Empowering Nursing Practices: Enhancing Patient Care Through Knowledge, Attitude and Practice Towards Urinary Catheterisation in Taicang City

Abstract

ABSTRACT

Aim

To assess the knowledge, attitude and practice (KAP) towards unnecessary urinary catheterisation among nurses in Taicang City, China.

Design

Cross‐sectional study.

Methods

This study included nurses from our hospital and was conducted between February 2023 and June 2023.

Data Sources

A self‐administered questionnaire was designed to collect their demographic characteristics and KAP.

Results

A total of 233 valid questionnaires were collected. The mean KAP scores were 13.44 ± 1.62 (possible range: 0–17), 45.28 ± 3.87 (possible range: 10–50) and 43.85 ± 5.98 (possible range: 10–50), which indicated moderate knowledge, positive attitude and proactive practice, respectively. The Pearson's correlation analysis showed positive correlations between knowledge and attitude (r = 0.253, p < 0.001), knowledge and practice (r = 0.279, p < 0.001), as well as attitude and practice (r = 0.441, p < 0.001). Partial correlation analysis adjusted for age, gender, department, working experience and experience in treating patients with catheter‐associated urinary tract infections also showed positive correlations among KAP. A structural equation modelling showed that both knowledge (β = 0.501, p = 0.047) and attitude (β = 0.691, p < 0.001) had direct effect on practice.

Conclusion

This study found moderate knowledge, positive attitude and proactive practice among the participants. Both knowledge and attitude might affect their practice.

Impact

We wanted to know the knowledge, attitude and behaviour of nurses in Taicang City towards unnecessary catheterisation. Moderate knowledge, positive attitude and proactive practice were found among the participants. The findings would provide evidence for policymakers to develop targeted educational intervention to improve nurses’ practice and might improve the outcomes of patients.

Reporting Method

This study was reported to be adhered to the STROBE guideline.

Patient or Public Contribution

No patient or public contribution.

Implications for the Profession and/or Patient Care

Targeted educational intervention was needed to improve nurses’ practice.

Introduction

Background on Urinary Catheterisation

A urinary catheter is a flexible tube used to empty the bladder and collect urine in a specialised bag. When this catheter remains inside the body, a process known as indwelling urinary catheterisation (IUC), it significantly heightens the risk of complex urinary tract infections (UTIs). These UTIs account for 40% of infections in healthcare settings worldwide and frequently lead to secondary bloodstream sepsis (Clarke et al. 2020; Flores-Mireles, Hreha, and Hunstad 2019). Despite efforts to minimise their usage, many hospitalised patients still receive unnecessary catheterisations, raising concerns about potential adverse effects including infections, urinary tract damage, confusion and discomfort (Wooller et al. 2018). Addressing this problem requires a more cautious approach to catheter use, ensuring it is justified and medically necessary.

Study Objective and Rationale

To address this, creating awareness among medical staff about the appropriate indications and risks associated with catheter use is crucial. We aimed to explore the knowledge, attitude and practice (KAP) towards unnecessary urinary catheterisation among nurses in Taicang City, Jiangsu Province China. For this purpose, the KAP theory suggests that informed and educated medical staff are more likely to adopt responsible practices (‘WHO Guidelines Approved by the Guidelines Review Committee’ 2008). Knowledge, a positive attitude and the implementation of correct practice are imperative to improve the quality and safety of nursing care (Yang et al. 2021; Yu et al. 2021).

Previous studies have investigated the effects of evidence-based interventions on reducing catheter use and catheter-associated urinary tract infection (CAUTI) rates (Flores-Mireles, Hreha, and Hunstad 2019; Sabih and Leslie 2023). Although the KAP of nurses and other healthcare workers towards the management of catheters has been formerly analysed (Benny et al. 2020; Menegueti et al. 2019; Niederhauser et al. 2020), these studies require further optimisation. Additionally, no research on this subject has yet been conducted in China (Huang et al. 2023). Recognising this gap, our research focuses on evaluating the KAP towards unnecessary urinary catheterisation among nurses in Taicang City, Jiangsu Province, China, aiming to identify areas for improvement and potential interventions.

Methods

Study Design and Participant Criteria

This cross-sectional study was conducted between February 2023 and June 2023, and included nurses in our hospital. The inclusion criteria were as follows: (1) possession of a nursing licence, (2) employment in designated departments and (3) voluntary participation with informed consent. Nurses in the department for further nursing training or nursing interns, as well as participants unwilling to participate in the study, were excluded. Nurses in training or interns were excluded from the study since they might possess gaps in knowledge and experience compared to their fully qualified counterparts.

Ethical Considerations

Before conducting the research, ethical approval was obtained from the ethics committee of our hospital (approval number: TCYY2020-KY-213), and all participants provided informed consent. The informed consent statement was presented on the first page of our electronic questionnaire, and included a clear explanation of the study's purpose, voluntary participation, and the right to withdraw at any time without consequences Nurses who wished to participate voluntarily were required to sign the consent form before proceeding with the questionnaire. Those who chose not to sign were unable to continue, and no data were recorded from these individuals. All data collected were anonymised and stored securely to ensure confidentiality and protect participants’ privacy, aligning with standard ethical guidelines for research integrity.

Questionnaire Development and Pilot Study

The initial design of the questionnaire was developed by the research team, drawing on relevant literature and previous studies (Zhong et al. 2020) as well as the Practice guidelines for the care of neurogenic bladder (2017). The validation of the questionnaire included both content validity and face validity. The content validity was enhanced by consulting four senior experts who reviewed the instrument to ensure theoretical alignment and applicability to clinical settings. On the basis of their feedback, duplicated or similar questions were removed, and unclear statements were refined to improve clarity, relevance and comprehensiveness. This revision process involved rephrasing questions, adjusting response scales and adding new items to fill content gaps, ensuring theoretical robustness and practical relevance.

For face validity, the experts confirmed that the questions accurately reflected the study's aims and were likely to be understood by the target participants. Additionally, during the pilot study, none of the 78 participating nurses reported confusion or difficulty in interpreting questions, indicating that the face validity of the questionnaire was satisfactory.

The reliability of the questionnaire was then assessed in the pilot study, where participants met the same eligibility criteria as those in the main study. This preliminary test provided a Cronbach's α value of 0.7275, demonstrating an acceptable level of internal consistency. Although validation and reliability were not measured through quantitative indices beyond the pilot study, these iterative refinements and assessments ensured validity and reliability in the questionnaire for capturing the variables of interest.

Data Collection Process

The final questionnaires were in Chinese and consisted of four sections: demographic characteristics (age, gender, education, professional title, department, working experience and experience on treating patients with urinary catheters), knowledge dimension, attitude dimension and practice dimension. The knowledge dimension consisted of eight questions, involving 17 items. Each correct response was assigned 1 point, while incorrect or unclear answers received 0 points, resulting in a score range of 0–17. In the attitude dimension, there were nine questions encompassing 12 items. Questions 3 and 4 were excluded from scoring. A 5-point Likert scale was employed, spanning from ‘Strongly Agree’ (5 points) to ‘Strongly Disagree’ (1 point), yielding a score range of 10–50. For the practice dimension, there were 7 questions, involving 10 items. A 5-point Likert scale was also used, ranging from ‘Always’ (5 points) to ‘Never’ (1 point), with a score range of 10–50. Following Bloom's cutoff, a widely recognised cutoff in KAP studies (Sitotaw and Philipos 2023), we categorised nurses’ KAP scores as follows: scores below 60% of the total (e.g., knowledge scores below 10.2 out of 17) were considered insufficient, negative or inappropriate; scores ranging from 60% to 80% (e.g., knowledge scores between 10.2 and 13.6) were deemed moderate and scores above 80% (e.g., knowledge scores over 13.6) were classified as sufficient, positive or appropriate. This cutoff framework is commonly applied in KAP studies to facilitate interpretation and comparison across similar research contexts, as it provides a standardised approach to categorise varying levels of competency and adherence. The questionnaires were distributed through the hospital's nursing management center via a WeChat link, with consistent instructions and explanations provided by the researchers. In order to ensure the quality and completeness of the questionnaire responses, all items were made mandatory. The research team members examined the integrity, internal consistency and validity of all questionnaires.

Sample Size Determination

The sample size was carefully determined to ensure the suitability of the data for factor analysis. The rationale behind sample size was based on Hair et al.'s (2010) suggestion that a minimum of 100 respondents is necessary for effective factor analysis. The calculation of the sample size for this type of analysis typically relies heavily on the number of components within the instrument. It is generally recommended to maintain a ratio of 5:1, meaning five respondents per item (Bryman and Cramer 2022). Consequently, for our study with 39 questions in KAP dimensions, the minimum sample size required to conduct a robust factor analysis had to be at least 195 nurses. In our hospital, there were 517 eligible nurses to participate. Of these, only 78 participated in the pilot study. Therefore, 439 nurses were approached.

Statistical Analysis

SPSS 26.0 and AMOS software (IBM Corp., Armonk, NY, USA) were used for statistical analysis. Continuous variables were expressed as mean ± standard deviation (SD) and compared using a one-way analysis of variance (ANOVA) or independent sample t-tests. Categorical variables were presented as n (%). Pearson's correlation analysis was conducted to explore the relationships among participants’ KAP. Given the need to account for potential confounding variables, we conducted a partial correlation analysis to adjust for relevant characteristics that might influence the relationships between KAP. Specifically, confounding variables, including age, gender, department, working experience and experience in treating patients with CAUTI, demonstrated a significant difference in the comparison of KAP and were subsequently adjusted for in the analysis. A structural equation modelling (SEM) was implemented to assess the relationships and pathways between multiple variables simultaneously. This approach allows for examining the complex interdependencies and direct and indirect effects among the three KAP in relation to urinary catheterisation among nurses (Bauldry 2015). For that purpose, we established a model based on the following hypotheses: (1) knowledge positively affects attitude, (2) attitude positively affects practice and (3) knowledge has a positive impact on practice. The hypothesized paths were based on the KAP theory, which posits that increased knowledge positively influences attitudes, and both knowledge and attitudes directly influence practice (WHO Guidelines Review Committee 2008). This theory provided the foundation for our model's structure, where knowledge was hypothesised to have a direct positive effect on both attitude and practice, and attitude was hypothesised to have a direct effect on practice. In evaluating SEM, we consider several key criteria: model specification clarity, proper identification ensuring the model is solvable, accurate parameter estimation via maximum likelihood methods and comprehensive model fit assessment. Maximum likelihood estimation (MLE) was used, as it is robust for moderate sample sizes and suitable for the continuous nature of our KAP data. The fitting of SEM was evaluated by the goodness-of-fit indices root mean square error of approximation (RMSEA), minimum discrepancy/degrees of freedom (CMIN/DF), comparative fit index (CFI), incremental fit index (IFI) and Tucker–Lewis index (TLI). These steps help ensure the model adequately represents the hypothesised relationships among variables. A two-sided p < 0.05 was considered as significant difference.

Results

Participant Demographics

A total of 260 questionnaires were collected (response rate: 59.23%); among them, 23 were answered too quickly (in < 150 s), 6 were duplicates with identical information (thus, considered as repeated questionnaires), 1 had incomplete information and 1 provided contradictory answers (by indicating too high working experience for their age). Thus, 233 valid questionnaires were finally included in this study. The reliability of the final questionnaire in our study was indicated by a Cronbach's α value of 0.8280, which also indicated an acceptable internal consistency. Among the participants, the mean age was 33.31 ± 6.22 years and their mean working experience was 11.64 ± 6.71 years. Most of them were women (98.28%), undergraduates (83.69%), frequently treated patients with indwelling urinary catheters (64.81%) and had intermediate professional title (51.07%; Table 1).

TABLE 1 Demographic characteristics and knowledge, attitude and practice scores.

Characteristics	N (%)	Knowledge	Attitude	Practice
Mean ± SD	p	Mean ± SD	p	Mean ± SD	p
Total	233	13.44 ± 1.62		45.28 ± 3.87		43.85 ± 5.98
Age (years)	33.31 ± 6.22
Gender
Male	4 (1.72)	12.75 ± 0.96	0.389	41.25 ± 2.63	0.036	40.50 ± 2.38	0.260
Female	229 (98.28)	13.45 ± 1.63	45.35 ± 3.86	43.90 ± 6.01
Education
Below Bachelor's degree	36 (15.45)	13.11 ± 2.20	0.280	44.56 ± 4.48	0.218	43.44 ± 5.99	0.888
Bachelor's degree	195 (83.69)	13.51 ± 1.48	45.45 ± 3.73	43.93 ± 6.02
Master's degree and above	2 (0.86)	12.50 ± 2.12	42.00 ± 5.66	43.00
Professional title
Junior	80 (34.33)	13.64 ± 1.79	0.363	45.78 ± 3.71	0.380	44.33 ± 6.00	0.834
Intermediate	119 (51.07)	13.26 ± 1.49	45.17 ± 3.95	43.53 ± 6.10
Vice-Senior	25 (10.73)	13.68 ± 1.18	44.28 ± 4.24	43.92 ± 5.19
No professional title	9 (3.86)	13.44 ± 2.46	45.11 ± 2.98	43.56 ± 6.82
Department
Operating room	13 (5.58)	12.92 ± 1.80	0.069	41.92 ± 4.79	0.009	38.85 ± 9.04	0.011
Intensive care unit	47 (20.17)	13.85 ± 1.63	45.57 ± 3.17	43.96 ± 5.04
Neurology department	50 (21.46)	13.70 ± 1.18	45.76 ± 3.38	45.42 ± 3.65
Surgery department	40 (17.17)	13.45 ± 1.83	46.12 ± 3.49	43.95 ± 5.58
Other departments	83 (35.62)	13.13 ± 1.66	44.94 ± 4.29	43.57 ± 6.82
Working experience (years)	11.64 ± 6.71
Experience treating patients with indwelling urinary catheters
Yes, frequently	151 (64.81)	13.67 ± 1.48	0.003	45.66 ± 3.27	0.122	44.48 ± 4.83	0.086
Yes, occasionally	74 (31.76)	13.12 ± 1.81	44.57 ± 4.78	42.70 ± 7.53
No	8 (3.43)	12.13 ± 1.13	44.63 ± 4.47	42.38 ± 8.25

Knowledge Scores and Analysis

The mean knowledge score was 13.44 ± 1.62 (possible range: 0–17). The knowledge scores were likely to be associated with their experience treating patients with indwelling urinary catheters (p = 0.003). In the knowledge dimension, ‘Timely removal of the urinary catheter can reduce the rate of catheter-associated infections’ was identified as the item with the highest accuracy rate (99.57%). On the contrary, the answer ‘entailed considering persistent urinary tract infections as a suitable indicator of IUC’ had the lowest percentage of accuracy (12.88%). It should be noted that the vast majority of the answers in the knowledge dimension (15 out of 17) had high percentages of accuracy (more than 60%), with 9 answers reaching more than 90% of correctness. Specific high-scoring items included the recognition of accurate urine output measurement for critically ill patients (98.71%), appropriate use for anticipated prolonged surgical procedures (97.85%) and absence of indications as a valid reason for catheter removal (97.42%; Table S1).

Attitude Scores and Analysis

In the attitude dimension, the scores showed differences among nurses according to their gender (p = 0.036) and department (p = 0.009), with the average score at 45.28 ± 3.87 (possible range: 0–50). Most items in the attitude dimension (8 out of 12) had high percentages of strong agreement (65.67%–87.12%). The highest was item 7 ‘c’, which responded ‘before catheter removal’ to the question ‘When do you think an evaluation of bladder function should be conducted?’. On the other hand, when asked if assessment catheter removal is better led by doctors (A3) or nurses (A4), or when removing or retaining the urinary catheter, it is essential to fully consider the opinions of patients and their family members (A5), considerable rates of neutrality were obtained (41.20%, 53.22% and 34.76%, respectively). Furthermore, notable disagreement values were present in those last three assessments (21.46%, 14.59% and 11.59%, respectively). Among the nurses, more than a half considered that the assessment for catheter removal was equally important for both doctors and nurses (56.22%), whereas the rest preferred the lead to be taken specifically by doctors or nurses in similar rates (22.32% and 21.46%, respectively). In addition to these insights, strong agreement was also evident in views on educating both patients and their caregivers about IUC to reduce complications, with 71.67% and 70.82% strongly agreeing, respectively. However, opinions on who should lead the assessment for catheter removal were divided, showing a preference for a balanced approach between doctors and nurses, as indicated by 56.22% agreement that it is equally important for both roles. The belief in timely bladder function assessments, such as before catheterisation (84.12% strongly agree) and within 24 h after removal (85.54% strongly agree), reflects a proactive attitude towards patient management. Finally, a significant consensus (65.67% strongly agree) was observed against the practice of inserting urinary catheters merely for nursing convenience, underscoring a critical stance on inappropriate catheter use (Table S2).

Practice Scores and Analysis

Practice scores averaged 43.85 ± 5.98 (possible range: 0–50). In the practice dimension, the department was the only characteristics that might show differences (p = 0.011). Most responses involved high frequency of practice, with ‘always’ being the most recurrent answer (63.52%–77.25%) in 7 out 10 items. Answer 5 ‘c’, which responded ‘Before catheter removal’ to ‘Under which circumstances do you conduct bladder function assessments for patients?’ had the highest percentage. When adding ‘frequent’ to ‘always’, those percentages increased even more, with 79.40%–96.14% in 8 of 10 items. Two questions showed rather scattered opinions: ‘Does your department prefer to remove catheters early and perform intermittent catheterisation to assess patients' bladder function?’ (Item 4) and ‘When deciding to remove or retain a catheter, do you consider the opinions of patients and their families?’(Item 6). The highest rate of ‘never’ as a response was found in Item 4 (14.59%). Additional key findings involved a significant majority of practitioners (73.82%) consistently educating both patients and their caregivers about catheterisation, which indicated a strong commitment to patient information sharing. Moreover, a majority of healthcare providers demonstrated a proactive stance towards professional development, with 63.52% always willing to engage in training related to neurogenic bladder management and an additional 30.04% frequently participating. Guidance on bladder training was also notably prevalent, although with some variability, as 51.93% always offered this support and 27.47% did so frequently (Table S3).

Correlations and SEM Analysis

The Pearson's correlation analysis for KAP showed positive significant correlations between knowledge and attitude (r = 0.253, p < 0.001), knowledge and practice (r = 0.279, p < 0.001), as well as attitude and practice (r = 0.441, p < 0.001; Table 2). The results of the partial correlation analysis show that the adjusted correlations remain statistically significant: knowledge and attitude (r = 0.218, p < 0.001), knowledge and practice (r = 0.253, p < 0.001) and attitude and practice (r = 0.419, p < 0.001; Table S4). The SEM showed that the path coefficient from knowledge to attitude (β = 0.205, p = 0.158) was positive but not statistically significant. On the other side, both knowledge (β = 0.501, p = 0.047) and attitude (β = 0.691, p < 0.001) had direct effect on their practice (Figure 1 and Table 3). The SEM model fitting data presented in Table 4 indicate a generally good model fit based on various fit indices. The CMIN/DF value of 2.470 fell within the excellent range (1–3), suggesting a very good fit between the hypothesised model and the observed data. The RMSEA value was 0.060, which was just below the threshold of 0.08, also indicating a good model fit. The IFI, TLI and CFI values, at 0.832, 0.817 and 0.831, respectively, were above the desired threshold of 0.8, also suggesting good alignment with the KAP theory. Thus, the overall indicators suggested that the model was well-fitted.

TABLE 2 Correlation analysis.

	Knowledge	Attitude	Practice
Knowledge	1
Attitude	0.253 (p < 0.001)	1
Practice	0.279 (p < 0.001)	0.441 (p < 0.001)	1

[IMAGE OMITTED. SEE PDF]

TABLE 3 SEM path analysis results.

Estimate	Estimate	p
Attitude ← Knowledge	0.205	0.158
Practice ← Attitude	0.691	< 0.001
Practice ← Knowledge	0.501	0.047

TABLE 4 SEM Model Fitting.

Indicators	Reference standard	Outcome
CMIN/DF	1–3Excellent, 3–5 Good	2.470
RMSEA	< 0.08 Good	0.060
IFI	> 0.8: Good	0.832
TLI	> 0.8 Good	0.817
CFI	> 0.8 Good	0.831

Discussion

Main Findings

The study demonstrated moderate knowledge, positive attitude and proactive practice towards unnecessary urinary catheterisation among nurses. Positive and significant correlations were found between knowledge and attitude, knowledge and practice, and attitude and practice. These findings suggest that higher knowledge and a positive attitude are related to better practice. Moreover, SEM results showed that both knowledge and attitude had direct influences on practice. To the best of our knowledge, this is the first Chinese study to offer insights into the KAP towards unnecessary urinary catheterisation. The findings underscore the potential for targeted interventions to enhance KAP and improve patient care in the context of urinary catheterisation.

Knowledge of Urinary Catheterisation

Nurses showed moderate levels of knowledge towards preventing indwelling CAUTI. They exhibited particular proficiency in understanding when to avoid unnecessary catheterisation in appropriate patients, such as those with bladder emptying dysfunction, and in advocating for timely catheter removal. Similar results were observed in previous descriptive research, in which the majority of assessed nurses were aware of the standard preventive measures for CAUTI, that is, urinary catheters should be inserted only when it is actually necessary and extracted as early as possible, and urinary catheter insertion should be conducted only by experts in aseptic insertion (Kulbay and Tammelin 2018; Mong et al. 2022; Shaver et al. 2018). Our findings of a weaker understanding of adequate indicators for catheterisation were in line with those of Mong et al. (2022), although in different aspects. Most of our population sample erroneously considered ‘Patients bedridden for extended periods during hospitalisation’ and ‘Persistent urinary tract infections’ as indicators. Meanwhile, in the study by Mong et al., a considerable number of nurses thought that mobile patients were candidates for catheterisation, and only a small percentage reckoned that urinary incontinence was not a proper indicator. Except for the above-mentioned two difficulties with indicators, all subsequent assessments about ICU's guidelines showed satisfactory results among our population sample, with high levels of accuracy. These results differ from several previous surveys, in which low percentages of nurses knew the standard guidelines (Shah et al. 2017) and expressed their awareness of the evidence-based guidelines of CAUTI (Cutinho, Sheilini, and Harish 2018), and some could not distinguish effective and ineffective measures of CAUTI (Jain et al. 2015).

The moderate knowledge base combined with specific gaps in understanding identified in this study suggests that there is considerable potential to enhance nursing practices through focused educational programmes. These programmes should not only reiterate when catheter use is warranted but also emphasise the clinical reasoning behind avoiding catheterisation in conditions that do not medically justify it. Key focus areas for these programmes include emphasising aseptic insertion techniques and ongoing catheter care, advocating for early removal protocols and strengthening decision-making and communication within healthcare teams. Programmes should also cover evidence-based CAUTI prevention practices and the management of catheter-related complications. Their implementation would help bridge the gap between knowledge and practice, leading to better clinical decisions and patient outcomes. Education is the main proactive tool for addressing knowledge gaps, and measures should be taken to design customised educational programmes, which help nurses and other healthcare workers incorporate standardised practice (Benny et al. 2020; Shaver et al. 2018).

Attitude Towards Catheterisation Practices

In line with our results, general positive attitude towards CAUTI prevention was detected in a systematic review (Huang et al. 2023). In our study, when nurses were asked whether the catheter removal was equally important for doctors and nurses, the majority agreed, and no preference towards any of the two professions was observed. This evidence of positive attitude towards nurses' own role and relevance in urinary catheterisation aligns with the findings of other authors (Conner et al. 2013; Viswanathan et al. 2015), in which a noteworthy number of nurses expressed interest in a nurse-driven programme that involved the removal of Foley catheters. Additionally, those nurses expressed a strong desire to be more actively engaged in the decision-making process regarding urinary catheter usage.

The positive attitudes detected are indicative of a broader cultural shift within nursing practice towards greater involvement in critical care procedures and decision-making. These attitudes likely contribute to enhanced patient outcomes by promoting more diligent and patient-centered catheter management practices. When nurses feel empowered and responsible, they are more likely to engage in practices that prevent infections and advocate for the well-being of their patients (Visiers-Jiménez et al. 2022). To capitalise on the positive attitudes towards CAUTI prevention, healthcare institutions should consider formalising the role of nurses in catheter management through policy changes and training programmes. Encouraging the implementation of nurse-led catheter removal protocols could further validate and reinforce the positive attitudes observed, ensuring these practices are standardised across healthcare settings. Additionally, creating more opportunities for nurses to lead educational sessions about CAUTI prevention could enhance their engagement and commitment to best practices.

Practice Outcome Towards Catheterisation Practices

Satisfactory responses were given in the practice dimension, contrary to internationally widespread undesirable practice on CAUTI's prevention and management, but in line with previous reports that a significant majority of healthcare workers attached importance to the prevention and control of CAUTI (Huang et al. 2023). Our findings indicating a positive predisposition among nurses towards advancing training are consistent with several previous publications. Mulcare et al. (2015) described that healthcare workers were eager to adopt a clinical protocol to standardise IUC practice and prevent infections. Nurses have also favoured nurse-driven catheter removal programmes and sought increased involvement in decision-making (Conner et al. 2013; Viswanathan et al. 2015). Additionally, healthcare workers have been found to value learning evidence-based practice for CAUTI, enhancing their confidence to improve patient care quality (Conner et al. 2013). The latter seems most relevant as nurses have a key role in the management of IUC, as they can promptly advise physicians to remove catheters when necessary. They have direct patient interactions and spend more time at the bedside with catheter care compared to doctors, thereby assuming greater responsibility for infection prevention and management details.

The SEM analysis showed that the path coefficient from knowledge to attitude was positive but not statistically significant. This suggests that although knowledge may contribute somewhat to shaping nurses’ attitudes towards catheter use, it is not a strong or reliable predictor in this sample. Practically, this finding indicates that increasing knowledge alone may not significantly enhance positive attitudes towards best practices in catheterisation. This lack of impact on attitude suggests that additional factors, such as experience or institutional culture, may play a more prominent role in influencing attitudes, warranting further exploration in future studies. On the other hand, the path from knowledge to practice showed a significant, positive effect, indicating that higher knowledge levels are directly associated with improved practice behaviours. This significant relationship highlights the importance of educational interventions targeting knowledge enhancement, as well-informed nurses are more likely to adhere to recommended catheter management practices. In practice, this suggests that investing in knowledge-focused training, such as infection prevention protocols, can directly improve clinical behaviours, potentially reducing the risk of catheter-associated infections. Finally, the significant effects of both knowledge and attitude on practice emphasise that while knowledge is foundational, attitudes play an equally crucial role in translating knowledge into action. Healthcare institutions could benefit from dual-focused programmes that improve knowledge while concurrently fostering positive attitudes towards catheter care, which could be achieved through regular training, reinforcement of best practices and supportive supervisory environments. Together, these factors can drive sustained improvements in catheter management, reduce infection rates and enhance patient outcomes.

Clinical Implications

The findings imply that when nurses are well informed and actively involved in CAUTI management strategies, they can effectively influence outcomes through their direct clinical actions and decision-making. Their frontline position not only allows them to apply their knowledge practically but also places them in a pivotal role to detect and mitigate potential complications early. The evidence suggests that the integration of structured training and clear protocols into nursing practice not only fills knowledge gaps but also translates into enhanced practical application, leading to improved patient outcomes.

While our results show positive practices, underlying knowledge gaps can significantly influence these practices. For instance, misunderstanding the appropriate indicators for catheter use can lead to either overuse or inappropriate management of catheters, thereby increasing the risk of CAUTI. Addressing these gaps through targeted education is crucial as it ensures that nurses are not only aware of the guidelines but understand the rationale behind them, which is essential for applying this knowledge effectively in clinical settings. Educated and well-informed nurses are more likely to adhere to best practices and guidelines, advocate for evidence-based interventions and engage in preventive actions that significantly reduce CAUTI risks.

Several barriers, however, impact practice adherence. Less experienced nurses show knowledge gaps that could lead to inconsistent care, indicating the need for experience-based training. Role ambiguity in catheter removal decisions, with mixed opinions on leadership roles (53.22% neutrality on nurses’ involvement), may limit initiative. Providing clear guidelines can empower nurses to act confidently. Additionally, practical constraints like high patient loads sometimes encourage convenience-based catheterisation, suggesting that staffing or workflow adjustments could help reduce unnecessary catheter use.

Facilitators for improved practices include a strong commitment to patient education, with 71.67% of nurses supporting this approach to reduce complications. Expanding proactive departmental practices, like early catheter removal and regular assessments seen in the ICU, to other units could promote consistency. Furthermore, 63.52% of nurses expressed interest in ongoing training, providing an opportunity for regular workshops to ensure up-to-date practices.

Limitations

The limitations identified in this study significantly influence the generalisability of the findings. Conducted in a single centre in Taicang City, the results might not reflect the practices, knowledge or attitudes found in other hospitals or regions due to varying healthcare practices and administrative policies. The demographic characteristics of the sample, being mostly female and predominantly holding undergraduate qualifications, are representative of the nursing population in Taicang City and consistent with the general demographics of the nursing workforce in China. This alignment supports the relevance of our findings within similar hospital settings in China. However, this limits the breadth of these findings across different genders or educational backgrounds, which might impact adherence to CAUTI prevention guidelines. The reliance on self-reported data introduces potential biases, such as recall bias and social desirability bias, where participants may report what they perceive as expected rather than actual practices. Another limitation of this study is the final sample size of 233, which is lower than the 439 nurses initially approached due to the removal of invalid questionnaires. Although the sample still meets the minimum requirements for factor analysis, the reduced number of valid responses may limit the generalisability of the findings. Future studies with larger, fully complete datasets would help confirm these results and strengthen their applicability across diverse nursing settings. Consequently, these limitations should be considered when conducting further analysis and interpretation. However, despite the local nature of the study, similar patterns of knowledge gaps and role perceptions among nurses may be relevant in other healthcare settings, particularly in regions with comparable healthcare structures. Future multi-centre studies across various regions are crucial to validate these findings and understand how they apply to a wider nursing population. Research incorporating direct observations, rather than relying solely on self-reported data, could offer a more accurate picture of urinary catheter management across healthcare settings. Longitudinal studies would also help assess whether improvements in knowledge and attitudes lead to lasting practice changes over time. Additionally, in-depth qualitative research on nurses’ perceptions and experiences could reveal the contextual factors and personal motivations that influence their approach to catheterisation, enriching our understanding of the barriers and supports for effective practice change and guiding tailored interventions in diverse settings.

Conclusions

In conclusion, nurses demonstrate moderate knowledge, positive attitude and proactive practice towards unnecessary urinary catheterisation. Despite the satisfactory attitude and practice, and moderate levels of knowledge, some gaps still need to be addressed to enhance catheterisation practice and patient care. Education and training appear to be an essential tool to provide nurses with the latest and appropriate guidelines for catheter placement. Moreover, fostering a collaborative culture among doctors, nurses and patients could help prevent infections, and encourage clinical leaders to take the initiative in providing education, supervision and increased empowerment opportunities for nurses.

Author Contributions

Hong Zhang and Lihong Zhang carried out the studies, participated in collecting data and drafted the manuscript. Yaxuan Wang, Hui Li, Ting Liu and Jingjing Qian performed the statistical analysis and participated in its design. Chi Wang and Lihong Zhang participated in acquisition, analysis or interpretation of data and drafted the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors have nothing to report.

Ethics Statement

This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. This study was approved by the Ethic Committee of the First People's Hospital of Taicang City (approval number: TCRMYY2020-KY-213), and all participants provided informed consent.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

All data generated or analysed during this study are included in this article and Tables S1–S4.

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