Assessment and Intervention
Knowledge of Nurses in Managing
Catheter Patency in Continuous
Bladder Irrigation Following TURP
Christine Ng
T
o achieve continuous irr igation of the bladder, the
p ro c e d u re
re q u i res
i n s e rting a three-way
Foley catheter that permits continuous flushing and drainage of
the bladder. This pro c e d u re is
commonly prescribed for 24
hours as part of postoperative
c a re following transure th ra l
resection. Bladder irrigation is
not to be taken lightly by nurses
because of the risks of immediate
complications such as postoperative bleeding, clot retention, genitourinary infection, and failure to
void due to hypotonic bladder
(Mebust, Holtgrewe, Cockett, &
Peters, 1989). A blocked catheter
resulting from clot retention following transurethral prostatectomy (TURP) is a common complication (Gilbert & Gobbi, 1989).
Nurses must ascertain the extent
of blockage before taking appropriate interventions to overcome
the problem. The extent to which
practicing nurses possess the necessary assessment and interv e ntion skills to undertake this type
of nursing pro c e d u re has not
been studied.
Christine Ng, RN, M.App.Sc., FRCN,
is a Nursing Lecturer, School of
Nursing and Public Health, Edith
Cowan University, Perth We s t e r n
Australia.
Continuous bl a dder irrigation (CBI) is an established procedure
designed to prevent the formation and retention of blood clots following transurethral prostatectomy (TURP). The purpose of this
study was to evaluate a tool designed to determine what steps the
nurse should follow to assess whether a catheter is bl o cked and the
actions to be taken to restore catheter patency for CBI.
Purpose of the Study
R e s e a rch Objectives
The purpose of this re s e a rc h
was to study a tool which consisted of a prioritized list of steps
taken to assess whether a
catheter is blocked and the
actions taken to restore catheter
patency for continuous bladder
irrigation. This instrument was
developed by a panel of expert
u rologic nurses based on a written simulation of a patient
requiring continuous bladder
irrigation following TURP. The
tool was then distributed to a
purposive sample of registered
nurses to prioritize the list of
steps practicing nurses would
take to assess whether or not a
catheter is blocked and the interventions needed to restore
catheter patency. The process of
testing the tool on a sample of
RNs was designed to determine if
there is a correlation between the
e x p e rts’ and practicing nurses’
ranking in assessing a blocked
catheter and appropriate actions
taken to unblock the catheter.
This study was not intended to
be a psychometric evaluation of
actual assessments or actions
performed.
1. To identify practicing nurses’
perception of the assessment
indicators of a blocked
catheter in continuous bladder irrigation.
2. To determine practicing nurses’ perception of the interventions needed to re s t o re
catheter patency.
3. To compare the assessment
and intervention indicators,
as determined by an expert
panel, with the indicators
given by practicing nurses.
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
Review of Literature
Although continuous bladder
i rrigation is usually prescribed
for a 24-hour period following
TURP, the management to ensure
a continuous flow of prescribed
solution is not without risk. Risks
include the development of urinary tract infection (Kennedy,
1984), localized clots that can
obstruct the patency of tubing
and cause the patient undue pain,
fluid overload, and ru p t u re d
bladder (Gilbert & Gobbi, 1989).
Nurses are responsible for pro v i ding effective patient care, which
includes ensuring a continuous
97
Figure 1.
Simulated Clinical Situation Designed to Study the
Management of Catheter Patency Following TURP
Mr. Everest returned to your ward from the operating room after having
had a TURP under spinal anesthesia. A continuous bladder irrigation was
in place, connected to a 2 x 2 liter bag(s) of normal saline bladder irrigation fluid. He also had an intravenous infusion line in place.
Two hours later, while the RN was taking a routine postanesthesia observation, she/he noticed that the solution drip rate in the chamber of the
bladder irrigation had slowed down and/or stopped. There was no fluid
draining from the catheter. Mr. Everest complained of fullness and discomfort in the “tummy.”
Nursing Assessment
If you are the RN being confronted with the above situation, what steps
would you take to determine if the catheter is blocked?
Nursing Actions/Intervention
What nursing actions/interventions would you take to unblock the
catheter?
F i g u re 2.
Assessment of a Blocked Catheter by the Panel of Expert s
Rank Order
by Panel
of Experts
Steps Taken to Assess a Blocked Catheter
1.
Check the saline irrigation for the:
a. Remaining volume.
b. Height of stand.
c. Level of fluid in drip chamber.
2.
Check the drainage bag for:
a. Amount.
b. Color.
c. Consistency.
d. Position.
3.
Adjust the clamps to ensure continuous flow rate.
4.
Assess the catheter and the tubing for:
a. Patency.
b. Kinking.
c. Traction.
d. Leakage.
5.
Check fluid balance/bladder irrigation chart(s) for signs of
urine/irrigation fluid retention.
6.
Percuss and/or palpate patient’s bladder.
7.
Ascertain patient’s degree of discomfort by:
a. Asking patient to rate the discomfort on a scale of 1-10 .
b. Comparing it with previous rating.
(In assessment of discomfort, take into account that spinal
anesthesia affects the degree of patient’s sensation.)
8.
Consider if there was a history of previous catheter blockage.
9.
Consider the size of the indwelling catheter.
98
flow of prescribed solution at all
times during this critical 24-hour
period. Therefore, nurses must
know how to identify a blocked
catheter and take appropriate
actions to remedy the situation.
However, there is little inform ation available in the literature on
the steps nurses take to assess and
unblock urinary catheters following bladder irrigation after TURP.
Literature reviewed to date
has not provided research-based
evidence to help nurses assess a
blocked catheter and re s t o re
catheter patency during continuous bladder irr i g a t i o n . G i l b e rt
and Gobbi (1989) described the
following signs of a blocked
catheter: severe continuous bladder spasms, leakage of urine
a round the catheter, distension at
the suprapubic region, adherence
of blood clots or shreds of tissue
to the lumen of the tubing, and
patient complaint of an urge to
defecate. Other signs demonstrated among semi-conscious patients
include restlessness and gripping
of the lower abdomen. These
signs have not been validated nor
prioritized according to severity.
In regards to the action taken to
restore catheter patency, one hospital manual of clinical nursing
pro c e d u res suggested to “milk”
the tubing and perf o rm a normal
saline bladder washout (Royal
Marsden Hospital, 1992). The
manual did not provide indicators or steps to be taken to assess
a blocked catheter. No research
references were given with either
source.
Although continuous bladder
i rrigation is used to reduce the
incidence of clot retention following TURP, some urologists
question its usefulness in light of
the risks it carries. Britton,
Fletcher, Harrison, and Royale
(1992) re p o rted that one-third of
the randomized group of patients
that were prescribed bladder irr igation postoperatively required at
least one bladder washout which
was perf o rmed as an intermittent
m e a s u re to dislodge blockage in
the urinary catheter. This was in
comparison to two-thirds of the
control group, which received at
least one bladder washout.
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
Although irrigation after TURP is
a well-established and widely
used technique designed to
reduce the incidence of postoperative clot retention, the study
demonstrated the use of bladder
irrigation did not totally eliminate the need for bladder
washouts among subjects in the
irrigation group. The two groups
did not significantly differ in
blood loss, electrolyte balance,
infection rate, or re c o v e ry. The
findings of the study resulted in a
local change in practice, from a
policy of routine irrigation of the
bladder to one of no irrigation
after TURP.
The above findings highlight
the need for establishing specific
guidelines for nursing practice,
which are based on scientific
i n q u i ry rather than tradition and
routine.
Due to cost-containment policies and bed constraints, many
teaching hospitals now place
patients who have undergone
TURP on wards that do not specialize in urology. Nurses on general wards, who may not have
had training in continuous bladder irrigation, are expected to
c a re for urologic patients.
There f o re, attention should
be directed at examining nursing
pro c e d u res and nurses’ knowledge of practice. The results of
this study could form the basis for
establishing a nursing pro c e d u re
protocol of assessment and i n t e rvention for managing catheter
patency following TURP.
Methodology
A descriptive study was
u n d e rtaken to compare the following: (a) the indicators of
assessment of a blocked catheter
and interventions taken to restore
catheter patency, as determined
by an expert panel, with (b) the
indicators of assessment and
actions taken by practicing RNs.
Sample. Definitions: Practicing nurses are RNs currently
working on urology wards or
w a rds allocated for inpatient
urology patients. An expert panel
refers to RNs with advanced clinical skills who have at least 5
years of experience in that clini-
Figure 3.
List of Nursing Actions Ranked in Order of Priority by
The Panel of Expert s
Assuming that the blockage is due to clot retention, what nursing
actions/interventions would you take in response to the blocked catheter?
Nursing Actions/Interventions
1. R e a s s u re patient and explain the problem.
2.
Tu rn off the bladder irrigation system.
3.
Milk the tubing (activate chuffer tube or similar device if in place).
4.
Observe drainage for: (a) amount, (b) color, and (c) consistency
( p resence or absence of clots).
5.
Restart irrigation if drainage is flowing freely and the level of
patient’s discomfort is decreasing.
6.
Initiate steps to prevent subsequent clotting: (a) ensure the irrigation
flow is at a maximum rate, and (b) attach manual irrigation aid, for
example chuffer tube or similar device.
7.
Reassess patient’s pain level and administer analgesia as required.
8.
If the output is bloody (like tomato soup) apply catheter traction.
9.
Identify patient as high risk of being a potential “clotter.”
cal speciality. The majority of the
panel members were clinical
nurse specialists with one member being a senior clinical nurse.
In this study an urologist was
included in the panel of experts.
Sample characteristics. The
sample comprised 83 RNs working in urology or wards allocated
urology patients from four major
teaching hospitals in the Perth
metropolitan region. Twenty-two
(26.5%) participants were from
Hospital A, 27 (32.5%) fro m
Hospital B, 19 (23%) fro m
Hospital C, and 15 (18%) from
Hospital D.
These nurses had a mean of
2.5 years of experience on their
present wards. Range of experience was from 1 month to a maximum of 11 years. Sixty-thre e
percent (52 RNs) had been practicing nursing for more than 6
years, 21.5% (18 RNs) had
between 2 and 6 years of experience while the remaining 13 participants had worked as RNs for
less than 2 years.
The majority of the nurses
w e re diploma-trained nurses
(72.5%) and 27.5% received a
bachelor in nursing which was
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
the highest degree achieved.
Experience with continuous bladder irrigation was as follows: (a)
57% (48 RNs) between 1 and 3
patient(s) requiring continuous
bladder irrigation per week, (b)
17% (14 RNs) 4 to 6 bladder irr igations per week, and (c) 15% (12
RNs) 7 to 10 bladder irrigations
per week. The remaining nine
subjects (11%) indicated their
experience ranged from 11 to 15
bladder irrigations per week.
R e s e a rch Design
To examine the practicing
nurses’ responses to steps they
would take to assess and unblock
the catheter, all RNs working on
urology wards or general ward s
allocated urology patients were
invited to participate in the study
(N=90). These nurses were
employed by four major teaching
hospitals in the metropolitan
region. A total of 83 RNs agreed to
participate in the study, pro v i ding a 92% response rate.
The panel of judges included
five urology nursing experts and
an urologist. Selection of the
experts was based on having
worked at least 5 years on a uro l-
101
Figure 4.
Simulated Clinical Situation for the Purpose Managing Catheter Patency Following TURP
Mr. Everest returned to your ward from the operating room after having had a TURP under spinal anesthesia. Continuous bladder irrigation was in place,
connected to a 2 x 2 liter bag(s) of normal saline bladder irrigation fluid. He also had an intravenous infusion line in place.
Two hours later, while the RN was taking a
postanesthesia observation, she/he noticed that the
irrigation had slowed down and/or stopped. There was
no fluid draining from the catheter. Mr. Everest complained of fullness and discomfort in the “tummy.”
Nursing Assessment
If you are the RN being confronted with the above
situation, what steps would you take to determine if
the catheter is blocked? Below is a list of steps that you
might take in this situation.
Please number in order of priority the steps you
would take to determine if the catheter is blocked. For
example, place 1 for the first step, 2 for the second
step, and so on.
Step
_________
_________
Assessment of Catheter Patency
Check the drainage bag for:
a. Amount.
b. Color.
c. Consistency.
d. Position.
A s c e rtain patient’s degree of discomfort
by:
a. Asking patient to rate the discomf o rt on a scale of 1-10.
b. Comparing it with previous rating.
(In assessment of discomfort, take
into account that spinal anesthesia
a ffects the degree of patient’s sensation.)
_________
Percuss and/or palpate patient’s bladder.
_________
Consider the size of the indwelling
catheter.
_________
_________
_________
_________
Check the saline irrigation for the:
a. Patency.
b. Kinking.
c. Traction.
d. Leakage.
Adjust the clamps to ensure continuous
flow rate.
Check fluid balance/bladder irrigation
c h a rt(s) for signs of urine/irrigation fluid
retention.
Nursing Actions/Interventions
Assuming that the blockage is due to clot retention,
what nursing actions/interventions would you take in
response to the blocked catheter? The following is a
list of actions you might take in this situation.
Indicate in order of priority the steps you would take to
unblock the catheter by placing a number in the space
provided below. For example, place 1 if the first step, 2
if the second step and so on.
Step
Actions
_________
Observe drainage for:
a. Amount.
b. Color.
c. Consistency (presence or absence
of clots).
_________
Tu rn off the bladder irrigation system.
_________
Identify patient as high risk of being a
potential “clotter.”
_________
Milk the tubing (activate chuffer tube or
similar device if in place).
_________
Initiate steps to prevent subsequent clotting:
a. E n s u re the irrigation flow is at a
maximum rate.
b. Attach manual irrigation aid, for
example chuffer tube or similar
device.
_________
R e a s s u re patient and explain the pro blem.
_________
Restart irrigation if drainage is flowing
freely and the level of patient’s discomf o rt is decreasing.
_________
Reassess patient’s pain level and administer analgesia as required.
_________
If the output is bloody (like tomato
soup), apply catheter traction.
Please list any comments or suggestions you have in
relation to the actions taken to restore catheter patency.
__________________________________________________
Consider if there was a history of pre v ious catheter blockage.
Please list any comments or suggestions you have in
relation to assessment of catheter patency.
__________________________________________________
102
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
F i g u re 4. (continued)
Simulated Clinical Situation for the
Purpose of Managing Catheter Patency
Following TURP
Indicate the importance of the following actions to
unblock the catheter by circling one of the statements listed below:
1.
2.
I n c rease the intravenous fluid.
Very important
Important
Not important
Tilt the bed.
Very important
Not important
Important
Your response to the following information will
assist in the conduct of this re s e a rch study. Please
indicate the information that is most applicable to
you.
1. Years of experience in nursing
(Place a (X) on one of the following statements)
Under 1 year
>1 to 2 years
> 2 to 4 years
> 4 to 6 years
> 6 years
(
(
(
(
(
)
)
)
)
)
2.
State the length of time you have been working
on your present ward or ward allocated urology
patients.
____ years ________ months
3. State your educational qualifications in nursing:
Diploma in nursing________________________
Degree awarded:__________________________
Masters degree____________________________
Other relevant qualification (s)
___________________________
4.
Approximately how many patients have you
been assigned per week that re q u i re continuous
bladder irrigation? Place a (X) next to the statement that best describe your experience.
1 to 3
( )
4 to 6
( )
7 to 10
( )
11 to 15
( )
16 to 20
( )
21 to 25
( )
26 to 30
( )
ogy ward. These experts were from four of the participating hospitals and the fifth expert was selected
from a nonparticipating private hospital. Among the
experts, there were a total of 120 instances of continuous bladder irrigations per week, resulting in an
average of 40 continuous bladder irrigations per
week for an expert.
Experts with specialist knowledge are an accept-
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
ed source in assessing the content validity of an
i n s t rument. Several authors on re s e a rch methods
have endorsed panel reviews to maximize the content validity of a well-constructed instrument. These
studies have used experts to determine the criteria
used in the development of instruments to measure
c o n s t ructs such as the observable and functional
dimensions of chemotherapy-induced stomatitis
(Dyck et al., 1991), and pediatric pain (Robertson,
1993). Waltz, Strickland, and Lenz (1991) suggested
that a panel of experts should have two reviewers
who are experts in the content area and at least one
member who is knowledgeable in instrument cons t ruction.
In this study, a panel of expert urologic nurses
initially developed the instrument that consisted of
two parts. The first part contained steps used in
assessing a blocked urinary catheter. The second
p a rt consisted of interventions that should be used
to restore urinary catheter patency. This tool was
then distributed to a sample of RNs who were asked
to rank the items in order of priority in each part of
the tool.
Instrument
A paper and pen simulation based on a commonly occurring clinical situation was used in this
study to determine nurses’ assessment of a blocked
catheter and their actions taken to unblock it. Several
investigators (Holzemer, Schleutermann, Farrand, &
Miller, 1981; Sedlacek & Nattress, 1972) have validated simulation as a measure of nurse practitioners’
ability in clinical problem solving.
Four RNs with 3 years clinical experience fro m
the four participating hospitals volunteered to establish the content validity of the written simulation.
The nurses agreed that the written clinical situation
was a common clinical problem that resulted in a
blocked catheter among patients on continuous bladder irrigation following TURP. The written simulation (see Figure 1) was then presented to the panel of
expert s. Their task was to develop and list, in order
of priority, the steps they would take to determine
whether a catheter is blocked or not and the actions
they would take to restore catheter patency. After a
total of three meetings (4.5 hours), the panel of nursing experts developed a definitive set of steps to
assess a blocked catheter (see Figure 2) and restore
catheter patency (see Figure 3). The experts, on the
basis of achieving an 85% agreement, determined
each step. According to Lynn (1986), a panel of six
raters is required to ensure 83% (five of six raters)
agreement for validity assessment to be achieved.
The tool developed in this study, consisting of
steps taken to assess catheter blockage and restore
catheter patency, was based on experts’ clinical
experience and opinions as there was a lack of documented empirical evidence in the literature. Once
the steps had been determined by the panel of
e x p e rts, they were placed in a random order for distribution to a sample of practicing nurses (see
F i g u re 4).
103
Table 1.
A Comparison of Nurses’ and Panel Experts’ Rankings in
Assessment of a Blocked Catheter
Nurses’ Experts’
Ranking Ranking Steps Taken to Assess a Blocked Catheter
3
1
Check the saline irrigation for (a) remaining volume, (b) height of stand, and (c) level of fluid in
drip container.
2
2
Check the drainage bag for (a) amount, (b) color, (c)
consistency, and (d) position.
7
3
Adjust the irrigation tubing clamps to ensure continuous flow rate.
1
4
Assess the catheter and the tubing for (a) patency,
(b) kinking, (c) traction, and (d) leakage.
6
5
Check fluid balance/bladder washout chart(s) for
signs of urine/washout fluid retention.
5
6
Percuss and/or palpate patient’s bladder.
4
7
A s c e rtain patient’s degree of discomfort by: (a) asking patient to rate the discomfort on a scale of 1-10;
(b) comparing it with previous rating. (In assessment of discomfort, take into account that spinal
anaesthesia affects the degree of patient’s sensation.)
9
8
Consider if there was a history of previous catheter
blockage.
8
9
Consider the size of the indwelling catheter.
Table 2.
A Comparison of Nurses’ and the Panel of Experts’ Ranking
of Steps Taken to Unblock the Catheter
Nurses’ Experts’
Ranking Ranking
Steps Taken to Unblock the Catheter
1
1
Reassure patient and explain the problem.
2
2
Turn off the bladder irrigation system.
3
3
Milk the tubing (activate chuffer tube or similar
device if in situ).
4
4
Observe drainage for (a) amount, (b) color, and (c)
consistency (presence or absence of clots).
6
5
Recommend irrigation if drainage is flowing freely
and the level of patient’s discomfort is decreasing.
5
6
Initiate steps to prevent subsequent clotting (a)
ensure the irrigation flow is at a maximum rate, (b)
attach manual irrigation aid, for example, chuffer
tube or similar device.
7
7
Reassess patient’s pain level and administer analgesia as required.
9
8
If the output is heavily bloodstained (like tomato
soup), apply catheter traction.
8
9
Identify patient as high risk of being a potential
“clotter.”
* A chuffer tube is a sterile large bore rubber tube, which has spigots, fixed on
both ends for attachment to the irrigation tubing. It is used to mechanically
dislodge clots formed on the outlet irrigation tubing by squeezing the tube.
104
Results/Analysis
Assessment of a blocked
catheter. To compare nurses’
ranking with those of the expert
panel, a statistical method (Siegel
& Castellan, 1988) known as
“ C o rrelation between several
judges and a criterion ranking Tc”
was used in this regard. Tc is the
c o rrelation between the set of
ranking of nurses or practitioners
and a criterion ranking of a panel
of experts. It measures how close
the ranking agrees with the specified ranking of experts. Figure 5
refers to the pro c e d u re for calculating Tc.
The result of the correlation
of assessment between the nurses
and a panel of experts is Tc=0.32.
This was statistically significant
(z = 11.02, p < 0.001). There was
a high degree of confidence that
the nurses showed a strong agre ement with the panel of experts.
Although a significant correlation was achieved between the
experts’ and the nurses’ ranking,
the nurses did not follow the
same order of steps ranked by the
experts in the initial assessment
of a blocked catheter as shown in
Table 1. For example the experts
rated “Check the saline irrigation
for: (a) remaining volume, (b)
height of stand, and (c) level of
fluid in drip chamber” as the first
step to assess a blocked catheter,
whereas the nurses would use it
as the third step in their assessment. This showed a diff e rence of
two ranks between the experts
and nurses. A step that experts
and nurses diff e red by four ranks
was, “Assess the catheter and
tubing for patency, kinking, traction and leakage.” The experts
ranked it as the third step and the
nurses rated it as the seventh
step. Another step that diffe red
by four ranks was “Ascert a i n
patient’s degree of discomfort.”
The experts ranked it as the seventh step whereas the nurses
rated it as fourth step (see Table
1). The same table also showed
that the nurses would use
“Assess the catheter and tubing
for patency, kinking, traction and
leakage” as the first step in assessment but it was ranked as the
f o u rth step by the expert s .
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
Figure 5.
The Calculation of Tc — Assessment of a Blocked Catheter
Preference Matrix
The data are ranked between the experts’ and nurses’ ranking for computation of Tc.
(Ranks according to experts - * see below)
Experts’ Ranking
Nurses’ Ranking
1
2
3
4
5
6
7
8
9
1
-
29
64
25
61
46
44
70
74
2
54
-
64
28
70
61
60
76
79
3
19
19
-
9
40
33
26
54
53
4
58
55
74
-
75
71
65
79
83
5
22
13
43
8
-
27
21
71
65
6
37
22
50
12
56
-
34
68
71
7
39
23
57
18
62
49
-
70
73
8
13
7
29
4
12
15
13
-
36
9
9
4
30
0
18
12
10
47
-
Top matrix is the number of nurses (out of 83) who ranked 1 and above 2, 2 above 3, 3 above 4, etc.
Bottom matrix - computed later from top half.
Sum: Numbers presented above the diagonal of the matrix is 3+ aij = 1,975.
3+ aij is the number of agreements in rankings with the experts taken across the rankers.
Experts’ Ranking of Assessment of a Blocked Catheter*
1. Check the saline irrigation for the:
a. Remaining volume.
b. Height of stand.
c. Level of fluid in drip chamber.
2.
Check the drainage bag for:
a. Amount.
b. Color.
c. Consistency.
d. Position.
3.
Adjust the clamps to ensure continuous flow rate.
4.
Assess the catheter and the tubing for:
a. Patency.
b. Kinking.
c. Traction.
d. Leakage.
5.
Check fluid balance/bladder washout chart(s) for signs of urine/washout fluid retention.
6.
Percuss and/or palpate patient’s bladder.
7.
A s c e rtain patient’s degree of discomfort by:
a. Asking patient to rate the discomfort on a scale of 1-10.
b. Comparing it with previous rating.
(In assessment of discomfort, take into account that spinal anaesthesia affects the degree of patient’s
sensation.)
8.
Consider if there was a history of previous catheter blockage.
9.
Consider the size of the indwelling catheter.
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
105
F i g u re 5. (continued)
Assessment of a Blocked Catheter
Key:
3+ aij = 1,975
K = 83
N=9
The result is stat i s t i c a l lysignificant at p < 0.001.
Interventions taken to unblock the catheter. There
was a statistically significant correlation between the
experts’ and the nurses’ ranking of actions taken to
restore catheter patency (Tc=0.61, and z = 41.54
(>1.96), p<0.001, see Figure 6).
A comparison of the steps taken to unblock the
catheter demonstrated that the practicing nurses took
similar steps as the panel of experts to restore catheter
patency. The experts and the nurses differed by one
rank in steps 5, 6, 8, and 9 (see Table 2).
Comparing Nurses’ Ranking Between the Four
Participating Hospitals
Assessment. To determine if there were diff e rences in nurses’ ranking between the four hospitals,
Kruskall-Wallis analysis of variance was used. It
showed that there were no statistically significant
diff e rences (p>0.05) for the nine assessment indicators and the nine intervention indicators.
106
I n t e rventions to restore catheter patency. There
w e re no significant diff e rences between the four
g roups of nurses in ranking the steps taken to restore
catheter patency. The nurses as a group, regardless of
their places of employment at one of the four hospitals, showed a strong agreement with the experts in
their ranking of the interventions taken to unblock
the catheter.
Statistical tests were used to examine the demographic profile of those nurses who were in agre ement with the experts’ ranking. The nurses’ profile
consisted of years of nursing experience, length of
employment on their present ward, nursing qualification, and number of continuous bladder irrigations managed per week.
To determine the demographic profile of nurses
who agreed with the experts’ ranking on assessment
of a blocked catheter, a t-test was used. The statistical test showed there was no significant difference
between the nurses’ years of nursing experience (less
than 6 years and more than 6 years), and their agre ement with the ranking of the experts on assessment
of a blocked catheter (t=0.60, p>0.05). A similar test
demonstrated a nonsignificant result of the actions
taken to unblock the catheter (t=0.50, p> 0 . 05).
A similar nonsignificant result was obtained
between nurses’ years of nursing experience and
their agreement with the panel of experts’ ranking of
i n t e rventions taken to unblock a catheter.
The number of continuous bladder irrigations by
nurses per week demonstrated a nonsignificant re l ationship between their clinical experience in the
procedure and their agreement with the panel of
experts’ ranking of the steps taken to assess a
blocked catheter and the actions that would be taken
to re s t o re catheter patency (rs=0.1509, p>0.05).
Spearman’s rank order coefficient correlation was
used to determine if a relationship existed between
the nurses’ length of experience working on their present ward and their agreement with the experts’ ranking of assessment and interventions of a blocked
catheter. The result showed there was no relationship
between experience and their agreement with the
experts’ ranking of assessment of a blocked catheter
and the actions taken to restore catheter patency,
rs=0.1046, p>0.05; rs=- 0.0787, p>0.05 respectively.
Given the few nurses with a degree education,
a comparison with the sample of diploma- trained
nurses using their demographic variable was not
possible.
Discussion
The statistically significant correlation between
the experts and the practicing RNs on assessment
and intervention to restore catheter patency provides evidence for the content validity of the tool.
Although a significant correlation was established on the assessment of a blocked catheter
between the experts and the practicing nurses, the
practicing nurses did not follow the same steps in
the initial assessment of a blocked catheter (see
Table 1). The practicing nurses focused directly on
the urinary catheter whereas the experts initially
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
Figure 6.
Interventions/Actions Taken to Unblock a Urinary Catheter
Preference Matrix
The data are ranked between the experts’ and nurses’ ranking for computation of Tc.
(Ranks according to experts - *see below)
Experts’ Ranking
Nurses’ Ranking
1
2
3
4
5
6
7
8
9
1
-
42
54
58
81
72
79
80
75
2
41
64
56
74
73
72
75
68
3
29
19
-
45
83
80
78
80
72
4
25
27
38
-
69
66
72
80
75
5
2
9
0
14
-
43
59
65
59
6
11
10
3
17
40
-
62
67
64
7
4
11
5
11
24
21
-
50
62
8
3
8
3
3
18
16
33
-
48
9
8
15
11
8
24
19
21
35
-
-
Top matrix is the number of nurses (out of 83) who ranked 1 above 2, 2 above 3, 3 above 4, etc.
3+ aij = sum of the numbers presented above the diagonal matrix is 2402.
3+ aij is the number of agreements in rankings of interventions with the experts taken across the rankers.
Ranking of the Actions Taken to Unblock Urinary Catheter*
1. R e a s s u re patient and explain the problem.
2.
Tu rn off the bladder irrigation system.
3.
Milk the tubing (activate chuffer tube or similar device if in situ).
4.
Observe draining for:
a. Amount.
b. Color.
c. Consistency (presence or absence of clots).
5.
Recommend irrigation if drainage is flowing freely and the level of patient’s discomfort is decreasing.
6.
Initiate steps to prevent subsequent clotting.
a. E n s u re the irrigation flow is at a maximum rate.
b. Attach manual irrigation aid, for example, chuffer tube or similar device.
7.
Reassess patient’s pain level and administer analgesia as required.
8.
If the output is heavily bloodstained (like tomato soup), apply catheter traction.
9.
Identify patient as high risk of being a potential “clotter.”
checked the saline irrigation for
remaining volume, height of
stand, and overflowing of the
drip chamber that can commonly
o b s t ruct the patency of the
catheter.
Practicing nurses and expert s
also diff e red on two assessment
indicators, “ascertaining patient’s
degree of discomfort” and “adjust
the clamps to ensure continuous
flow.” The practicing nurses
a s c e rtained patient discomfort
b e f o re checking if there was fluid
retention in the bladder. In contrast to the practicing nurses’
method of problem solving, the
experts used a method of ruling
out the possibilities of catheter
blockage resulting from faults due
to the mechanics of the irrigation
system before focusing on cues
related to the patient.
In her re s e a rch, Benner
(1982, 1984) re p o rted expert s
made decisions by honing in on
the region of the problem directly
instead of considering irrelevant
alternatives. In contrast, the
novice followed rigid rules and
guidelines in making decisions
that are often incorrect. Holden
continued on page 110
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
107
F i g u re 6. (continued)
The Calculation of Tc I n t e rventions/Actions Taken to Unblock a
U r i n a ry Catheter
Key:
3+ aij = 2,402
K = 83
N=9
The result is stat i s t i c a l lysignificant at p < 0.001.
If z = > .1.96, the result is significant.
Conclude: The results of 11.02 > 1.96 therefore is a
high degree of confidence that the raters as a gro u p
show a sgrong agreement with the experts’ ranking of
assessment of a blocked urinary catheter.
Advanced Research
continued from page 107
and Klingner (1988) also studied diff e rences in decision making between novices and experts and found
that the experts used less information in making a
m o re accurate diagnosis.
Some of the indicators prioritized in the steps
taken to assess a blocked catheter (see Figure 2) were
consistent with Gilbert and Gobbi’s (1989) description of signs of a blocked catheter. These included
severe bladder spasm that was referred to as patient’s
discomfort in this study (see Step 7, Table 1) and
urine leakage around the catheter (see Step 4, Table
1). Gilbert and Gobbi (1989) also mentioned adherence of blood clots to the lumen of the tubing as
another sign of a blocked catheter. In this study it
was referred to as checking of drainage bag fluid for
color, amount, and consistency (presence or absence
of blood clots) (see Step 12, Table 1). Further comparison of the findings of this study with that of
G i l b ert and Gobbi (1989) is not possible as their
information of signs of a blocked catheter were not
prioritized and validated by research.
Interestingly, the finding that the practicing
nurses’ ranking of steps taken to unblock a catheter
was similar to that of the experts’ rankings suggest
practicing nurses are more consistent in taking
actions/interventions commonly known as ward
procedures in comparison to the assessment skills.
The findings raise questions about the extent to
which nurses are educated in the area of assessment
skills and whether emphasis continues to be placed
on nursing pro c e d u res and actions. This study also
p rompts questions about the clinical context within
which nursing care is provided. Wa rd pro c e d u re
manuals have tended to focus on actions to be taken
rather than nursing assessment of clinical problems.
Clinical attention to this issue may be warranted.
One prior study in decision making showed that
years of clinical experience influenced decision
making (Watson, 1994). However, findings from this
research do not support Watson’s results. The findings of this study suggest that the clinical context of
w a rd pro c e d u res may be a more powerful indicator
of nurses’ decision-making skills than years of experience.
Further study is warranted to examine the re asons practicing nurses are less consistent with
experts in their steps taken to assess a blocked
catheter.
Study Limitation
This study recognizes that simulated patient situations only present specific cues based on writing
and the participants are devoid of sound, sight,
touch, smell, and critical relationship.
Recommendations
The process of developing and validating the
p a t t e rn of expert inferences to a particular state of
knowledge and conclusion has the benefit of educating novices in clinical decision making. The vali110
UROLOGIC NURSING / April 2001 / Volume 21 Number 2
dated indicators could be converted to computer-assisted learning tools and adapted for use in
nursing education in the clinical
setting or universities. The indicators could form the basis of a
protocol for nursing practice.
Conclusion
The findings of this study
suggest that there is a need for
nurses to improve their assessment skills in clinical pro c edures, specifically catheter patency following TURP. This has
implications for educating nursing students as well as educating
nurses in hospitals to enhance
their skills in clinical problem
solving. Having these skills
would enable them to carry out
sound nursing practice based on
scientific evidence. •
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