Two interns were excluded from the analysis after participating in the pilot studies. Of the 38 remaining new interns, 100% (n = 38) completed all the questionnaires from which 34% (n = 13) were men and 66% (n = 25) were women. At the time of the study, 74% (n = 28) have already performed at least one UC, but only 16% (n = 6) felt prepared to correctly perform this manipulation.
Concerning the best method of UC training (Table 1), 53% (n = 20) interns considered the live demonstration at the simulation center the best, and 47% (n = 18) considered a supervised catheterization at the patient bed superior. None voted for learning via a lecture or by video watching.
Table 1
Interns’ perception on the best way of urethral catheterization training
Method of training
|
n
|
%
|
Live demonstration at a training center
|
20
|
53%
|
Supervised catheterization at the patient bed
|
18
|
47%
|
Video
|
0
|
0%
|
Lecture
|
0
|
0%
|
The knowledge of the new interns was assessed using 6 multiple choice questions covering the different steps of UC: history taking, recognition of contra-indications before catheterization, proper use of lubricant, proper depth of insertion of the catheter, and the importance of the assessment of the drained volume (Table 2).
Table 2
Interns’ knowledge about urethral catheterization
Field
|
Answers
|
n
|
%
|
Taking history on previous catheterization or surgery
|
Important
|
38
|
100%
|
Not important
|
0
|
0%
|
Contra-indications to UC
|
Yes
|
38
|
100%
|
No
|
0
|
0%
|
Lubrication before catheter insertion is best applied to
|
Catheter
|
19
|
50%
|
Urethra
|
10
|
26%
|
Urethral meatus
|
9
|
24%
|
The angle at which the penis is stretched before catheterization
|
Perpendicular to the body
|
32
|
84%
|
Parallel to the body
|
6
|
16%
|
No particular angle
|
0
|
0%
|
The depth of catheter insertion
|
Past the mid-point of the shaft of the catheter
|
5
|
13%
|
To the hub (where the connection for a drainage tube and the inflation port meet)
|
24
|
63%
|
No particular level: the balloon is inflated as soon as the urine passes from the catheter
|
9
|
24%
|
The volume of urine drained
|
Important
|
34
|
89%
|
Not important
|
4
|
11%
|
All participants (n = 38) considered history taking and contra-indication recognition as important steps before UC. Half of them (n = 19) considered correct the application of lubricant to the catheter and 24% (n = 9) chose the urethral meatus. Only 26% (n = 10) would deliver the lube inside the urethra. All students agreed that the penis should be stretched before catheterization. Only 16% (n = 6) maintained the penis parallel to the body, and 84% (n = 32) agreed that the penis should be stretched perpendicularly to the body to allow easier insertion. Students didn’t agree on the depth of catheter insertion. Nine students considered there is no particular level, and the remaining answers were past the mid-point of the shaft of the catheter in 13% (n = 5) or to the hub of the catheter in 63% (n = 24). Most of the interns (89%, n = 34) considered the volume of urine drained important.
Table 3
Immediate training assessment
Field
|
Answers
|
n
|
%
|
Satisfaction from training
|
Good
|
35
|
92%
|
Fair
|
3
|
8%
|
Training quality
|
Good
|
38
|
100%
|
Fair
|
0
|
0%
|
Response to trainees’ needs
|
Good
|
37
|
97%
|
Fair
|
1
|
3%
|
Usefulness of the skill learned in daily work
|
Yes
|
37
|
97%
|
No
|
1
|
3%
|
Recommendation of this training to others
|
Yes
|
37
|
97%
|
No
|
1
|
3%
|
At the end of the training (Table 3), the survey showed that 92% (n = 35) of the trainees were highly satisfied. All of them (n = 38) rated the quality of training as good, and 97% (n = 37) stated that the training responded to their needs and that the skills gained are useful in their daily work routine. Nearly all the interns (97%, n = 37) recommended this training to others. Interns were asked to rate their confidence level (CL) concerning UC in the before and immediately after training on a scale from 1 to 10, where 10 is the highest. Before the training, CLs varied from 1 to 10, with a median of 7 and a mean of 6.6 ± 1.79. After the training session, the levels varied exclusively between 7 and 10. The mean confidence level rose to 8.66 ± 0.94, with a median of 9 (Fig. 1).
Interns were more confident about UC (mean CL 8.66 ± 0.94) after the training session than before (mean confidence level 6.60 ± 1.79) (Table 4). A statistically significant improvement of 2.05 points over 10 (SD = 2.03, 95% CI, 1.39 to 2.72, p < 0.05) was observed on paired samples t-test (Table 5).
Table 4
Mean confidence levels of interns concerning urethral catheterization before and after training
Status
|
n
|
Mean confidence level
|
SD
|
Before training
|
38
|
6.60
|
1.79
|
After training
|
38
|
8.66
|
0.94
|
SD: standard deviation
|
Table 5
Comparison of mean confidence levels of interns concerning urethral catheterization before and after training using paired samples t-test
Paired Differences
|
Mean
|
SD
|
95% CI
|
p-value
|
Lower
|
Upper
|
2.05
|
2.03
|
1.39
|
2.72
|
.000
|
CI: Confidence interval
|
A distant assessment was conducted 6 months later. It showed that 42% (n = 16) requested further training. Of the 38 interns included, 37% (n = 14) encountered failure during at least one UC (Table 6).
Table 6
Distant assessment showing rates of trainees who encountered failure during catheterization or requested further training
Description
|
n
|
%
|
Total number of trained interns
|
38
|
|
Trainees who encountered failure
|
14
|
37%
|
Trainees who requested further training
|
16
|
42%
|
Over 6 months, 274 UC were performed by our new interns, from which 7% (n = 19) failed. The most common causes of failure were (Table 7) urethral meatal stenosis in 32% (n = 6) and difficulty identifying the urethral meatus in females in 32% (n = 6). The other reported causes were an inadequate exposition of the genitals due to patient disability (associated with hip fracture) in 26% (n = 5) and phimosis in male patients in 10% (n = 2).
Table 7
Distant assessment measuring rate and causes of failed urethral catheterization
Description
|
n
|
%
|
Total UC performed
|
274
|
|
Failed attempts
|
19
|
7%
|
Identification of urethral meatus in females
|
6
|
32%
|
Phimosis in males
|
2
|
10%
|
Inadequate exposition (patient disability)
|
5
|
26%
|
Urethral meatus stenosis
|
6
|
32%
|
UC: urethral catheterization
|
Overall, 4% (n = 11) of the UC (n = 274) were complicated (Table 8). The most common complication was urethrorrhagia with spontaneous resolution in 55% (n = 6). It was followed by occurrence of false passage in 18% (n = 2), urinary tract infection in 18% (n = 2) and necessity of supra-pubic catheterization in 9% (n = 1).
Table 8
Distant assessment measuring rate of complications following urethral catheterization
Description
|
n
|
%
|
Total UC performed
|
274
|
|
Complications
|
11
|
4%
|
Urethrorrhagia with spontaneous resolution
|
6
|
55%
|
False passage
|
2
|
18%
|
UTI
|
2
|
18%
|
Necessity for SPC insertion
|
1
|
9%
|
UC: urethral catheterization; UTI: urinary tract infection; SPC: supra-pubic catheter
|