective chart review at both facilities performed over 3 months prior to this study identi- fied UTI as a diagnosis for 53% of residents.

Study Population Anecdotal data indicated there was a total of 40

potential participants. Complete data sets were received from 21 participants, which calculates to a 52.5% response rate. Since both sites received the same intervention and study inclusion criteria were consistent, one data set was developed.

Results Study population. Study participants included

18 registered nurses (RNs) and 3 licensed practical nurses (LPNs), with an average work experience of 6 years. Each participant completed all study activi- ties. These individuals were employed as direct care providers either full-time, part-time, or per diem. These individuals are described in Table 1.

Questionnaire results. Data were evaluated using paired sample t test. There was no statistical significant UTI knowledge difference from pre- to post-intervention. Participants pre-presentation evaluation achieved a mean knowledge score of 9.0 (SD = 1.06), which increased to 9.47 (SD = 0.87) post intervention (t = -1.817, p = 0.088). Individual item paired sample t tests were performed to find content that was most improved after the educational pro- gram. Results from this analysis identified a signifi- cant improvement in knowledge related to how UTIs are prevented (p = 0.003).

Discussion There have been few reports on the effect of an

educational program on knowledge and manage- ment of UTIs in long-term care facilities. The lack of significance in pre- and post-test scores was a posi- tive finding in this project. This demonstrated that

Urinary Tract Infection Knowledge of Long-Term Care Nursing Staff: The Effect of an Educational Intervention

Table 1. Study Population Demographics

Job classification n %

RN 18 85.7

LPN 3 14.3

Gender n %

Male 4 19.0

Female 17 81.0

Age in years n %

18 to 26 3 14.3

27 to 35 2 9.5

36 to 50 6 28.6

Years of experience Cumulative

< 5 years 57.1

> 5 years 42.9

10 UROLOGIC NURSING / January-February 2020 / Volume 40 Number 1

participants in the two study settings were profi- cient in an understanding of signs and symptoms of UTI, as well as UTI management strategies. Post- program assessment showed an increase in knowl- edge related to the question regarding knowledge in UTI prevention. Furthermore, there was a reduction in documented UTIs and antibiotic use for treatment of UTIs in two nursing facilities where this interven- tion was carried out. Following the program, there was a demonstrated 5% reduction in documented UTI and antibiotic use associated with UTI, which means the number of diagnosed and treated UTIs decreased after the program.

Results of how UTIs are diagnosed and managed were not statistically significant. The most likely explanation for this finding is that most project par- ticipants were experienced health care providers. Thus, it is possible the content of the program on diagnosis and management of UTIs was well known to these individuals. Therefore, for effective results in future studies, education must be tailored to par- ticipant educational and experience level. This can be achieved by including an interprofessional team in the development and assessment of material for educational interventions. Furthermore, with the support of nursing leadership, more programs can be implemented to embrace a wider audience, such as nursing assistants, physical therapists, occupa- tional therapists, and speech therapists. This could help diagnose UTIs in a timely manner.

Although nursing staff were supportive of the program, attendance was identified as a barrier. Among those who did not attend, “being too busy” was one reason. A solution to this barrier could be addressed through collaboration with nursing man- agement (e.g., shifting schedules so staff could attend the program).

In conclusion, UTIs are associated with aging. Studies have demonstrated that education for health care providers specific to the prevention and manage- ment of UTIs in the older adult population can improve knowledge and awareness of symptoms, and thus, reduce the number of patients diagnosed with UTIs. Frequent reviews on prevention and manage- ment of UTIs can help avoid re-hospitalization.

Limitations The project had several limitations. First, the

study population was a small sample, and thus, results cannot be generalized. Comparison of the pre-intervention level of knowledge to job classifica- tion was not feasible without compromising study data confidentially. The ability to describe residents of study sites was not possible. The health condition of residents and their risk of UTI may affect policies related to routine assessment for UTIs. Finally, the educational program was developed based on the published research literature. Assessment of nursing

staff knowledge, then developing and presenting an intervention guided by these results, would provide a data-specific educational program.

Implications for Practice Results of this study emphasize an importance

of an educational program for health care providers employed in long-term care facilities. Improved knowledge and awareness results in early and effec- tive recognition of UTIs, thus decreasing the neces- sity of inpatient hospital care and mortality from this health condition.

References Benton, T.J., & Nixon-Lewis, B. (2007). The aging urinary tract

and asymptomatic bacteriuria. https://www.consultant360. com/articles/aging-urinary-tract-and-asymptomatic-bacter iuria

Centers for Disease Control and Prevention (CDC). (2018). Urinary tract infection. https://www.cdc.gov/nhsn/PDFs/ LTC/LTCF-UTI-protocol-current.pdf

Centers for Disease Control and Prevention (CDC). (2019). Nursing homes and assisted living (long-term care facilities [LTCFs]). https://www.cdc.gov/longtermcare/index.html

Caterino J.M., Ting, S.A., Sisbarro, S.G., Espinola, J.A., & Carmargo, C.A., Jr. (2012). Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments, 2001-2008. Academic Emergency Medicine, 19(10), 1173-1180. https://doi.org/10.1111/j.1553-2712. 2012.01452.x

Freeman-Jobson, J.H., Rogers, J.L., Ward-Smith, P. (2016). Effect of an education presentation on the knowledge and awareness of urinary tract infection among non-licensed and licensed health care workers in long-term care facilities. Urologic Nursing. 36(2), 67-71. https://doi.org/10.7257/1053-816x. 2016.36.2.67

Genao, L., & Buhr, G.T. (2012). Urinary tract infections in older adults residing in long-term care facilities. Annals of Long- Term Care, 20(4), 33-38.

Girard, R., Gaujard, S., Pergay, V., Pornon, P., Martin-Gaujard, G., & Bourguignon, L. (2017). Risk factors for urinary tract infec- tions in geriatric hospitals. Journal of Hospital Infection, 97(1), 74-78. https://doi.org/10.1016/j.jhin.2017.05.007

Grover, M.L., Bracamonte, J.D., Kanodia, A.K., Edwards, F.D., & Weaver, A.L. (2009). Urinary tract infection in women over the age of 65: Is age alone a marker of complication? Journal of the American Board of Family Medicine, 22(3), 266-271. https://doi.org/10.3122/jabfm.2009.03.080123

High, K.P., Bradley, S.F., Gravenstein, S., Mehr, D.R., Quagliarello, V.J., Richards, C., & Yoshikawa, T.T. (2009). Clinical practice guideline for the evaluation of fever and infection in old er adult residents of long-term care facilities: 2008 Update by the Infections Diseases Society of America. Clinical Infectious Diseases, 48(2), 149-171. https://doi.org/10. 1086/595683

Horney, C., Capp, R., Boxer, R., & Burke, R.E. (2017). Factors asso- ciated with early readmission among patients discharged to post-acute care facilities. Journal of the American Geriatrics Society, 65(6), 1199-1205. https://doi.org/10.1111/jgs.14758

Jeon, B., Tamiya, N., Yoshie, S., Iijima, K., & Ishutzaki, T. (2018). Potentially avoidable hospitalizations, non-potentially avoidable hospitalizations and in-hospital deaths among residents of long-term care facilities. Geriatrics and Gerontology, 18(8), 1272-1279.

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Urinary Tract Infection continued from page 10 Johns Hopkins Hospital/Johns Hopkins University. (2016). Johns

Hopkins Nursing Evidence-Based Practice Model – Appendix C: Evidence level and quality guide. Retrieved from https://www.hopkinsmedicine.org/evidence-based- practice/_docs/appendix_c_evidence_level_quality_guide. pdf

Jump, R.L.P., Crnich, C.J., Mody, L., Bradley, S.F., Nicolle, L.E., & Yoshikawe, T.T. (2012). Infectious diseases in older adults of long-term care facilities: Update on approach to diagnosis and management. Journal of the American Geriatrics Society, 66(4), 789-803.

Juthani-Mehta, M., Drickamer, M.A., Towle, V., Zhang, Y., Tinetti, M.E., & Quagliarello, V.J. (2005). Nursing home practitioner survey of diagnostic criteria for urinary tract infections. Journal of the American Geriatrics Society, 53(11), 1986- 1990.

Rantz, M.J., Alexander, G., Galambos, C., Vogelsmeier, A., Popejoy, L., Flesner, M., Lueckenotte, A., Crecelius, C., Zwygart-Stauffacher, M., & Koopman, R.J. (2014). Initiative to test a multidisciplinary model with advanced practice nurses to reduce avoidable hospitalizations among nursing facility residents. Journal of Nursing Care Quality, 29(1), 1- 8. https://doi.org/10.1097/NCQ.0000000000000033

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