Intermittent self catheterization (ISC) is the gold standard for the management of urinary retention. Patient’s perspectives of ISC and adherence to this technique have already been reported in the literature. However, no data exists regarding the viewpoint of the professional caregivers including nurses and doctors. 

The aim of the study was to explore the opinion of the urologist on self-catheterization and to evaluate the need for dedicated nurses specialized in ISC through a self-administered questionnaire.

A questionnaire was designed by a panel of expert urologists and nurses to explore the opinion of the professional caregiver on self-catheterization and to evaluate the need for specialized education/or teaching of nurses in ISC. The questionnaire consisted in 52 multiple choice questions that assessed 6 dimensions: demographical data (6 questions), knowledge about ISC (15 questions), decisive factors to offer ISC to patients (11 questions), reasons for not offering ISC to patients (5 questions), ISC as a treatment option for themselves (3 questions) and professional experience with ISC (12 questions). Participants were asked to rate each item from 1 (no influence/strongly disagree) to 5 (major influence/strongly agree). A total score was calculated as the equal average of the ratings (RA, rating average) per question. The link to the questionnaire was sent to the members of the French Association of Urology (AFU) in 2018 and was made available online by using Surveymonkey website (https://www.surveymonkey.com). 

The statistical analysis was carried out by using SPSS version 19.0. The results were presented in mean + 95% -confidence interval and percentages. The results were interpreted using the one-sample Student’s t-test.

Demographical data
Questionnaires were sent to the 1607 available email addresses of urologists. The overall survey response rate was 12.8% (preliminary results). 50% (n=64) of urologist responders worked in a private hospital setting, 16% (n=20) in a public hospital, 26% (n=34) in a university hospital, 7% (n=9) in a mixed practice (other: 1%). When asked about their experience, 5.5% (n=7) were resident urologists, 28.1% (n=36) had less than 10 years of experience, 42.2% (n=54) had between 11-25 years of experience and 24.2% of the respondents had more than 25 years of experience. 61.7% (n=79) of the urologist responders offered ISC to 1 to 3 new patients each month and 5.5 % (n=7) never offered ISC to patients. Only 47.7% (n=61) of the urologists reported to have a permanent dedicated nurse in their team in order to teach ISC. 25% (n=32) of the participants reported to have a dedicated nurse to their disposal ‘most of the time’, and 14.8%  (n=19) did not have a dedicated nurse.

Decisive factors to offer ISC to patients 
Older age was an influencing factor (age between 55-75 had a rating average of 1.68 [0.67-2.7] and age >75 years old 2.94 [1.70-4.18]). Hand function (RA 4.24 [3.40-5.08]), tremor (RA 3.77 [2.87-4.66]), visual handicap (RA 3.35 [2.13-4.56]) and decreased mobility of the patient (RA 3.05 [1.81-4.28]) were rated as factors influencing the decision to propose ISC to a patient.  Reduced mobility and impaired cognitive function were scored with a rating average of 3.04 [1.81-4.28] and 4.09 [3.06-5.12] respectively.

Decisive factors for not offering ISC to patients 
36% (n=46) of the respondents thought that patients refused ISC (RA 2.23 [1.96-2.51]). The statement that ISC was repulsive and invasive was scored with a rating average of 3.19 [2.17-4.20] and 3.39 [2.43-4.34] respectively. The need for time and for explanation to convince patients to perform ISC was not perceived as an issue for respectively 64.8% and 63.7% of the respondents (2.28 [1.19-3.45] and RA 2.32 [1.19-3.44]). 

Knowledge about ISC
75.8% (n=97) of the urologists considered their knowledge related to ISC to be sufficient, but 42.2% (n=54)reported that they would have offered ISC to more patients if they had had a better knowledge related to ISC.

Professional experience with iSC
When asked if urologists would be more eager to propose ISC to patients if they had a specialized nurse at their disposal, 33.0% of the study population fully agreed (RA 1.87 [1.08-2.66]). 14.9% of the participants thought that they would consider teaching self-catheterization to more patients if they had some kind of financial compensation (RA 2.03 [0.90-3.17]).

ISC as a treatment option for themselves
Only 32.8% of the respondents disagreed with the fact that ISC was considered ‘invasive’ (RA 2.53 [1-5]) (4.7% (n=6) fully disagree). 25.8% (n=33) of the questioned urologists did not find ISC repulsive (RA 1.99 [1-5]).
When asked what kind of catheterization they would have preferred for themselves, 97.7% would choose self-catheterization, and nobody would choose an indwelling catheter.

It is clear that age has to be considered when proposing ISC. The self-catheterization becomes less convenient with age due to co-morbidities (e.g. tremor, vision impairment) or loss of the skills needed to perform ISC. Performing ISC involves a number of key skills: organizational skills (preparation of materials), broad motor skills (when and how to sit and stand), fine motor skills (hand dexterity), and sensory input (perception and interpretation of sensory input). The survey shows that, in order of importance, impaired hand function, tremor and decreased vision are factors that influence the decision to propose ISC. 
Factors such as mobility and central obesity may interfere with positioning for introducing the catheter into the urethra. Our results show that diminished mobility is perceived as less important than fine motor skills. 
A major part of the urologists thinks that patients perceive ISC as invasive and repulsive but patients report the self-catheterization as easy, mostly painless, not interfering with their daily life activities and a serious improvement of their life quality.
Two out of ten urologists think that a financial compensation would give them more incentive to propose ISC to patients. More than half of the participants think they would offer ISC to more patients if they had a specialized nurse to their disposal. 
It is clear from this survey that not only financial factors play a role, but also the presence of expertise and time for a qualitative ISC care. This indicates the need for training courses and dedicated nurses.

In order of importance, impaired hand function, tremor and decreased vision are factors that are of paramount importance in the decision to propose ISC to patients. Other factors include cognitive status of the patient, impaired mobility and older age. A surprisingly high number of urologists still think that patients perceive this procedure as invasive and repulsive, but this perception is not supported by literature. A financial compensation for ISC is desirable, but it is clear that not only financial factors play a role, but also the presence of expertise and time for qualitative ISC care. Herein lays a potential role for dedicated nurses.