Summary of main findings
Although the majority of interns participating in this study had performed more catheterizations than those in previous studies and were confident in their skills, there was still a widespread perception that training in catheter insertion is lacking. Gaps exist in the knowledge and practice of interns on the step by step performance of catheter insertion compared to the urologic standard, and a significant number of interns are unable to identify an iatrogenic injury, the mechanism of injury, and factors that can contribute to an increased risk of such injuries. Training in catheterization should be reviewed and redesigned in order to prevent avoidable patient injury.
Strengths and limitations
This study has considerable strengths in the context of existing literature. All interns in one year in a national government teaching hospital were surveyed. The response rate was very high and the survey includes considerably more interns than previous studies. The questionnaire investigated interns' knowledge in greater detail than previously and the study establishes a baseline for the future evaluation of an educational intervention in the same institution. The study also has limitations that must be acknowledged. The questionnaire was not validated. That said, the methods are comparable with previous research. The survey is set in a teaching hospital in an Asian country and the generalizability of its findings to other regions is uncertain. From a skills training methodology point of view, direct observation is a better method than a questionnaire survey for evaluating acquired competencies, but this was not possible due to resource constraints. It is unfortunate that the questionnaire did not record the proportion of interns who explain the catheterization procedure to patients in order to put them at ease, which is standard practice, as patient anxiety may contribute to difficult catheterization. Lastly, asking multiple-choice questions without feeding the correct answers to the respondent is a challenge. However, the questionnaire was reviewed by senior consultants involved in the development of examinations for medical graduation and was piloted amongst interns.
The study in the context of the literature
Interns in this study reported high levels of experience of catheterization compared with those in a previous survey of first year interns in the UK published by the Annals of the Royal College of Surgeons of England in 2010, which found that one in five had never performed male catheterization and nearly half (45%) had never performed female catheter . In addition, supervision at first catheterization in this study is higher compared to a previous Irish study . The high level of experience in this study may be born of necessity through internship in a charity hospital in a developing country where catheterization is seldom performed by nurses and where working hours are longer and the patient to clinician ratio is generally much higher than in many other countries.
Nevertheless, the results show that only just over half (55.6%) of medical interns feel that they have had adequate theoretical training and two-thirds (66.7%) adequate practical training. Although better than the 36% and 52% reported by the Irish study that used the same questionnaire , these results are still worrying. Similar interns' concerns about the adequacy of their training are echoed in a French study in which only 26% felt that they were able to perform male catheterization and 38.3% female catheterization at the end of their medical education .
Although generally experienced and confident in the procedure, shortcomings were identified in the interns' knowledge of correct catheterization practices. It was found that less than a quarter of interns surveyed ask for a history of previous catheterization and surgery, knowledge of which can help predict the presence of urethral strictures or enlarged prostates . Only a handful of interns inject 10 mL of lubricant in the urethra, a practice that ensures adequate lubrication and more efficient insertion and can be of particular benefit in the presence of prostatic enlargement . Although a majority of participants report that they insert the catheter to the correct level before inflating the balloon, it is of concern that more than 10% report inserting the catheter to the shaft only or that they inflate the balloon when urine flows regardless of level inserted, practices that can increase the risk of iatrogenic urethral injury and indicate a training deficit. While three quarters of the interns correctly identified the cause of the catheter-related problem presented to them, only just over half were able to identify the mechanism of an associated iatrogenic injury and overall understanding of possible contributory factors in such injuries was poor.
It has been reported previously that lack of knowledge and skills have led to improper catheterization and urethral injury . Gaps in knowledge and skills were detected amongst interns in this study despite relatively high levels of experience in catheter insertion compared to studies from other countries. It is possible, therefore, that the risks of improper catheterization are higher elsewhere and the need for improved training greater.
Implications for medical education
More thorough training of incoming medical interns in urinary catheterization may help improve knowledge and practice and reduce the risk of complications and injury. Our study supports previous suggestions that urologists should take the lead in training medical students in urethral catheterization [3, 6, 7]. Participating interns displayed more experience and confidence than those in other studies, yet gaps in knowledge were identified relating to specific elements of the catheterization process and to factors that can increase the risk of urethral injury. French research highlighted the beneficial effect on trainees' confidence in catheterization associated with a period of training in a urology department .
Whether through lectures, video or demonstration, training should be carefully designed to establish the step by step catheterization procedure, with particular emphasis on the key points of lubrication, position of the penis and the extent to which a catheter should be inserted. The importance of history taking prior to the insertion should be stressed and conditions and scenarios that are associated with increased risk of urethral injury upon catheterization should be discussed. The timing of training sessions should also be considered. Given the risk of patient injury associated with the procedure, it may be best to have a session delivered by urologists just prior to the start of internship.
Implications for research
Training in catheterization is being redesigned in our institute in accordance with the findings of this study, and a further survey of interns in two years will shed light in the effectiveness of these changes. Similar studies in other regions and settings may provide evidence as to the generalizability of our findings.