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Evaluation of a nurse-driven protocol to remove urinary catheters: nurses' perceptions.

This article describes nurses' perceptions of the effect of a nurse-driven protocol in a Magne[R]-designated hospital. Post-protocol implementation data indicate improved job ease and positive patient feedback following protocol implementation. Younger or less-experienced nurses were likely to use the protocol.

Key Words: Nurse-driven protocol, indwelling urinary catheter, nurses' perceptions, catheter associated urinary tract infections.

doi: 10.7257/1053-816X.2015.35.2.94


Urinary tract infection (UTI) is one of the most common hospital-associated infections, and urinary catheters are associated with 70% to 80% of those infections (Lo et al., 2014). Research data indicate that the risk of infection increases about 5% each day a catheter remains in place; thus, it is imperative that catheters be removed as soon as possible (Gould et al., 2014). The Joint Commission (2015) recognizes catheter-associated urinary tract infection (CAUTI) prevention as one of the National Patient Safety Goals for hospitals. Nursing care plays a vital role in CAUTI prevention; thus, the American Nurses Association (ANA) (2007) has classified CAUTI as one of 14 nurse-sensitive indicators, meaning the measure reflects the quality of nursing care and interventions provided. In addition, the Centers for Medicare and Medicaid Services (CMS) considers CAUTIs "never events" and will not reimburse hospitals for treatment of these events (Saint et ah, 2013).

Despite attention paid to maintenance bundles and decreased utilization rates, CAUTI prevention and treatment remain a challenge. Maintaining a closed drainage system, keeping the drainage bag below bladder level, catheter care, and removing the catheter as quickly as possible are all interventions recognized by the Centers for Disease Control and Prevention (CDC) and others to decrease CAUTI rates (Association for Professionals in Infection Control and Epidemiology [APIC], 2014; Fakih et ah, 2012; Gokula, 2012; Gould et ah, 2009; Oman et ah, 2012; Saint et al, 2009). Barriers to implementing these interventions include difficulty with nurse and physician engagement, patient and family request for indwelling catheters, and cultural habits of leaving catheters in place (Krein, Kowalski, Harrod, Forman, & Saint, 2013). In addition, evidence suggests that younger registered nurses (RNs) may be more likely to use a removal protocol than veteran RNs (The Advisory Board, 2014).

CAUTI rates at the study site were reported to be above the National Healthcare Safety Network (NHSN) benchmark (Dudeck et ah, 2013) for eight consecutive quarters prior to implementation of the removal protocol. Nurse-driven catheter-removal protocols have been described as successful interventions in decreasing catheter utilization (Alexaitis & Broome, 2013; Hooton et al., 2010; Lo et al., 2014; Parry, Grant, & Sestovic, 2013; Purvis et al., 2014; Saint et al., 2013; The Advisory Board, 2014). Nurses' perceptions of the protocol are of interest because the link between nurse satisfaction and patient outcomes has been established (National Database of Nursing Quality Indicators [NDNQI], 2014). In addition, nurses' perceptions of their professional practice work environment has been linked to job satisfaction and quality of care (Lambrou, Merkouris, Middleton, & Papastavrou, 2014).

Removal Protocol Implementation

The purpose of this research study was to evaluate nurses' perceptions of an RN-driven urinary catheter-removal protocol at a 500-bed Magnet[R]-designated teaching hospital. In 2012, an interdisciplinary Lean Six Sigma (Pyzdek & Keller, 2014) quality improvement team formed to address CAUTI rates higher than benchmark data. Prior efforts to decrease CAUTI focused on evidence-based interventions were included in hospital policy but required a physician order for urinary catheter removal. The project focused initially on barriers to catheter removal and ultimately narrowed focus to implementation of the catheter removal protocol. A team of nurse leaders and physicians developed and approved a urinary catheter removal protocol that could be implemented without a physician's order. Qualifying indicators for indwelling catheter use were adapted from CDC criteria (Gould et al., 2009). Appropriate indications for a catheter include promoting comfort at end of life, open pressure ulcers in incontinent patients, acute urinary retention, strict prolonged immobilization, post-operative urologic surgery or surgery on adjacent genitourinary tract, day of surgery, and accurate measurement of urinary output in critically ill patients. Additional qualifying indicators for burn patients with fresh perineal skin grafts and patients with epidural catheters were included, as recommended by medical staff to address specific patient population needs. The protocol included nurses' ability to straight catheterize the patient if over 300 ml was retained, identified by bladder scan six hours after catheter removal if the patient had not voided. If the patient is still unable to void after an additional six hours, the physician is notified for further direction. The protocol instructions were based on review of other hospitals' removal protocols and expert opinion of medical staff.

Two medical-surgical pilot emits tested the protocol over a six-week period, showing decreased urinary catheter utilization rates in both areas. Hospital-wide implementation of the protocol, which included all inpatient emits, began in July 2013. Masters-prepared RNs whose role is to facilitate implementation of evidence-based practice provided education and rounding support for four weeks following protocol implementation. All patients, regardless of health status or length of catheterization, were evaluated daily for indications of use. When catheters did not meet qualifying indicators, RNs were coached on protocol implementation and encouraged to talk aloud about concerns or barriers to protocol use. Data were collected on the number of catheters removed per protocol, the number of patients requiring reinsertion of catheters after initial removal, and the barriers to removal. The most common reason catheters remained in place was the inability to meet qualifying indicators, including the need for accurate urinary outputs in non-critically ill patients and patients with indwelling catheters for chronic urinary retention. Ongoing monitoring of catheter utilization rates and CAUTI rates per unit are the metrics used for ongoing evaluation. Initial results showed a 20% decrease in catheter utilization rates post implementation (see Figure 1).


Survey of Nurses After Implementation Of Removal Protocol

This exempted research study was conducted at the study site after receiving local institutional review board approval. The descriptive study was modeled after work by Rothfield and Stickley (2010) that measured nurse satisfaction with an RN-driven catheter removal protocol.

The current study used a self-developed survey designed to elicit nurses' perceptions of the effect of an indwelling urinary catheter removal protocol on job ease, empowerment, job satisfaction, patient feedback, and physician feedback. RNs were asked to rate each item as "better," "worse," or "no impact." An open-ended question was included to elicit nurses' perceptions about the protocol. Convenience sampling was used. Inclusion criteria included English-speaking RNs over 18 years of age who were employed on the hospital's nursing care units who may have used the protocol. Four months after the house-wide protocol was implemented, the nursing research facilitator sent an email to RNs eligible for the study, inviting them to complete an anonymous online survey administered through Survey Monkey[R] and available through the organization's secure Intranet. A waiver of consent was used. No financial incentive was offered, but employees were compensated at their regular rate of pay if they completed the survey while on duty.



Ninety-one RNs completed the online survey out of a potential sample of 750. Respondents were primarily female (91%, n = 83) and worked full-time (82%, n = 75) on dayshift (70%, n = 64). Most RNs in this organization are scheduled for 12-hour shifts. The majority of respondents (51%, n = 46) worked on medical-surgical units, 20 RNs (22%) worked in intensive care units, and the remainder (27%, n = 25) provided care in other areas, such as same-day surgery and post-anesthesia care. The majority of respondents held a Bachelor's Degree in Nursing (BSN) (61%, n = 61); other responses came from Associate Degree prepared RNs (ADN) (21%, n = 19), Diploma RNs (3%, n = 3), and Masters-prepared RNs (MSN) (3%, n = 3). Five RNs (6%) indicated they had a degree outside of nursing. The age of respondents is displayed in Table 1; most (34%, n = 31) were 21 to 30 years old.

Table 2 displays the range of experience in nursing and within the organization. Respondents were fairly evenly distributed with slightly more having greater than 20 years of experience in nursing and in the organization.

Nurses' Perceptions Of Protocol Use

Data demonstrate that only 48 of 91 respondents used the protocol. It was of interest to determine if using the protocol influenced ratings of its benefit on job ease, empowerment, personal satisfaction, patient feedback, and physician feedback. This analysis was completed using Chi-square statistics, with significance at (p < 0.05). Table 3 displays the responses separated by protocol use. Results for each area are presented; statistically significant differences are noted with an asterisk.

Job ease. Of the 91 RNs completing the survey, 53% (n = 48) used the protocol. Job ease ratings were significantly higher (71%) when RNs used the protocol compared to 29% for RNs who had not used it ([chi square] = 13.33, df = 1, p < 0.001).

Empowerment. Although the impact on personal empowerment was not statistically different between groups ([chi square] = 0.19, df = 1, ns), 80% of respondents indicated the protocol was empowering whether they used it or not. This suggests that implementing nurse-driven protocols may empower RNs even if they have not had occasion to use them.

Job satisfaction. Protocol use was determined to have no significant effect on job satisfaction ([chi square] = 1.94, df = 2, ns). Half of respondents in each group rated the protocol as having no effect on job satisfaction, and two RNs who used the protocol indicated the protocol negatively impacted their job satisfaction.

Patient feedback. RNs' perception of patient feedback was rated significantly higher among RNs who had used the protocol (80%) compared to ratings (20%) by RNs who had not used the protocol ([chi square] = 10.31, df = 1, p = 0.001).

Physician feedback. There was no significant difference in nurses' perceptions of physician feedback based on protocol use. The majority of RNs responding to this question in either group indicated that the protocol had no effect on physician feedback, but a few RNs rated physician feedback as worse.

Demographic Characteristics And Protocol Use

Those who used the protocol were interested in the research and if this was influenced by demographic characteristics. To answer this query, subgroups were developed, and protocol use was compared to these variables (see Table 4). Staff nurses were evenly divided between using and not using the protocol, whereas charge nurses and "others" demonstrated a strong tendency to use the protocol ([chi square] = 7.52, df = 2, p = 0.023).

Years of experience at the study site and total years in nursing were both found to be significant factors for protocol use (see Table 5). Experience as an RN also influenced protocol use. The Chi-square indicated that protocol use was significantly higher (89%) in the least-experienced RNs (< 1 year) and then declined to a low of 23% for RNs with more than 20 years of experience ([chi square] =19.47, df = 5, p = 0.002). Similarly, protocol use was significantly higher (88%) in the least-experienced RNs in the organization (< 1 year) and then declined to a low of 29% for RNs who at been at the study site (> 20 years ([chi square] = 13.02, df = 5, p = 0.023]).

A significant relationship was achieved between age and the proportion of RNs who used the protocol (see Table 6). There was an inverse relationship between age and use of the protocol. That is, the older the RN, the smaller the proportion that used the protocol ([chi square] = 13.60, df = 4, p = 0.009). These results parallel the results of experience in the organization and as a RN. Of the 46 respondents working on medical-surgical units, slightly more (54%, n = 25) had used the protocol. A significant Chi-square indicated that the proportion of RNs using the protocol was highest (95%, n = 19) in the intensive care units (ICU) and lowest (16%, n = 4) in the "other" group ([chi square] = 27.92, df = 2, p [less than or equal to] 0.0001).

Statistical analyses failed to identify any differences based on shift work and frequency of using the protocol. Neither educational preparation nor gender were predictors of protocol use.

Nurses' Feedback

Participants in this research were provided with the opportunity to add comments regarding the removal protocol. These data described several negative and positive experiences. Positive comments included reference to autonomy and time saving; "It has saved time for the RNs and provided more autonomy in the nursing role." Another response stated it is positive for patients and nurses because it "empowers RNs to assist patients to increase their independence and decreases risk of catheter associated infection." Other RNs mentioned that the protocol has increased nurse/physician collaboration and communication regarding indwelling catheters in general. Fewer catheters are "forgotten" as an outcome of the new protocol, and physicians make note of the catheter in their progress notes.

Negative comments included mention of increased time and effort required to assist patients with toileting activities, which identifies a potential barrier to catheter removal. Another mentioned that not all RNs are comfortable following the protocol and prefer to speak to a physician prior to removal. Comments regarding physician reaction were mixed, as physician resistance was mentioned in several comments as a reaction to the protocol, "Doctors are not happy that [catheters] are being removed without their knowledge," while others mentioned that physicians were neutral or positive to the protocol, "Our physicians are already pretty good about this," and "I have not heard any comments from physicians good or bad." Another stated, "It is useful on night shift as there is no need to wake a physician up to remove a [catheter]."


The catheter removal protocol resulted in a reduction in catheter utilization throughout the study site that has been sustained one-year post-implementation as evidenced in Figure 1. The negative impact of CAUTI on patient outcomes is established and discussed previously. The focus of this study was on nurse satisfaction with the removal protocol. As importance of nurse satisfaction in patient outcomes is known (NDNQI, 2014), focus on initiatives that impact the nurse practice environment and nurse satisfaction warrants further study. Results of this study show a positive effect on nurses' job ease, with no significant change noted in nurses' job satisfaction or empowerment. Nurses' ability to remove an indwelling urinary catheter without contacting a physician was perceived as making their job easier. Participants who used the protocol reported more positive patient feedback. Results were similar to those found in the Rothfeld and Stickley (2010) study, although this study attained greater improvement in job ease than the previous study. It is possible that job ease and the ability to respond to care needs more quickly may be why RNs perceived positive patient feedback.

Although RNs who participated in this study perceived the protocol had no effect on physician feedback, anecdotal comments revealed some concerns. Individual physician concerns were proactively addressed by hospital leadership. Similar to findings discussed by The Advisory Board (2014), younger and less experienced RNs were more likely to use the protocol than veteran RNs. This finding is of interest, and may be due to evidence-based practice exposure in nursing school and openness to changes in practice. The results of this study may be skewed because units with the highest number of opportunities to remove catheters per protocol have younger RNs on average. Limitations of the study include lack of randomization, a relatively small sample size, and implementation in a single facility.


The RN-driven protocol was perceived positively by most nursing staff resulting in higher perception of nurses' job ease. In an era of higher performance expectations and decreasing reimbursements, job ease and efficiency of nursing workflow is integral to success. Understanding the needs of more experienced RNs during change initiatives may be needed. Although the removal protocol resulted in decreased urinary catheter utilization rates, CAUTI rates remain higher than desirable in patients who are critically ill and those with acute chronic urinary retention. Personnel at the study site are exploring other initiatives to decrease CAUTI rates, including catheter product review and expanded education and training of caregivers. Further research is needed to investigate initiatives to decrease catheter utilization and infections in patients who are critically ill and those with acute and chronic retention.

Research Summary


Nurse-driven catheter-removal protocols have shown success in decreasing urinary catheter utilization rates and catheter-associated infections. The effect of protocol implementation on nurses' work environment and job is of interest.


To evaluate nurses' perceptions of a nurse-driven urinary catheter-removal protocol at a 500 bed Magnet-designated teaching hospital.


This descriptive, exempted study used a self-developed survey to elicit nurses' perceptions of the effect of an indwelling urinary catheter removal protocol on job ease, empowerment, job satisfaction, patient feedback, and physician feedback. Ninety-one (91) RNs completed the survey, and of those, 48 used the removal protocol.


Data were analyzed using Chi-square statistics. Nurses' perceptions of both job ease ([chi square] = 13.33, p < 0.0001) and patient feedback ([chi square] = 10.31, p = 0.001) were significantly higher with protocol use. Younger or less-experienced RNs were more likely to use the protocol. No significance was found in empowerment, job satisfaction, or nurses' perceptions for physician feedback in those who used the protocol.


Implementation of a nurse-driven urinary catheter-removal protocol significantly improved nurses' perceptions of job ease and patient feedback.

Level of Evidence--VI (Polit & Beck, 2012)


Alexaitis, I., & Broome, B. (2014). Implementation of a nurse-driven protocol to prevent catheter-associated urinary tract infections. Journal of Nursing Care Quality, 29(1), 1-8.

American Nurses' Association (ANA). (2007). National Database of Nursing Quality Indicators[R]. Retrieved from mainmenucategories/anamarket place/anaperiodicals/ojin/tableof contents/volumel22007/no3sept07/ nursingqualityindicators.aspx

Association for Professionals in Infection Control and Epidemiology (APIC) (2014). Guide to preventing catheter-associated urinary tract infections. Retrieved from Resource_/EliminationGuideForm/ 0ff6ae59-0a3a-4640-97b5-eee38b 8bed5b/File/CAUTI_06.pdf

Dudeck, M.A., Weiner, L.M., Allen-Bridson, K., Malpiede, P.J., Peterson, K.D., Pollock, D.A., ... Edwards, J.R. (2013). National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. American Journal of Infection Control, 41, 1148-66.

Fakih, M.G., Watson, S.R., Greene, M.T., Kennedy, E.H., Olsted, R.N., Krein, S.L., & Saint, S. (2012). Reducing inappropriate urinary catheter use: A statewide effort. Archives of Internal Medicine, 172(3), 255-260.

Gokula, M., Smolen, D., Gaspar, P.M., Hensley, S.J., Benninghoff, M.C., & Smith, M. (2012). Designing a protocol to reduce catheter-associated urinary tract infections among hospitalized patients. American Journal of Infection Control, 40(10), 1002-1004.

Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., & Pagues, D.A., for the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2009). Guideline for prevention of catheter-associated urinary tract infections. Retrieved from 001_cauti.html

Hooton, T.M., Bradley, S.F., Cardenas, D.D., Colgan, R., Geerlings, S.E., Rice, ... Nicolle, L.E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases, 50, 625-663.

Krein, S.L., Kowalski, C.P., Harrod, M., Forman, J., & Saint, S. (2013). Barriers to reducing urinary catheter use: A qualitative assessment of a statewide initiative. JAMA Internal Medicine, 173(10), 881-886.

Lambrou, P., Merkouris, A., Middleton, N., & Papastavrou, E. (2014). Nurses' perceptions of their professional practice environment in relation to job satisfaction: A review of quantitative studies. Health Science Journal, 8(3), 298-317.

Lo, E., Nicolle, L.E., Coffin, S.E., Gould, C., Maragakis, L.L., Meddings, J., ... Yokoe, D.S. (2014). Strategies to Prevent catheter-associated urinary tract infections in acute care hospitals: 2-14 update. Infection Control and Hospital Epidemiology, 35(5), 463-479.

National Database of Nursing Quality Indicators (NDNQI). (2014). ANA inspired care infographic. Retrieved from News/National-News/Nurse-Job-Satisfaction-Improves-Patient Outcomes-NDNQI-Data-Show.aspx

Oman, K.S., Makic, M.B., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2012). Nurse-driven interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control, 40, 548-53.

Parry, M.F., Grant, B., & Sestovic, M. (2013). Successful reduction in catheter-associated urinary tract infections: Focus on nurse-directed catheter removal. American Journal of Infection Control. 41,1178-81.

Polit, D.F. & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed). Philadelphia: Wolters Kluwer Lippincott Williams & Wilkins.

Purvis, S., Gion, T., Kennedy, G., Rees, S., Safdar, N., VanDenBergh, S., & Weber, J. (2014). Catheter-associated urinary tract infection: A successful prevention effort employing a multipronged initiative at an academic medical center. Journal of Nursing Care Quality. 29(2), 141-148.

Pyzdek, T., & Keller, P. (2014). The Six Sigma handbook (4th ed). New York, NY: McGraw Hill.

Rothfeld, A.F., & Stickley A. (2010). A program to limit urinary catheter use at an acute care hospital. American Journal of Infection Control, 38(7), 568-571.

Saint, S., Olmsted, R.N., Fakih, M.G., Kowalski, C.P., Watson, S.R., Sales, A.E., & Krein, S.L. (2009). Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle. The Joint Commission Journal on Quality and Patient Safety, 35(9), 449-455.

Saint, S., Greene, T., Dowalski, C.P., Watson, S.R., Hofer, T.P., & Krein, S.L. (2013). Preventing catheter-associated urinary tract infection in the United States: A national comparative study. JAMA Internal Medicine, 173(10), 874-879.

The Advisory Board (2014). Frequently asked questions about the HOUDINI protocol: Post-web conference Q&A with BJC nurse leaders. Retrieved from nursing-executive-center/expert-insights/2013/faqs-houdini-protocol

The Joint Commission (2015). 2015 National patient safety goals. Retrieved from http://www.jointcommission. org/standards_information/npsgs. aspx

Kristi Olson-Sitki, MSN, RN, NE-BC, is the Magnet[R] Coordinator, Memorial Medical Center, Springfield, IL.

Geri Kirkbride, PhD, RN, CPPS, CENP, is a Nursing Research Facilitator, Memorial Medical Center, Springfield, IL.

Gordon Forbes, PhD, is a Statistician and Professor of Psychology Emeritus, Millikin University, Decatur, IL.

Table 1.

Age      21 to 30   31 to 40   41 to 50   51 to 60   than 60

%(n)     34 (31)    21 (19)    20 (18)    20 (18)      5(5)

Table 2.
Years of Experience

                                  1 to
Years of             Less         less
Experience          than 1       than 3       3 to 5

As Nurse % (n)      10 (9)      16 (15)       12(11)

In Organization
% (n)              13 (12)      15 (14)      25 (23)

Table 3.
Ratings and Protocol Use

Variable             Protocol    Rating
% (n)                  Use       Better     No Effect    Worse

Job Ease *              No      29.1 (14)   67.4 (43)      --
                       Yes      70.8 (34)   32.6 (14)      --

Empowerment             No      43.8 (32)   61.1 (11)      --
                       Yes      56.2 (41)   38.9 (7)       --

Job Satisfaction        No      46.5 (20)   50.0 (23)    0 (0)
                       Yes      53.5 (23)   50.0 (23)   100 (2)

Patient Feedback *      No      20.0 (5)    57.8 (37)      --
                       Yes      80.0 (20)   42.2 (27)      --

Physician Feedback      No      21.4 (3)    52.9 (36)   37.5 (3)
                       Yes      77.6 (11)   47.1 (32)   62.5 (5)

* Statistically significant differences.

Table 4.
Nurse Role

                    Protocol Use

Role                     No          Yes

Staff Nurse % (n)     52 (36)      48 (33)
Charge Nurse          4.0 (2)      86 (12)
Other                 62.5 (5)     37.5 (3)

Table 5.

                than 1    1 to 3   3 to 5    6 to 10

Nurse % (n)     11 (1)             18 (2)    40 (4)
                89 (8)    60 (9)   82 (9)    60 (6)

Organization    17 (2)    50 (7)   30 (7)    55 (6)
% (n)           83 (10)   50 (7)   70 (16)   45 (5)

                           Greater   Protocol
                11 to 20   than 20     Use

Nurse % (n)      44 (7)    77 (23)      No
                 56 (9)    23 (7)      Yes

Organization     57 (4)    71 (17)      No
% (n)            43 (3)    29 (7)      Yes

Table 6.
Protocol Use by Age

               Age of Respondents

Protocol Use   21 to 30   31 to 40   41 to 50   51 to 60   Older
                                                           than 60

No % (n)        29 (9)     32 (6)    67 (12)    67 (12)    80 (4)
Yes % (n)      71 (22)    68 (13)     33 (6)     33 (6)    20 (1)
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Title Annotation:Research
Author:Olson-Sitki, Kristi; Kirkbride, Geri; Forbes, Gordon
Publication:Urologic Nursing
Article Type:Report
Date:Mar 1, 2015
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