3. METHODOLOGY
The Working Group has prepared this guidelines document to help nurses assess the evidence-based management and incorporate the recommendations into their clinical practice. These guidelines are not meant to be prescriptive, nor will adherence to them guarantee a successful outcome in all cases. Ultimately, decisions regarding care must be made on a case-by-case basis by healthcare professionals after consultation with their patients, using their clinical judgement, evidence-based knowledge, and expertise. The expert Working Group consists of a multidisciplinary team of nurse specialists, including Susanne Vahr Lauridsen (Chair), Veronika Geng (Vice Chair), Sajida Chagani, Anne Daniels, Therese Kelly, Marcin Popiński, Bente Thoft Jensen, Giulia Villa, Sally Wildeman, as well as urologist Ian Pearce. (see ‘About the authors’, Chapter 18).
3.1 Literature search
Informed by the main question “Is there any evidence for intermittent catheterisation and urethral dilatation for nursing interventions in different care situations such as preparation, insertion or care of intermittent catheters as well as catheter materials or complications?”, a structured search strategy was developed and the search was carried out by Yuhong Yuan, Department of Medicine, Hamilton Health Science Center, McMaster University, Hamilton, ON, Canada, commissioned by the European Association of Urology Nurses (EAUN).
The initial search was performed from inception until 5 November 2021 and an update search until 31 July 2023. Conference abstracts, study protocols, editorials, letters, comments, and case reports were excluded. In all databases, output was limited to human studies and English language publications.
Databases:
- EBM Reviews
- Cochrane Central Register of Controlled Trials
- Embase
- OVID Medline Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R)
- CINAHL
If a topic was not covered by the results of the search, references from the first edition were used.
Additional searches were not limited to any level of evidence. For chapter 12 on patient perspective, only qualitative studies were used. Occasionally, book chapters were also used.
The search was based on the main keywords “intermittent catheterisation”, “urethral dilatation”, “urethral stricture”, and “urinary retention”. For the detailed search strategy, please contact the EAUN at eaun@uroweb.org.
All publications identified from the searches were uploaded to Covidence systematic review software for removal of the duplicates. Then, all titles and abstracts were screened according to the predetermined eligibility criteria.
The title and abstract screening were performed independently by two panel members and any potentially relevant studies were forwarded for full-text screening. Assessments of full-text studies were conducted independently by all members of the guideline group and new references were included if they were relevant to the topic described in the guidelines.
3.1.1 Search results
The initial search in November 2021 resulted in 1433 abstracts from scientific publications (after removal of duplicates, abstracts and irrelevant results). After reading the abstracts, 273 were retained and full-text articles were made available to the Working Group. Of these, 49 articles were used in the guidelines. The update search in July 2023 resulted in 553 articles. From this search, 30 abstracts were selected for full-text assessment and 17 were included in the guidelines. The results are shown in the PRISMA Flow diagram below. [4]
In the process of working with the articles, 45 new references were found and added to the reference list, if they were relevant for the topic and cited in the text. Ninety-six references from the previous version of these guidelines (2013 edition) were retained and additionally, 1 article mentioned by a reviewer and considered useful by the Working Group, was included.
Diagram 1. PRISMA Flow diagram of the search
3.2 Limitations of the document
The EAUN acknowledge and accept the limitations of this document. It should be emphasised that the current guidelines provide information about the treatment of an individual patient according to a standardised approach. The information should be considered as providing recommendations without legal implications. The intended readership is pan-European practising urology nurses and nurses working in a related field.
Cost-effectiveness considerations are best addressed locally and therefore fall outside the remit of these guidelines. Other stakeholders, including patient representatives, have not been involved in producing this document.
The list of catheter companies mentioned in the guidelines is not intended to be exhaustive. The catheters highlighted are illustrative only, and nurses may use similar products from other companies not listed in the guidelines.
3.3 Rating system
The recommendations provided in these documents are based on a rating system modified from that produced by the Oxford Centre for Evidence-based Medicine: Levels of Evidence (March 2009). [5] All group members participated in the critical assessment of the scientific papers identified. Disagreements were solved by the Chair and Vice Chair.
Whenever possible, the Working Group has graded treatment recommendations using a three-grade recommendation system (A–C) and inserted levels of evidence to help readers assess the validity of the statements made. The aim of this practice is to ensure a clear transparency between the underlying evidence and a recommendation given. This system is further described in Tables 1 and 2.
Some of the literature was not easy to grade. However, if the Working Group thought that the information would be useful in practice, it was ranked as level of evidence 4 and grade of recommendation C. Low-level evidence indicates that no higher level evidence was found in the literature when writing the guidelines, but cannot be regarded as an indication of the importance of the topic or recommendation for daily practice.
The literature used in these guidelines included qualitative research, but because there was no systematic ranking for these types of studies, the qualitative studies were all graded level 4.
The Working Group aims to develop guidelines for evidence-based nursing, as defined by Behrens (2004): “Integration of the latest, highest level scientific research into the daily nursing practice, with regard to theoretical knowledge, nursing experience, the ideas of the patient and available resources”. [6] The group based the text on evidence whenever possible, but if evidence was missing, it was based on best practice. Most of the text in the appendices is based on expert opinion.
Four components that influence nursing decisions can be distinguished: personal clinical experience of the nurse; existing resources; patient wishes and ideas; and results of research. [7] This statement implies that although literature is important, the experiences of nurses and patients are also necessary for decision-making. Subsequently, it is not only the written guidelines that are relevant for nursing practice.
Fig. 1 The four components that should be included in evidence-based nursing practice
Adapted from Tammy Hoffmann, Sally Bennett, Chris Del Mar Introduction to evidence based practice Chapter one – Nurse Key https://nursekey.com/introduction-to-evidence-based-practice/
Table 1. Level of evidence (LE)
| LE | Type of evidence |
| 1a | Evidence obtained from meta-analysis of randomised trials |
| 1b | Evidence obtained from at least one randomised trial |
| 2a | Evidence obtained from one well-designed controlled study without randomisation |
| 2b | Evidence obtained from at least one other type of well-designed quasi-experimental study |
| 3 | Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies, and case reports |
| 4 | Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities* |
Table 2. Grade of recommendation (GR)
| Grade | Type of evidence – Nature of recommendations |
| A | Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial |
| B | Based on well-conducted clinical studies, but without randomised clinical trials |
| C | Made despite the absence of directly applicable clinical studies of good quality |
3.4 Review process
A blinded review was carried out by specialised nurses, urologists in various countries, and a patient organisation representative. The Working Group revised the document based on the comments received and included relevant references received (also from after the search period). A final version was approved by the EAUN Board and the EAU Executive responsible for EAUN activities.
3.5 Disclosures
The Working Group members have provided disclosure statements of all relationships that might be a potential source of conflict of interest. The information has been stored in the EAU database. This guidelines document was developed with an unrestricted grant from Coloplast and Wellspect.
The EAUN is a non-profit organisation and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have been provided.