Nurse’s knowledge and practice towards prevention of catheter-associated urinary tract

Nurse’s knowledge and practice towards prevention of catheter-associated urinary tract infection: A systematic review Fatmah Alsolami MSN, RN, PhD, Nahla Tayyib MSN, RN, PhD First published: 24 September 2023 https://doi-org.chamberlainuniversity.idm.oclc.org/10.1111/ijun.12380 Sections PDF Tools Share Abstract Catheter-associated urinary tract infection (CAUTI) is a common complication associated with indwelling urinary catheters, frequently used in healthcare settings. Nurses play a critical role in preventing CAUTI, as they are often responsible for inserting, maintaining and removing urinary catheters. Therefore, it is important to comprehensively assess nurses’ level of knowledge about CAUTIs and the variables that influence their application of best practices and recommendations for preventing these infections. The PRISMA principles were used to conduct a literature search for relevant research publications across several online databases (Web of Science, PubMed, MEDLINE and Scopus). The quality of these studies was evaluated using the Mixed Methods Appraisal Tool. There were 397 research articles, however only 21 articles were included after the screening. The majority of participants possessed diplomas ranging from 3% to 88.2%. In addition, the percentage of nurses with bachelor’s degree’s ranges from 11.80% to 100%. Moreover, 23.90% of registered nurses hold a master’s degree. Most nurses had between 1 and 5 and more than 5 years of experience. Nurses held good/adequate and average knowledge and practices regarding prevention and control of CAUTIs. Furthermore, age, gender, work experience, professional experience, in-service training, CAUTI prevention guidelines, time, equipment, personnel availability and work unit were all identified barriers. While continuing/in-service education and self-guided modules served as facilitators for the prevention of CAUTIs. Meanwhile, studies were found of good methodological quality. Improving nurses’ knowledge and practice towards preventing CAUTI is crucial to reducing the prevalence of the infection and improving patient outcomes. Implementing evidence-based interventions can help bridge the gap in knowledge and practice among nurses, ultimately leading to better patient care and outcomes. What is Known About this Topic? Catheter-associated urinary tract infection (CAUTI) is a one of the common complication associated with indwelling urinary catheters. Preventing CAUTI is one of the priorities in nursing practice. Nurses are responsible for inserting, maintaining and removing urinary catheters, therefore the risk of complications is common if nurses have insufficient knowledge about this practice. Assessing nurses’ level of knowledge about CAUTIs and the factors that influence their application of best practices are essentials to prevent infection related complications. What this Paper Adds? Education and training are essential elements in improving nurse knowledge and practice in CAUTI prevention. It is important to develop educational programs to improve nurse knowledge and practice in this area, such as in-service training, online modules or simulation-based training and therefore evaluate the outcome of these programs. The nursing practice consider strategies to eliminate the impact of the barriers that effect CAUTI prevention. 1 INTRODUCTION Complications from catheter-associated urinary tract infections (CAUTIs) can extend hospital stays, cause patient discomfort, and raise medical expenses and death.1 Meanwhile, catheterization of the urinary tract is a routine hospital operation with a high risk of hospital-acquired urinary tract infections (UTIs). It is responsible for over 70% of all UTIs.2 Similarly, an indwelling urinary catheter (IUC) is the leading risk factor for CAUTIs.3 Suppose a patient has an IUC and exhibits at least one of the following symptoms within 48 hours of the onset of infectivity such as fever, urgency, dysuria, suprapubic tenderness, pain or costovertebral angle tenderness, and a urine +ve culture. In that case, they are considered to have a CAUTI.4 The World Health Organization (WHO) reports that healthcare-associated infections (HAIs) cause serious harm to hundreds of millions of people every year, resulting in high mortality rates and substantial economic losses for healthcare systems around the globe.5 Over 150 million people worldwide get CAUTIs every year, making them the most common infectious disease.6 In particular, complicated UTIs significantly burden healthcare systems since they are a common reason for hospitalization.6 Catheter-associated UTIs account for the vast majority of the 1.4%-5.1% of healthcare-associated UTIs that occur yearly.6 Meanwhile, according to the Centers for Disease Control and Prevention (CDC), 12%-16% of hospitalized individuals require catheterization at some point, and the risk of complications increases by 3%-7% daily that a catheter remains in place. More than 13 000 deaths a year are attributed to UTIs.7 Furthermore, patients sometimes experience discomfort due to urethral damage, immobility, and unintended removal,8 and CAUTI is claimed to account for 6% of HAIs in the United States.9 Furthermore, HCPs must perform the insertion and management of urinary catheters. Therefore, they must possess the requisite expertise and knowledge to protect patients having indwelling catheterization from developing UTIs,10 and to reduce the incidence of UTIs, nurses should get training on how to use and manage urinary catheters.11 Similarly, nurses typically administer catheter care and are the primary caregivers for patients with IUCs in hospitals, so they are responsible for inserting, maintaining, and removing the catheters. Because they are in charge of collecting samples, nurses are crucial in identifying CAUTIs and are generally the first to detect a shift in patient care or a malfunction in equipment. Therefore, to avoid UTIs, nurses should be well-trained in properly caring for catheters and how to use them. A nurse’s education level is crucial to the care she can provide.12 Even though there are insufficient literature due to a lack of published studies highlighting the role of nurses in preventing CAUTIs.3 Some studies reported using a daily checklist for insertion of catheter and its maintenances based on scientific data and guided by nurses to prevent infections.13 Infection control services have established a number of policies and practices for preventing CAUTI infections. Infection surveillance and prevention programs have been shown to reduce HAIs, especially in ICU, focused on increasing hand hygiene compliance.14 There are novel preventive methods, including catheter coatings, immunization, and bacterial interference as well as new methods for identifying antibiotics and rationally designing small-molecule inhibitor options for CAUTI treatment are being developed.15 A nurse-driven catheter insertion and removal protocol based on medical necessity can help ensure proper catheter use and removal. Nurse-driven protocols allow competent nurses to make decisions, define the circumstances, and describe the processes without consulting physicians.16 According to the joint commission the source, a decision-making flowchart or checklist helps the professional nurse decide if a urinary catheter is needed and when to remove it to prevent CAUTIs.17 Modifying catheters with antibiotics, bioactive chemicals, and nano-formulations by surface functionalization, impregnation, mixing, or coating has been shown to be helpful in preventing the biofilm formation of bacteria.18 Moreover, reducing the need for indwelling catheters and removing them as soon as possible once they are no longer needed are the most effective measures for avoiding bacteriuria and infections.19 The nurse has a crucial role in removing the IUC when it is no longer needed. When deciding whether or not to continue using an IUC, start by checking in with the CDC’s criteria for proper use each day.20 Healthcare facilities’ infection control programs should implement and track measures to reduce CAUTI, such as monitoring catheter use, ensuring adequate indications for catheter placement, and identifying and resolving difficulties associated with catheter placement.19 The Infectious Diseases Society of America’s prepared guidelines regarding CAUTI is meant to be used by healthcare providers of all disciplines who provide direct patient care, particularly those who work in institutional settings like hospitals and nursing homes.21 The Center for Disease Control and Prevention’s guideline for the prevention of CAUTIs is developed for use by those responsible for designing, executing, and assessing infection prevention and control initiatives in healthcare facilities. Further implementation guidelines for preventing CAUTI can be developed using the recommendation as a resource for societies and organizations.22 Similarly, the American Nurses Association (ANA) has joined with the Partnership for Patients to make preventing CAUTIs a priority focus. The ANA aims to mobilize the nation’s 4 million nurses to reduce CAUTIs by efficiently applying a novel, simplified, evidence-based clinical tool. There are other guidelines published to prevent CAUTIs, such as the European Association of Urology (EAU), the Urological Association of Asia (UAA), and others collaborated in the early part of 2008 to issue European and Asian Guidelines on Treatment and Prevention of CAUTIs.23 Nursing Strategies to decrease the risk of CAUTIs were published in 2009 by the Wound, Ostomy, and Continence Nurses Society (WOCN).24 Timely care is achieved by nurse autonomy with patients and situational awareness facilitated by discussions about catheter necessity. In-dwelling urinary catheters have been shown to decrease CAUTIs when removed according to a protocol overseen by nurses.25 Nurses will benefit from this study since they will know how to improve the care by addressing the factors that hinder the best practice. Those working in the medical field must be well-trained and competent enough to prevent UTIs in hospitalized patients with indwelling catheters and educate patients adequately on how to avoid CAUTIs.26 Thus, systematically evaluate the level of awareness among nurses and identify the associated factors that affect nursing practice in implementing best practice/guidelines to prevent CAUTIs. 2 RESEARCH QUESTIONS What are the practices defined by different guidelines for the prevention of CAUTIs? What is the most effective nursing practice/effective nursing intervention to prevent CAUTIs? What are the barriers that affect implementing guidelines for preventing CAUTIs? 3 MATERIALS AND METHODS This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.27 3.1 Literature search Different databases such as Google Scholar, PubMed, Medline, Web of Sciences and Scopus were searched for the relevant research articles. The search phrases included MeSH terms and keywords such as ‘urinary tract infections’ and ‘catheter-associated urinary tract infection,’ and CAUTIs ‘nurses’ and ‘health staff,’ and ‘health knowledge, attitudes, practice, prevention, control’ and barriers. In addition, AND, OR, and NOT Boolean operators were used to broaden or narrow the search (Table 1). TABLE 1. Search strategy for different databases. Databases Key terms PubMed (((Nurses) AND ((((Knowledge) OR (Attitude)) OR (Opinion)) OR (Perception))) AND ((Prevention) OR (Control))) AND ((((Urinary tract infection) OR (UTI)) OR (Catheter-associated urinary tract infection)) OR (CAUTI)) Scopus (“Nurses”) AND (“Knowledge” OR “Attitude” OR “Opinion” OR “Perception”) AND (“Prevention” OR “Control”) AND (“Urinary tract infection” OR “UTI” OR “Catheter-associated urinary tract infection” OR “CAUTI”) Web of Sciences (((ALL = (Nurses)) AND ALL = (Knowledge OR Attitude OR Opinion OR Perception)) AND ALL = (Prevention OR Control)) AND ALL = (Urinary tract infection OR UTI OR Catheter-associated urinary tract infection OR CAUTI) Medline AB (“Nurses”) AND (“Knowledge” OR “Attitude” OR “Opinion” OR “Perception”) AND (“Prevention” OR “Control”) AND (“Urinary tract infection” OR “UTI” OR “Catheter-associated urinary tract infection” OR “CAUTI”) Google Scholar (“Nurses”) AND (“Knowledge” OR “Attitude” OR “Opinion” OR “Perception”) AND (“Prevention” OR “Control”) AND (“Urinary tract infection” OR “UTI” OR “Catheter-associated urinary tract infection” OR “CAUTI”) 3.2 Inclusion criteria Articles conducted on the knowledge and practices of nurses to prevent CAUTIs. Studies that assess nurses’ knowledge and practice of CAUTI (about IUC management or compliance with CAUTI), as well as the effectiveness of CAUTI intervention strategies. Guidelines published by different scientific societies and organizations for the prevention of CAUTIs. Only English-published articles were included. 3.3 Exclusion criteria Studies that included healthcare workers other than nurses, non-English articles, case studies, reviews, protocols, and posters were excluded. 3.4 Study selection and assessment Publications were reviewed, together with research titles and abstracts, independently. Full texts of articles that matched the inclusion criteria were examined by two reviewers, who then discussed and agreed on a final decision. Disputes, if any, were resolved by discussion and negotiation with the third impartial reviewer. 3.5 Data extraction Data extraction was done on the shortlisted studies that match the requirements for inclusion. After evaluating the titles, abstracts, and full texts of the papers, the data were recorded using a data extraction form. Two reviewers independently recorded each study’s authors, publication year, study design, country, sample size, level of education, experience, patient (adult) data collection tool, awareness (adequate/inadequate), practices (adequate/inadequate), guidelines followed for care, on-job training (CAUTIs/infection control), hand washing facility, type of CA infections, barriers, facilitators, findings, conclusion, and limitations. 3.6 Quality assessment The Mixed Methods Appraisal Tool (MMAT) (Table 1; Table A1) was used to assess the study’s methodology quality, and quality scores were calculated using the approach described by Charette, McKenna, Deschênes, Ha, Merisier and Lavoie28 Studies were classified as either low (scoring ≤3) or high (score >3) depending on the reviewer answered: ‘yes’ (1 point) or ‘no’ (0 points).29 3.7 Data analysis We used a results-based mixed-methods synthesis process predicated on theme analysis to compile the qualitative and quantitative research findings.30 Moreover, the PRISMA checklist was also used to perform a systematic review of pertinent literature, and a step-by-step method for choosing articles was provided. 4 RESULTS After an investigation of the scientific literature using various electronic databases (PubMed, Scopus, Web of Sciences, Medline and GoogleScholar), it was revealed that all of the research articles had been published in peer-reviewed journals, generating a total of 397 relevant articles. A total of 129 of the duplicated articles were deleted from the list. After that, 268 publications were reviewed for titles and abstracts, and 220 articles were removed again since they were irrelevant to our study. The remaining 48 full-text articles were thoroughly scrutinized, and 27 were removed for various reasons (Figure 1). Tables 1-3 highlight the 21 publications and identify their key features. FIGURE 1Open in figure viewerPowerPoint Literature searched and screening flowchart. 4.1 Where and when did studies takes place? Most of the studies were reported from India (6 studies)26, 31-35: followed by United States (3 studies),36-38 Ethiopia (3 studies),2, 39, 40 Iraq (2 studies)41, 42 and single study from Pakistan,43 Saudi Arabia,44 Yeman,12 Solvakia,45 Nepal46 and Malaysia47 (Figure 2). FIGURE 2Open in figure viewerPowerPoint The numbers of studies conducted in each country throughout the world. The majority of studies have been done in India, United States, Ethiopia and Iraq. Most of the studies that met the inclusion criteria were published over the last decade, there has been increased tendency of the publication since 2021, and 2022 was the year with more published articles (Figure 3). FIGURE 3Open in figure viewerPowerPoint The total number of studies in the systematic review dataset published per year. 4.2 Studies characteristics Most of the studies followed a cross-sectional study design.2, 12, 26, 37, 39, 40, 42-47 In contrast, one study followed a randomized experimental design,31 a prospective cohort study design,38 as stated in Table 2. There were 3019 study participants in the included studies; the maximum number of participants was 423,40 while the minimum was 30.32 Most participants had diplomas ranging from 3%36 to 88.20%.12 Moreover, nurses with bachelor’s degrees range from a minimum of 11.80%12 to a maximum of 100%.32 Meanwhile, 23.90% of nurses had a master’s degree, the maximum number of participants having a bachelor’s degree.2 In terms of nurse’s experience, most of the studies described the experience of nurses (1-5 or >5 years); however, four studies did not mention the experience.31, 35, 38, 43 Nurses working in different wards or departments and data collection tools used in the studies are listed in Table 2. TABLE 2. Characteristics of included studies. References Year Study design Sample size Education Experience Working stations Data collection tool Diploma Bachelor’s degree Master’s degree 1-5 years >5 years 31 2014 Randomized experimental 90 NA NA NA NA NA Different wards A structured self-administered knowledge questionnaire 36 2015 A Descriptive study 91 3% 61% 3% 12% 11% Medical, surgical, ICU A self-developed survey 32 2016 Pre-experimental, one group pre-test -post-test design 30 NA 100% NA 100% NA CCU and wards A structured questionnaire and observational checklist 37 2017 A cross-sectional 94 50% 50% 43.30% 46.70% Rehabilitation units Knowledge, attitudes and behaviours (KAB) 43 2018 A Cross-sectional descriptive study 160 69.40% 28.80% 3.1% NA NA ICUs Adopted questionnaire based on CDC guidelines 38 2018 Prospective cohort study 48 NA NA NA NA NA Emergency room and trauma/surgical and medical ICU Questions were based on CDC guidelines 33 2018 A descriptive survey 108 59.30% 40.70% 0% 62% 28.70% ICU Structured knowledge questionnaire (30 items) while practices through observation checklist 41 2019 A quasi-experimental design 40 NA 40% (study group), 35% (control group) 5% for both groups 75% (study group) and 60% (control group) 5% (study group), 20% (control group) CCU, medical, general surgical and emergency wards A questionnaire 44 2019 A cross sectional 137 35% 62% 2.90% 19.10% 81% Medical/surgical ICU and medical unit Knowledge and Practices Questionnaire 34 2020 Non-experimental descriptive design 250 72% 24.80% 0.80% 92.00% 8% General ward, orthopaedic ward, ICU and OBG A self-structured questionnaire 26 2020 A cross-sectional descriptive study. 235 NA 65.10% NA NA 65.10% Medical college hospital A structured knowledge questionnaire 46 2021 A cross sectional 160 NA 15.00% NA 67.50% 5.00% Medical, surgical, IC/CCU, ED, Peds, Gyn. A self-administered semi structured questionnaire 12 2021 A descriptive cross-sectional 93 88.20% 11.80% NA 81.70% 18.30% ED and ICU A self-administered questionnaire 35 2021 Pre-experimental study 50 NA NA NA NA NA Hospital units A structured questionnaire 47 2022 A cross-sectional 301 NA 85.71% 14.28% 55.14% NA Medical and surgical A self-reported questionnaire 45 2022 A cross-sectional, correlational study 67 34% 64.00% 2.80% NA 53.20% Medical and ICU Knowledge and Practices Questionnaire 39 2022 A cross-sectional study 408 7.80% 87.50% 4.70% 19.60% 19.60% Surgical Gyn, Peds, ICU, OR, OPD, ED, Medical A structured self-administered questionnaire 42 2022 A cross-sectional, correlational 50 12% 54% NA 58% Not clear Medical and ICU Knowledge and Practices Questionnaire 2 2022 A cross sectional 184 1.60% 74.50% 23.90% 50% 28.80% Medical and surgical ICU and Peds ICU A self-administered semi-structured 40 2023 A cross sectional 423 2.20% 75.60% 22.20% 28.60% 50.20% ICU, surgical, Medical, Peds, ED, fistula unit, OR, recovery unit, Out-patient unit. A structured English version self-administered questionnaire Abbreviations: CCU, critical care unit; CDC, Centers for Disease Control and Prevention; ED, emergency department; ICU, intensive care unit; NA, not available; OBG, obstetrics and gynaecology; OPD, out-door patient; OR, operating room; Peds, paediatric. 4.3 Outcomes Regarding awareness or knowledge, 12 studies reported a high/good level of awareness/knowledge, which ranges from a minimum 0%35 to a maximum 80%.32 A total of 17 studies reported that nurses had average/adequate awareness/knowledge related to CAUTIs, ranging from a minimum 25%38 to a maximum 82.80%.33 In comparison, 13 studies reported a poor level of knowledge/awareness among the nurses, which ranges from a minimum 0.90%33 to a maximum 90%41 (Table 3). Regarding practices related to preventing CAUTIs, 11 studies described the level of practice among the nurses. A maximum of 97.67% of nurses in a study had good practices,34 while a minimum 11.10% had a good level of practice.45 Two studies reported that most nurses had poor practices,33, 37 and a minimum 2.40% of the nurses had poor practices.34 A study conducted by Algarni, Sofar and Wazqar44 and Babečka and Gulasova45 reported 90.20% of the nurses had in-job training related to CAUTIs (Table 3). Furthermore, 11 studies did not report anything about the hand washing facilities, while the remaining studies reported different percentages of handwashing before and after using a catheter to prevent CAUTIs (Table 3). The conclusions and limitations of each study are stated in Table 3. TABLE 3. Outcomes. References Year Awareness/knowledge Practices Guidelines followed Additional/on-job training Hand washing facility/Hand washing Conclusion Limitations High/good Average/adequate Poor Good Poor Yes No 31 2014 NA 28.8% 58.8% NA NA NA NA NA NA The outcome demonstrated the effectiveness of the intended pedagogical approach. NA 36 2015 NA NA NA NA NA Nurse-driven catheter-removal protocols NA NA NA The nurses simplified the procedure of removing urinary catheters, which benefited both patients and staff. Lack of randomization, small sample size, and single-site implementation. 32 2016 80% post test 73% pretest, 20% post test 27% pre test 43.3% pretest, 60% post test 3.3% pre test NA NA NA NA The group’s pre- and post-test knowledge and practice results varied greatly. Generalizability, time constrain, difficulty in data collection, non-probability purposive sampling 37 2017 NA Maximum NA NA Maximum Elsevier’s Clinical Skills NA NA 45% It was shown that nurses did not implement techniques based on scientific evidence to prevent UTIs in patients undergoing intermittent catheterization. Small sample size, lower internal consistency. 43 2018 3.13% 48.75% 48.13% NA NA CDC 2009 Guidelines for prevention of CAUTIs NA NA NA Most individuals have moderate CAUTI knowledge and a negative attitude. Small sample size, time constrain, sampling bias. 38 2018 66.70% 25% 8.30% Not clear NA NA NA NA NA Training and education increased nursing knowledge of Foley catheter insertion and management. Small sample size, small number of observations 33 2018 16.70% 82.40% 0.90% Not clear Maximum Lacking of guidelines 14.80% 85.20% Non-compliance The report suggests that nurses read up on hospital and CDC guidelines for preventing urinary catheter care infections. NA 41 2019 NA Pre-test 10% (study group), 15% (Control group) (Pass) Pre-test 90% (Study group), 85% (Control group) (fail) NA NA NA Majority NA NA Most nurses did not know how to avoid female CAUTIs. NA 44 2019 0.73% 36.50% 62.77% 16.06% 83.94% Lacking of guidelines 91.20% 8.80% Yes (83.2%) Lack of education and ineffective methods contribute to the spread of CAUTI. NA 34 2020 38.80% 61.20% NA 97.60% 2.40% NA NA NA NA Staff nurse ages strongly correlated with CAUTI prevention practice. Most participants had average knowledge and good practice. NA 26 2020 7.23% 80.85% 11.20% NA NA NA 52.30% 47.70% NA The nurses’ level of CAUTI preventive knowledge was around average. Study was restricted a single centre. A study design and sample size 46 2021 NA 59.37% NA 64.38% NA CDC Guidelines for the prevention of CAUTI 35.00% 65% 26.87% Nurses’ attitudes are negative because they lack understanding about CAUTIs prevention. Small sample size. 12 2021 18.30% 72% 9.70% NA NA Lacking of guidelines 51% 49% 87% For CAUTI prevention specifically, there is a considerable gender gap in nurses’ knowledge. NA 35 2021 0% 38% 62% NA NA NA NA NA NA The teaching program improved knowledge. NA 47 2022 NA Majority NA 6 4.8% NA Lacking of guidelines 88.7% 11.30% 100% Attitude influenced perceived practice more. Generalizability, self-reported data by the nurses. 45 2022 0.72% 35.40% 77.76% 11.10% 89.90% NA 91.20% 8.80% 82.10% Nurses have poor CAUTIs prevention knowledge and practices. NA 39 2022 NA 63.50% NA 34.60% NA 82.4% have access to guidelines in departments 51.20% NA 74.50% More than half of nurses know how to prevent catheter-related infections, but only one-third practice it. Study design, did not include all health professionals. 42 2022 NA Majority NA NA NA NA 82% 18% 42% Staff nurses in ICUs lacked information about CAUTIs prevention. NA 2 2022 36.96% NA 63.04% 52.17% 47.83% 51.6% have access to guideline or protocols NA NA 63% Nurses’ understanding and practice of CAUTI prevention was inadequate. Study design, social desirability bias. 40 2023 53% NA 47% 50% 50% 53.7% presence of guidelines and 50.2% following guidelines 54.90% 45.10% 93.60% More than half of nurses understood CAUTI prevention. Social desirability bias and recall bias, self-reported questionnaire. Abbreviations: CAUTIs, catheter associated urinary tract infections; CDC, Centers for Disease Control and Prevention; NA, not available. 4.4 Barriers and facilitators After reviewing all quantitative and qualitative research, the barriers and facilitators of nurses’ CAUTI knowledge/awareness and practices were summarized. Age, gender, work experience, professional qualification, in-service training, CAUTI prevention guidelines, time, equipment, staff availability, and working unit were all barriers. While ongoing/in-service education, self-instructed module were the facilitators (Table 4). TABLE 4. Barriers and facilitators of nurse’s prevention and control of CAUTIs. Barriers Reference Facilitators Reference Time, equipment, staff availability, training, patient and family variables, shift change, patient schedule, communication, physicians order set and time demands. 37 Ongoing/In-service education. 2, 31, 35, 37, 38, 42 Clinicians’ workflow misalignment caused communication barriers due to organizational complexity. Pager usage and communication silos caused cognitive and social complexity. 48 An educational program on female CAUTIs improves study group nurses’ understanding. 41 In-service training, ICU work, and infection prevention guideline access. 39 Self-instructed module (SIM). 32 Age, designation, professional qualification, previous knowledge, current area of practice or training on CAUTI prevention. 45, 46 Gender, working unit, work experience, training on prevention of CAUTIs, and presence of guideline. 40, 45 Abbreviations: CAUTIs, catheter associated urinary tract infections; ICU, intensive care unit. 4.5 Quality assessment The Mixed Methods Assessment Tool was used to evaluate the methodological quality of the included studies (Table 5). A qualitative investigation and a randomized controlled trial were both of good methodological quality. Three studies had good methodological quality data collecting for four qualitative investigations. In contrast, one research article had poor methodological quality and needed to address the participants, whether they were the actual representation of the community or not, and also required to address cofounders. A total of 13 descriptive cross-sectional studies were of good quality, one research needed to be of better quality, and there needed to be more clarity in the four MMAT categories. TABLE 5. Summary of Mixed Methods Appraisal Tool (MMAT) methodological quality assessment. Reference Study design MMAT criteria for different studies 1.1 1.2 1.3 1.4 1.5 48 Qualitative Yes Yes Yes Yes Yes 2.1 2.2 2.3 2.4 2.5 31 Randomized experimental No Yes Yes Can’t tell Yes 3.1 3.2 3.3 3.4 3.5 32 Pre-experimental, one group pre-test-post-test design No Yes Yes No Yes 38 Prospective cohort study No Yes Yes No Can’t tell 41 A quasi-experimental design No Yes Yes Yes Yes 35 Pre-experimental study Can’t tell Yes Yes No Yes 4.1 4.2 4.3 4.4 4.5 36 Descriptive study Yes Yes Yes Yes Yes 37 A cross-sectional Yes Yes Yes Yes Yes 43 A cross-sectional descriptive study No No Yes Yes Yes 33 Descriptive survey Yes Yes Yes Yes Yes 44 A cross sectional Yes Yes Yes Yes Yes 34 Non-experimental descriptive design Yes Yes Yes Yes Yes 26 A cross-sectional descriptive study. Yes Yes Yes Yes Yes 46 A cross sectional Yes Yes Yes Yes Yes 12 A descriptive cross-sectional Yes Yes Yes Yes Yes 47 A cross-sectional Yes Yes Yes Yes Yes 45 A cross-section, correlational study No Can’t tell Can’t tell Can’t tell Can’t tell 39 A cross-sectional study Yes Yes Yes Yes Yes 42 A cross-section, correlational Yes Yes Yes Yes Yes 2 A cross sectional Yes Yes Yes Yes Yes 40 A cross sectional Yes Yes Yes Yes Yes Note: Y, yes; N, no; C, cannot tell, means that the paper does not report appropriate information to answer. 5 DISCUSSION CAUTIs are a common complication in hospitalized patients, leading to increased morbidity, mortality, and healthcare costs.49 Nurses play a crucial role in preventing CAUTIs by implementing evidence-based catheter insertion, maintenance, and removal practices. This systematic review aims to assess the current state of knowledge and practice among nurses regarding the prevention of CAUTIs. The review also synthesized findings from studies conducted in various healthcare settings and explore the factors that influence nurses’ adherence to CAUTI prevention protocols. In the present study, most of the nurses had at least bachelor’s degree while 23% had master’s degree which is a good sign at least that the nurses working in the hospital especially in emergency wards had degree level qualifications and are better equipped with the knowledge and skills to prevent CAUTIs. Because during the degree level education, they receive more comprehensive education and training on infection prevention and control, which includes strategies for reducing the risk of CAUTIs. Nurses with a Bachelor’s/Master’s degree have a broader understanding of the underlying factors contributing to the development of CAUTIs, such as the impact of catheterization on the patient’s immune system and the importance of aseptic technique during catheter insertion and maintenance.50 Furthermore, nurses with a Bachelor’s/Master’s degree are more likely to engage in evidence-based practice, which is critical in preventing CAUTIs. They are skilled in accessing and interpreting current research findings and implementing best practices in their clinical work. These nurses can use their knowledge and skills to educate patients, families, and other healthcare providers on the importance of proper catheter care and the risks associated with CAUTIs. In the present study, nurses had a good/adequate and average knowledge and practices regarding CAUTIs. However, more than 80% of the nurses in a recent survey of Saudi Arabia’s medical and surgical ICU had a poor knowledge of CAUTI prevention.44 The research identified one probable explanation for nurses’ poor performance as a deficiency in clinical CAUTI prevention guidelines.44 In contrast, in our case why nurses had an adequate/good knowledge may be due to the availability and accessibility of guidelines. There can be other reasons such as education level as we identified, most of the nurses were with higher degree inste

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