Brian T. Conner, PhD, RN, CNE Medical University of South Carolina Exploring Factors Associated With Nurses’ Adoption of an Evidence-Based Practice to Reduce Catheter-Associated Urinary Tract Infections Brian T. Conner, PhD, RN, CNE Assistant Professor College of Nursing Medical University of South Carolina Welcome to my oral defense of my dissertation entitled: Exploring Factors Associated With Nurses’ Adoption of an Evidence-Based Practice to Reduce Catheter-Associated Urinary Tract Infections

Problem Identification Risk of hospital-acquired infections (HAIs) remains high Urinary tract infections are most common HAI (HA-UTI) 80% of HA-UTIs are related to urinary catheterization (HA-CAUTI) The incidence of being admitted to a hospital as an inpatient carries with it a significant amount of risk for any person. Nosocomial infections, as defined by the Centers for Disease Control (CDC), include any infections developed as a result of a healthcare encounter and the most recent terminology is reflected as healthcare-acquired infections (HAI) (Centers for Disease Control, 2005). HAIs continue to represent not only risks to hospital inpatients but also to healthcare organizations in terms of costs. Hospital-acquired urinary tract infections (HA-UTI) are well-documented adverse events that constitute the most common type of HAI around the world (Nazarko, 2008). Strikingly, over 1 million HA-UTIs are diagnosed each year in the United State alone and approximately 80% of those are linked with urinary catheterization (Gentry & Cope, 2005; Lockwood, Page, Conroy-Hiller, & Florence, 2004; Loeb et al., 2008; Newman, 2007; Reilly et al., 2006).

Specific Aims Explore nurses’ perceptions of EBP in general and specific to the use of a nurse-driven urinary tract infection prevention protocol aimed at reducing duration of catheterization.

Rogers’ Diffusion of Innovation Theory Characteristics Concept Definition Relative advantage Degree to which the innovation is perceived as an improvement over what it replaces. Compatibility Degree to which the innovation is seen as being a good fit with the potential adopters. Complexity Degree to which the innovation is perceived as difficult to understand and use. Trialability Degree to which the innovation can be tried prior to adoption. Observability Degree to which the results of the innovation are visible and measurable. The primary benefit of using DoI Theory is its application among groups of people or within organizations. A number of organizational change theories exist but are focused on processes and procedures rather than on group or organizational readiness to change (Certo, 2006). DoI Theory addresses issues related to how new ideas or processes are adopted by members of a group (Lundblad, 2003). Diffusion may be viewed as a social process involving interpersonal communication among group members, and the five stages or steps in Diffusion Theory are related to the innovation-decision process (Van Patter Gale & Schaffer, 2009).

Questionnaire Development/Modification EBPQ – 24-item self-report with three subscales: Practice Attitudes Knowledge/skills AECDPQ – 17-item self report with three underlying constructs: Relative advantage/compatibility Complexity Observability The EBPQ, developed in 1995 using Streiner and Norman’s methods for questionnaire development (Upton & Upton, 2006), is a 24–item self-report questionnaire organized into three subscales to measure the variables considered important for the implementation of evidence-based practice (EBP). The subscales (practice, attitudes, knowledge/skills) include practice items consisting of the steps in the EBP process, attitudes related to workload, and perceptions of knowledge/skills of EBP including information technology skills. The instrument uses a 7-point Likert-style scale with higher scores indicating a more positive attitude towards clinical effectiveness/EBP, or use and knowledge of clinical effectiveness and EBP. The participants will also be given the opportunity to write their own comments regarding perceived barriers and feelings related, in general, to EBP. The AECDPQ is a compilation of established and investigator-developed/modified instruments used to measure the perceived attributes of an innovation based on Rogers’ DoI theory. Pankratz, Hallfors, and Cho (2002) developed a scale to assess the perceived attributes of innovation adoption during the diffusion a federal drug prevention policy entitled the Principles of Effectiveness. The authors based the items in their scale on previously developed diffusion research instruments by Brink et al. (Brink et al., 1995), Steckler et al. (Steckler et al., 1992, and Moore and Benbasat (Moore & Benbasat, 1991). The scale included 17 items that were subjected to component factor analysis with a varimax rotation and a promax rotation (Pankratz, Hallfors, & Cho, 2002). The results revealed three underlying constructs representing relative advantage/compatibility, complexity, and observability. Internal consistency was demonstrated with Cronbach’s  for the constructs ranging from 0.89 to 0.71. Correlations between the perceived attributes of the innovation and the adoption of the policy were analyzed using Pearson’s correlation coefficient with all correlations being in the expected direction and significant at the P < 0.05 level (Pankratz, Hallfors, & Cho, 2002).

Qualitative Data Collection Focus groups of 4-6 nurses from intervention unit Two groups to include various shifts Grounded Theory The strengths of using qualitative methodology in conjunction with quantitative data collection include the ability to elicit deeper, meaningful data related to the subjects' perceptions, feelings, and experiences rather than strictly numbers, percentages, and statistics. The qualitative study design will use focus groups comprised of a purposive sample of the nurses employed on the intervention unit. This descriptive study will use a hermeneutic-phenomenological methodology and is designed to incorporate an inductive approach to explore nurses' perceptions and attitudes regarding the intervention protocol (Ajawii & Higgs, 2007).  Hermeneutic-phenomenology includes description as well as interpretation of lived experiences (Van der Zalm & Bergum, 2000). Dingwall and Mclafferty (2006) used such a phenomenological approach in their study of nurses’ promotion of urinary continence in hospitalized older people. The aim of this inquiry will be to gain understanding through participants’ reflections of their experiences with the implementation of the early catheter discontinuation protocol. The purpose of using focus groups is related to the concept that group interactions may yield responses and build insights that might not occur during one-on-one interviews (Slade, Molloy, & Keating, 2009). On the other hand, one difficulty with focus groups may be scheduling difficulties (Dingwall & Mclafferty, 2006). In addition, some participants may not contribute as readily in a group setting as when interviewed alone. Participants' shifts will be correlated in order to arrange the focus groups for optimum participation while reducing the conflict with work hours. A limit of six participants per focus group will be maintained to ensure maximum participation by each member. The participants will be informed of the purpose of the study, the design, and how the data will be used. In addition, the participants will be informed that the focus group interviews will last approximately one hour. Open-ended questions will be used with more specific follow-up questions designed to elicit relevant details.  Focus group interviews will be conducted by a facilitator with a transcriber present to record all responses as well as any pertinent non-verbal behaviors. The use of a transcriber allows the facilitator to remain focused on the participants rather than the recording process (Mclafferty & Morrison, 2004). The facilitator and transcriber will confer post-session to discuss the transcription, clarify any necessary points, and reach agreement on the content.

Responses to AECDPQ

Catheter duration

Themes developed from qualitative data

Conclusion EBP education + practical application of an EBP > increases nurses’ perceptions and attitudes of EBP. Nurse-driven protocol seen as having relative advantage and compatibility Need collaboration to test nursedriven protocol in other hospitals around the state