ORIGINAL ARTICLE

Urinary tract infection: under treated and investigated: an examination

of the nursing management of urinary tract infections in nursing home

residents experiencing impaired cognition

Sue Brown RN, DN

School of Nursing, Midwifery and Nutrition, James Cook University, Cairns, Qld, Australia

Rhonda Nay BA, MLitt, PhD, RN

Gerontic Nursing Clinical School, Latrobe University, Melbourne,Vic., Australia

Submitted for publication: 9 February 2006

Accepted for publication: 29 November 2006

Correspondence:

Sue Brown

James Cook University (Cairns Campus)

PO Box 6811

Cairns

Qld 4870

Australia

Telephone: þ61 7 4042 1488

E-mail: sue.brown@jcu.edu.au

BROWN S. & NAY R. (2007)BROWN S. & NAY R. (2007) International Journal of Older People Nursing 2,

20–24

Urinary tract infection: under treated and investigated: an examination of the

nursing management of urinary tract infections in nursing home residents experi-

encing impaired cognition

This research in nursing management of urinary tract infections in nursing home

residents experiencing impaired cognition was informed through qualitative nat-

uralistic enquiry. The findings suggest the response to this infective process lacks

cohesive planning and the dearth of available evidence concerning the nursing

management in this cohort has the potential to lead to detrimental health outcomes.

The study exposes the complexities of issues which impact on satisfactory outcome.

Key words: cognitive impairment, dementia, nursing home, urinary tract infection

Introduction

Symptoms of a urinary tract infection (UTI) in the cognitively

impaired older adult residing in a nursing home often present

with an increase in confusion, disorientation or altered

behaviour patterns. Accurate diagnosis and treatment may be

hindered due to an inability by the client to articulate

symptoms or participate in urinary health maintenance strat-

egies. A recent systematic review of current literature con-

firmed the deficit of nursing research concerning this issue and

in response to these findings a qualitative study was initiated to

investigate nursing management of the infective process

focusing on Registered Nurses (RN) directly responsible for

client care (Brown, 2001). Through naturalistic inquiry,

narrative data were collected and thematically analysed,

informed by Heideggerian–Gadamerian hermeneutic traditions.

The incidence of UTI on mortality and morbidity is

difficult to isolate. Data recorded on death certificates for

example often fails to enumerate the co-morbid conditions,

including those of neuro-degenerative diseases which have an

impact on mortality (Solomon, 1999). It is increasing

acknowledged globally that neuro-degenerative diseases rise

exponentially with an increasing lifespan and additional co-

morbidity also increase with age (Aguero-Torres et al., 2004).

In Australia, estimates of people living in nursing homes,

suffering from cognitive impairment vary from 54% to 90%,

whilst the majority of clients in residential care exhibit

multiple chronic degenerative conditions (Flicker, 2000).

These clients represent approximately 6% of the population

over the age of 70 years who required a high level of care

(Pearson et al., 2001). For the purposes of wider communi-

cation the Australian term ‘high care aged care facilities’ will

be replaced by the common usage term ‘nursing home’.

Methods

Naturalistic enquiry is a qualitative approach which explores

an issue in the context of the ‘real’ world. Hermeneutics is

20 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

concerned with the interpretation and the necessity to

mediate between practical and theoretical knowledge. It was

used here to discover if the theory related to UTI management

was congruent with nursing culture and client requirement.

By gathering and interpreting data from RN through focus

groups and interviews, the nursing management of UTIs from

the perspective of this sample emerged.

Design and sample

After gaining the ethics approval from the university and the

nursing homes who agreed to be involved in the study,

advertisements were posted for a convenience sample, invi-

ting RN in specific facilities to a focus group at a place and

time determined by the potential participants during prior

contact. The sample was restricted to those RN with currency

of practice in a nursing home environment but due to the

recruitment issues no limits were set as to the participant’s

length of experience in the industry. However, the average

duration of the participants’ aged care specific practice was

10.6 years. Staff shortages and turnover reduced the capacity

to attend focus groups so individual interviews were also

offered. A total of 19 nurses from 10 homes volunteered to

participate in the study of which two were male and 17

female; 14 attended focus groups and five participated in

individual interviews. The majority of the participants

worked in nursing homes with 30–40 bed occupancy. Focus

groups and the individual participants were assigned numbers

and letters to preserve anonymity.

Data collection

The principle researcher was a RN currently caring for

older adults and therefore had the potential to understand

and impose prior knowledge. It was therefore necessary to

work in a continuing partnership with those supplying data

(Guba & Lincoln, 1981). The trustworthiness and cred-

ibility of the content was assessed by sending transcripts

and emerging themes to participants for ratification and to

an external reviewer with relevant methodology experience

who evaluated texts and the emerging themes for con-

gruence. The themes were supported by examples from

the data and a further audit of literature raised issues

which demonstrated certain anomalies between theory and

practice.

Data analysis

The 19 participants involved in the study offered rich data

and their observations are used to support the themes which

were identified. All the interviews commenced with the

question asking how RN manage UTI in the cognitively

impaired resident, the data were transcribed within 2 days by

the researcher following interview or focus group in an

attempt to capture the gestalt of the data not merely

transposing the oral words to written text. Coding of the

themes within the data was continuous and sub-themes

emerged which were collapsed into major themes converging

into a core category ‘balancing act’.

Findings

Various themes were exposed throughout the data and were

succinctly expressed by the comment, ‘there is no one correct

way of going about what you should be doing’ (10a). The

first theme identified was termed the ‘shopping trolley effect’

coined and accepted as a term in a context where a variety of

resources were available but chosen randomly, individually

and without logical sequence often unsupported by evidence.

It was clearly stated throughout the data that there was a

presumption of a causal link between fluid intake and

potential for infection. ‘In winter you would not expect them

(residents) to be getting as much fluid as they would in

summer and then at the other end in summer they are not

getting enough because it is so hot and they are getting more

dehydrated’ (1b). This belief was partially supported by data

collated concerning UTIs in a nursing home which demon-

strated ‘last year urinary tract infection rates peaked in May

(Winter) and then dropped right down and from August to

November’ (Spring) ‘There were only two people that had it’

(5). Variation such as environmental temperature control,

urogenital integrity and overall health status which also

impact on outcomes was not linked to care planning. One

participant noted that the long held response to a UTI of

‘push fluids’ could be best summed up in this cohort as

‘presenting optimal fluids in a 24-hour period as can be

realistic’ (1a). Or in another’s words ‘you cannot force fluids

down people who don’t want to drink’ (9a). Co-morbidity

such as cardiac conditions and swallowing deficits were seen

to constrain how much fluid could be ‘pushed’.

Contained in this theme was the use of largely untested

popular products such as cranberry juice (Brown & Nay,

2006). There is little evidence of either compliance or efficacy

in relation to the use of cranberry juice as a urinary antiseptic

and staff openly acknowledged that, ‘Cranberry juice is

pretty tart, they don’t like it and you break it up with water

and you reduce the efficacy and may be you make it too

weak’ (4) and ‘We have people who are on cranberry juice

who still have problems with infections’ (6). Despite these

observations many participants continued to offer the juice in

UTI: under treated and investigated

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 21

response to demands by family, significant others and

unlicensed care staff.

There was also wide variation in the way nurses recognized

the signs and symptoms of UTIs:

We tend to use our nose and look for changes in behaviour (3)

Instinct once you get to know the resident (5)

Tongue of course is always a goodie (1c)

More frequency of pads we go through (9a)

Gee, she’s a bit off (3)

Typical symptoms of UTI frequently reported in academic

and carer literature such as pyrexia, burning, stinging,

delirium were not mentioned by staff as diagnostic criteria.

The observations made by the RN, however, initiated the

decision to obtain a urine specimen forward analysis and/or

microscopic laboratory analysis, culture and sensitivity. The

decision-making process was demonstrated as one made by

the RN alone without sanction from the client’s doctor. The

process of obtaining a specimen from people with cognitive

impairment appeared challenging and was a key issue in both

focus groups and interviews. The methods, though varied,

could be consistently summed up by the comment that

specimens were obtained ‘with great difficulty’ (9a). Others

stated ‘we don’t try and get an MSU because it is impossible’

(5) but ‘you try to get a clean specimen’ (6). A further barrier

to obtain a specimen was noted by the frequency of ‘faecally

contaminated specimens’ (6). The need to obtain a specimen

appeared paramount despite these challenges ‘I have been

told various methods by various people nothing really

surprises me (as to) how you the get the specimen’ (3).

With the altered presentation of symptoms and difficulty in

obtaining a suitable specimen of urine for culture and

sensitivity, what constitutes asymptomatic bacteriuria in the

older client and treatments for UTIs needs further research.

The findings of Kass, who more than 40 years ago, conducted

trials on indigent pregnant women, demonstrated that

asymptomatic bacteriuria was a precursor to symptomatic

infection and significant illness holds little implication in this

cohort (Kass, 1959). The result of Kass’ trial, however, meant

there was an increasing trend when bacteriuria was con-

firmed to treat the client with antibiotics. This course of

treatment has been refuted in more recent studies, which

demonstrated that antimicrobial treatment had little efficacy

in the older population group with a simple diagnosis of

bacteriuria (Abrutyn et al., 1996; Levin, 1997; McMurdo &

Gillespie, 2000). If the shopping trolley approach is reflective

of common practice, cognitively impaired older people with

UTIs are not receiving quality care.

Turf wars

This theme ‘turf wars’ exposed the difficulties of balancing the

various stakeholder’s needs and directives concerning inter-

ventions and treatments. Different role perceptions and

tensions between nurses and doctors impacted adversely on

care. There was a perceived lack of support or acknowledge-

ment given by medical colleagues, ‘the doctor will say she’s

old, she has a lot of UTIs, stick her on Amoxil’ (1b). There was

also tension concerning acknowledgement of professional

knowledge, ‘I can see that the resident is quite distressed and

the specimen has shown up as nitrates and whatever … and

it’s Friday! … I sort of say can we commence her on something

because we are not going to get it (the specimen) back before

Monday and she really is going to get a lot worse’ (3).

Having initiated the collection of a specimen, formed a

decision as to whether to send the sample for further

analysis, received the results of laboratory finding, and

liaised with the pharmacist concerning drug therapy, many

RN were frustrated by the lack of acknowledgement of their

role and the need for a doctor to legitimize their decisions.

‘Sometimes we have finished the course of treatment before

we get a (doctor’s) signature and we should not be giving

the medications’ (4).

Lack of professional recognition from families was also

noted by the nurses ‘They (family) don’t think our profes-

sional skills are adequate. We must be seen to be calling in

these allied health people to come and confirm the diagnosis

and this is, you know, sometimes policy. I think we have lost

the plot a little bit’ (3). It was also anticipated by families that

only the doctor could effect treatment. ‘They expect the

doctors to be called if there is behavioural change. They will

ask if the doctor has been notified’ (4). This was felt as

de-valuing nursing input and had the potential to initiate a

treatment response to appease family and friends even when

it was known to be futile.

Paper chase

The third theme ‘paper chase’, related to the reporting

mechanism required in Australia to justify government

funding. The current reporting system remains open to

interpretation, is contentious, and beyond the scope of this

paper but many participants felt there was no correlation

between the care documentation and care delivery. There

were also numerous examples of dissatisfaction as to the lack

of scope to exercise professional judgement citing one

example ‘I do not like our care plans, they are too

prescriptive’ (2d). However, on the upside one contributor

noted ‘I think the introduction of the infection control

S. Brown and R. Nay

22 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

register in the front of the medication chart where we have a

list of everybody on antibiotics so you can look at when its

was commenced, completed and resolved or not resolved, has

been a good addition’ (3).

Catch phrases

The final theme ‘catch phrases’ resonates throughout aged

care. ‘Push fluids’ is a typical example, however, participants

also noted house keeping routines such as leaving a water jug

on the resident’s locker without consideration as to if or how

it might be accessed. They also noted that: ‘they (residents)

can’t be bullied into drinking’ (1c). Most significant to the

topic under investigation was the concern that the catch

phrase: ‘confusion equals a UTI’ in many workplaces,

assumes that any alteration in behaviour is automatically

linked to a UTI. This can result in under diagnosis and

treatment of other conditions and symptoms. ‘I don’t think

that (altered behaviour) is necessarily indicative of a UTI even

if there is a presence of bugs in the urine because I think this

whole thing has a clinical significance which is important;

there could be many other variables for change in behaviour

that is what I am saying about a catch cry (sic) is, people say

there is a change in behaviour and that person has a UTI’

(10a).

Discussion

The core category ‘Balancing Act’ integrates the other

themes and explains how nurses are easily side-tracked by

the needs of other stakeholders rather than focussed on

providing an evidence-based nursing response. Advocacy on

behalf of the resident was recognized as important, but

responses were often overwhelmed by the expectations of

doctors and other health professionals, family, unlicensed

staff, and perceived documentation requirements. This

balancing effectively silenced the nurse’s voice and disad-

vantaged the resident. The overall effect was that the

response to a suspected UTI appeared to be randomly

chosen rather than based on assessment and knowledge. All

of the themes suggest a reactive, task-based approach to

care rather than critical analysis of data pertaining to a

specific client.

Without appropriate assessment and documentation, the

RN is unable to ascertain whether bacteria are a constant in

the urine of a specific resident or indicative of a UTI or if the

presenting signs and symptoms are suggestive of other

pathology. McMurdo and Gillespie, express concern that

non-specific symptoms including anorexia, malaise and

fatigue are often attributed to urinary infection and they

council that without clear clinical evidence supporting these

symptoms, other causes should be investigated before embra-

cing an antimicrobial response (McMurdo & Gillespie,

2000).

Most studies in UTIs and the older age group specifically

exclude those with dementia from the sample, and whilst

acknowledging there are many barriers concerning this

cohort’s inclusion, this omission leaves the care of an

increasing number of nursing home residents without an

evidence-base. Guidelines are required that reflect the

Maintenance• Team approach• Invitation to all

stakeholders to participate • Daily review until stable

FBC & bowel chartVital signsBehavioral changesMobility

• Commence client focused critical pathway of care.

Building on treatment • Assessment of daily review• Best options of treatment • Framework of continuing

care NutritionHydrationMobility Cognitive assessment

• Develop multidisciplinary client centered critical pathway.

Planning• Multidisciplinary • Diagnosis confirmation• CSU if possible• Catheter specimen if suitable • Alteration to care plan• Staff and significant

others education • Clear communication

lines.• Food/diet plan• Behavior modification plan

Data collection• Current practice initiatives• Clinical status

Vital signsUrinalysisConstipationDehydration

• Behavioral observation • Case history• Mini mental test or • Confusion assessment

method • Mobility assessment • Evidence based practice

guidelines

Figure 1 Nursing issues concerning diag-

nosis.

UTI: under treated and investigated

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 23

complexity of recognizing and treating UTIs in the presence

of co-morbid conditions, the financial and staffing con-

straints, and the fact that many nursing homes are isolated

from main stream health delivery. Nurses working in nursing

homes require contemporary knowledge, accessible evidence,

assessment skills and the confidence to make, implement and

justify evidence based decisions to generate professional

respect. If the focus of care is quality outcomes for the

resident, turf wars become irrelevant. Instead of managing a

difficult balancing act, nurses will be able to manage UTIs

and older people will benefit.

Recommendations

Figure 1 suggests the nursing issues concerning the diagnosis.

Due to the propensity for contamination of urine specimens

in this client population the definition of UTI, as more 10 000

bacteria/ml, should be modified. There is a further need to

assess and compare baseline urinalysis results to eliminate the

potential for persistent asymptomatic bacteruria. For the

purposes of this framework cognitive impairment is taken to

mean the presence of chronic or progressive impairment

which effect memory, orientation, parallel thinking, altered

communication and judgement but consciousness is not

clouded. It may present in combination with delirium and

depression.

Conclusion

The focus of this work was on in-depth understanding not

generalizability, however, it is expected that the emergent

themes will strike a cord with many in practice and allow

transferability to other settings. If it causes nurses to at least

question their current management of UTIs and encourages

further research it will have served nursing and older people

experiencing cognitive impairment and UTI.

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