Training effect on knowledge of new interns regarding urethral catheterization

Complications from urethral catheterization (UC) increase hospital stay and costs. We aim to assess the knowledge of new interns at a university hospital and to study the effect of training in the short and long terms. Methods New medical interns (n = 40) at a university hospital were included. Using a pre-training survey, interns' needs and their condence level (CL) about UC were assessed. They were divided into small groups. The workshop was divided into three educational parts (PowerPoint presentation, video demonstration, and simulation with peer feedback) and a nal examination. At the end of the session, an evaluation questionnaire assessed satisfaction of interns, and their new CL about UC. A distant evaluation 6 months later, evaluated the number of UC performed, the failure and the complication rates, and the need for further training. Descriptive statistics and paired t-test were used with a condence interval of 95% and a signicant p-value < 0.05.


Introduction
Urethral catheterization (UC) is a routine procedure performed during hospital stay [1]. Iatrogenic urethral trauma occurs in 0.3% during the insertion process. It is caused most commonly by false passage creation or balloon in ation in the urethra. Although complications from UC increase hospital stay and costs, mechanisms to prevent catheter-related injuries receive little attention [2]. Multiple studies showed that a signi cantly higher UC-related morbidity is caused by interns especially at the beginning of their internship [1,3]. More studies are demonstrating the insu cient training and knowledge in junior doctors which raises the need to implement educational strategies and proper training [4].
This study aims to assess the knowledge of new interns in a university hospital regarding UC and to study the effect of training on their con dence level (CL) regarding UC in the short-term, and the rates of failure and complication in the long-term.

STUDY POPULATION
The study included new medical interns (n = 40) at our university hospital for the academic year 2020-2021. All had completed ve years of medical education at the same medical school. In the concerned UMC, urethral catheterization is not performed by nursing staff and so training in catheterization is included in the medical curriculum.

TRAINING DEVELOPMENT
Before the workshop, we analyzed the experience, knowledge, and need of the trainee and set the goals of each session based on a pre-training survey. It contained 11 questions, covering 4 areas: the preparedness and the level of con dence performing UC on a scale from one to ten, the previous experience, the best way to acquire theoretical knowledge and skills, and theoretical knowledge of the different steps of UC (taking the history, ruling out contraindications, the best location to apply the lube, the best way to handle the penis during catheterization, the depth of catheter insertion and the importance of observation of the volume drained). The elements of the questionnaire were focused on the factors that increase the risk of urethral injury rather than aseptic technique and were based on previous similar work done by Thomas and colleagues [3] and Manalo and colleagues [4]. The questionnaire was reviewed by a consultant urologist in the institution to evaluate its adequacy in the evaluation of theoretical and practical knowledge relating to correct UC. It was then piloted with 2 medical interns who were thereafter excluded from the study. Modi cations were made based on their feedback. It was then administered to all medical interns between the second and the third week of September 2020 (their rst month of training in the university hospital). Responses were collected anonymously and analyzed using Microsoft Excel. The workshop was designed based on the data collected. We chose to use multiple learning styles: lecture, demonstration by a video, and simulation with a nal examination to assess the mastery of the skill. Training materials were selected from the Campbell-Walsh Urology, 11th edition [5]. We picked audiovisual aids demonstrating the skill on the same dummies available at the center, from the provider's website [6,7]. We established a checklist for skill evaluation, and created and validated surveys for training evaluation in the short and long term. The course was then implemented and ran in 5 sessions. The evaluation of the training was conducted immediately after the workshop for objectives, satisfaction, and rating of the materials and trainer. Long-term evaluation, rates of failed catheterization and complications, and the assessment of the need for new training was done 6 months later.

WORKSHOP
Interns were divided into ve small groups of eight individuals each. Each group received the same training. The workshop was divided into three educational parts of twenty minutes each and a nal examination. The rst part consisted of a short interactive PowerPoint presentation that highlighted key points in UC. The second part consisted of two videos demonstrating the skill and the steps with verbal descriptions using female and male dummies. The third part was the simulation in which each intern performed UC on male and female dummies at our simulation center, with the supervision of the urology fellows that commented on their skills and outlined their weaknesses. At the end of the session, each trainee underwent examination with peer feedback. All teaching sessions were given by an experienced urologist with more than 5 years of teaching experience. The main points discussed in the lecture were the anatomical considerations of the urethra and urethral meatus in males and females, indications and contraindications of UC, catheters types and selection criteria, catheterization technique and steps, technical considerations in males and females, the importance of documentation, complications, and mechanisms of iatrogenic urethral injury. Trainees were encouraged to seek help in speci c situations. We also focused on the importance of the"one gentle attempt only" rule, in reducing the likelihood of iatrogenic false passage [2].

EVALUATION
At the end of the session, an evaluation questionnaire was lled by all the participants to assess their satisfaction from the training, the response to their needs, the need for further training, the usefulness of the learned skills, and the CL performing UC after the training session. A distant evaluation was conducted 6 months later using a survey to evaluate the number of UC performed by the trainees, the failure and the complication rates, and the need for further training. All methods were carried out in accordance with relevant guidelines and regulations.

STATISTICAL ANALYSIS
Descriptive statistics were used to report interns' experience, perceptions, and knowledge concerning UC. Data from surveys were collected and analyzed using Microsoft Excel. Paired t-test was used to compare the mean con dence levels performing UC before and after the training session with a con dence interval of 95% and a signi cant p-value < 0.05. The statistical analysis was conducted using SPSS 26.0.

Results
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. 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). 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 in ation port meet)

63%
No particular level: the balloon is in ated 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. At the end of the training (Table 3), the survey showed that 92% (n = 35) of the trainees were highly satis ed. 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 con dence 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 con dence level rose to 8.66 ± 0.94, with a median of 9 ( Fig. 1).

Discussion
Approximately 25% of hospitalized patients undergo UC. The incidence of iatrogenic urethral trauma varies between 0.3 and 0.67% during the insertion process [1,2]. In one study, a complication Clavien-Dindo grade 2 or greater was reported in 81% of patients undergoing UC. Those complications lengthened hospital stay by 9.4 ± 10 days, and increased costs by €335,377 over 6 months [2]. The manipulation, particularly in men, is more challenging due to the tortuous anatomy of the urethra and the possibility of prostatic obstruction. Unsuccessful catheterization may result in complications in the short and long terms and may engender interventions like the percutaneous insertion of a suprapubic catheter (SPC) or cystoscopy with catheter insertion over a guidewire. Short-term complications from UC include among others urosepsis, obstructive uropathy that may predispose to acute kidney injury, hematuria requiring blood transfusion and or continuous bladder irrigation, repeat cystoscopy to catheterize to the bladder, epididymo-orchitis, and additional length of stay [2]. In the long-term, a persistent urethral stricture can necessitate lifelong self-urethral dilation or long-term indwelling SPC or urethral catheter [2]. Successful UC is operator dependent, even if patient risk factors (enlarged prostate, urethral strictures….) were present. The operator remains the main actor in the prevention of complications by early detection and correct decision taking during UC. A study in a large Irish teaching hospital reported that three-quarters of catheterization related morbidities occurred when the procedure was performed by interns [3]. A signi cantly higher UC-related morbidity was caused by newly quali ed interns compared to interns in their last six months of training [1]. Therefore, to optimal patient care, it is essential that interns acquire the basic clinical skills at the beginning of their internship, so that they feel safe, con dent, and competent in performing UC [4].

ADULT LEARNING THEORY
To achieve successful training, adult learners have to be involved and need to see the relevance of the information delivered to their daily work [8]. Accordingly, the self-assessment questionnaire conducted before the training, helped the trainee identify their weaknesses, strengths, and con dence level regarding UC, creating an inner motivation to get the ultimate learning experience from the subsequent workshop.

TRAINING DEVELOPMENT
We used the instructional systems development (ISD) model, being the most effective way of training [8].
At the beginning of the session, objectives and criteria for evaluation were clearly stated. At the end of the session, we evaluated trainee performance using an exam on the simulator. In a later period, we measured the effect of our intervention by the rate of complicated UC. We organized short learning sessions of 20 minutes to increase knowledge retention. And based on the fact taht the brain remembers the rst and the last parts of a training best (the primacy-recency effect) [9], we made the presentation and the simulation (the most important parts) the rst and the last parts respectively. We chose small group learning with eight individuals in each group, to optimize the learning experience. This learnercentered approach actively involves the students, and allows them to test their ideas with their peers and to receive feedback [10]. We used a facilitative or participatory training style, in which the trainer guides the learners to discover what they need to learn. This approach was shown to be more appropriate than instructive-style learning for adult learners [8]. We based the content of our training on speci c weakness points detected in the pre-evaluation survey (where the lubricant should be applied, the direction of the penis, the depth of catheter insertion, and the importance of the volume drained). The information was delivered using an interactive presentation that covered indications, contraindications, choice of catheters with a rapid anatomical review. The skill was divided into small steps. We explained the purpose of each one, focused on key points and demonstrated it through a video. Trainees were allowed next to practice the skill using a male and female simulator with expert feedback about each step for every single trainee. At the end of the workshop, we encouraged further questions, designated reference for further assistance if needed.
We incorporated different methods in our training (lecture, demonstration, and simulation) to maximize the teaching experience of our students. We used video-based learning because it has been related to increased levels of self-con dence [11] before skill practice. We also used simulation-based training with peer feedback. This method, by offering the trainees the opportunity to identify their errors before the clinical settings [12] is considered superior to other teaching methods and shows better attainment and retention of procedural skills [13], reduced learning curve, and less skill degradation over time [13].
In the pre-training survey, the majority considered that patient-based training in catheterization would be the most bene cial. Unfortunately, this is not practical due to the limited number of urology fellows and the high frequency of UC. Moreover, UC is frequently performed in urgent situations (retention, output surveillance in a shocked patient) that can't wait for the reunion of the intern on duty and the urology fellow. However, one important consideration that might resolve this issue, could be a mandatory core rotation in urology to address this training de ciency.
In the short-term, the training conducted at our center succeeded in increasing the CL of the new interns from a mean of 6.60 to a mean of 8.66 over 10, which was statistically signi cant (p < 0.05).
In the long term, 4% of UC performed by our new interns were complicated 4% (Table 8). This rate is high compared to previous rates of the literature that ranged between 0.3 and 0.67% [1,2]. This could be explained by the selectivity of our population, which included only new interns in their rst 6 months of internship. Since UC is performed by medical students from different years and different specialties at our university hospital, the complication rate obtained in the actual study does not re ect the overall complication rates of UC in the hospital and is only speci c for the current study population. The distant assessment showed that 42% (n = 16) requested further training. This is consistent with the previous studies that showed also the necessity of continuous training for skill optimization [1], which would ideally be inspired from the most common causes of failed catheterizations in a given institute (meatal stenosis management and di culty identifying urethral meatus in female in our case) ( Table 7).

LIMITATION
Despite using simulation with peer feedback which is considered superior to other conventional learning styles (lectures, videos, demonstration), a metric-dependent pro ciency-based progression training is considered recently the most e cient way to optimize the learning experience and to improve performance [13] and will be our near future project.

Conclusion
With more evidence revealing the insu cient knowledge and training in junior doctors, it is crucial to implement speci c educational strategies. After assessment of knowledge of the concerned medical professionals and identi cation of gaps, a trainee based workshop speci c for each institution has to designed and conducted. Simulation is superior to other teaching strategies. The UC training conducted at our institution helped our interns become more con dent regarding UC. Continuous training is necessary for skill optimization.

Declarations a) Ethics Approval and Consent to Participate
This study was approved by the ethics board of "Notre Dame des Secours" University hospital, and all methods were carried out in accordance with relevant guidelines and regulations.
Informed consent was obtained from all participants.

b) Availability of data and supporting materials
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

c) Competing Interests
Authors declare no competing interests for this article.

d) Funding
Authors declare no sources of funding for this review article.

e) Authors' contributions
All authors made substantial contributions to conception and design, acquisition of data and analysis and interpretation of data; Authors participated in drafting the article and revising it critically for important intellectual content.
Authors gave nal approval of the version to be submitted.
Each author participated su ciently in this work and takes public responsibility for appropriate portions of the content.
All Authors declare no con ict of interest f) Acknowledgements Not applicable Figure 1 Interns' con dence levels distribution regarding urethral catheterization, on a scale from 1 to 10, before and after the training