Healthcare professionals' knowledge, attitudes, and practices in preventing catheter-associated urinary tract infections: a cross-sectional study in a rehabilitation facility

Summary

Background

Catheter-associated urinary tract infections (CAUTIs) are prevalent yet preventable healthcare-associated infections. Effective prevention requires healthcare professionals (HCPs) to possess adequate knowledge, positive attitudes, and adherence to best practices.

Objective

To evaluate the knowledge, attitudes, and practices (KAPs) of HCPs regarding the prevention and management of CAUTI in a Maltese rehabilitation facility.

Methods

A cross-sectional survey was conducted with a self-administered online questionnaire from January to March 2023, using total population sampling of doctors, nurses, and nursing assistants (N = 315). Descriptive and inferential analyses were conducted using SPSS.

Results

Of the 315 HCPs invited, 215 responded (68.3%). KAP levels towards CAUTI prevention were moderate to adequate. The attitude scores of doctors and nurses varied significantly based on nationality (P = 0.011), professional designation (P = 0.010), and educational level (P<0.001). Positive correlations were identified between CAUTI knowledge and practices among doctors' and nurses' (P=0.002, r = 0.309). For nursing assistants, significant differences were observed across knowledge (P<0.001), attitude (P<0.001), and practice scores (P<0.001), based on age, educational level, job experience, and timing of their last infection prevention and control training. Positive correlations were observed between knowledge and attitudes (P<0.001, r = 0.471), knowledge and practice (P<0.001, r = 0.383), and attitudes and practice (P<0.001, r = 0.403) for nursing assistants.

Conclusions

HCP knowledge and attitudes directly influence CAUTI prevention practices. Continuous education and targeted training programmes are critical to improving practices and reducing CAUTI-related patient harm.

Introduction

Patients exposed to indwelling urinary catheters face an increased risk of developing catheter-associated urinary tract infections (CAUTIs), which are a major subset of healthcare-associated infections (HAIs). CAUTIs contribute substantially to patient morbidity, extended hospital stays, and increased healthcare costs worldwide [1,2]. According to the most recent European point prevalence survey (2022–2023), healthcare-associated urinary tract infections, including CAUTIs, accounted for 19.2% of all reported HAIs, making them the second most common type [3].

Despite their prevalence, up to 69% of CAUTIs are considered preventable through adherence to evidence-based infection prevention and control practices [4]. Effective prevention requires addressing a complex set of modifiable, interrelated behaviours performed by multiple healthcare professionals (HCPs). This presents an opportunity to implement preventive strategies, such as ensuring hand hygiene when indicated, catheter insertion only when clinically indicated, adhering to aseptic insertion procedures, maintaining catheters appropriately, and removing them promptly [5,6].

Persistent knowledge–practice gaps in urinary catheter care highlight the need for comprehensive knowledge and a positive attitude among HCPs [6]. The Theory of Planned Behaviour has established the link between attitudes and practices, emphasizing the importance of fostering a proactive attitude towards CAUTI prevention among HCPs.

Ensuring that HCPs are well-trained and competent in catheter insertion and maintenance, including preserving a closed drainage system, is essential for safe catheter care and reducing CAUTI risk [7,8]. Equipping HCPs with evidence-based knowledge enables them to critically evaluate catheter use and address inappropriate indications [9].

While existing research has addressed the knowledge, attitudes, and practices (KAPs) of physicians and nurses in CAUTI prevention, their role and contributions in long-term and rehabilitation settings, as well as the specific role of nursing assistants, remain insufficiently explored. This study aims to address these gaps by exploring the knowledge, attitudes, and perceived practices of HCPs, including nursing assistants, in a Maltese rehabilitation healthcare setting. The study seeks to answer the question: what are the knowledge, attitude, and perceived practices of HCPs regarding CAUTI prevention and how are these aspects influenced by demographic factors?

Methods

Study design and context

A cross-sectional survey was conducted using self-assessment questionnaires. Data collection occurred between February and March 2023 in a rehabilitation healthcare facility specializing in the treatment of adults and older adults recovering from postorthopaedic, musculoskeletal, and neurological injuries as well as post-acute medical issues. The target population consisted of HCPs, including doctors (N = 23), nurses (N = 130), and nursing assistants (N = 162), amounting to a total of 315 HCPs employed at the facility. A total population sampling approach was employed. Based on the overall population size (N = 315), it was calculated that a minimum sample size of 174 participants was required to achieve statistical results with a 95% confidence level, and 5% margin of error.

Study questionnaires

Two semi-structured questionnaires were employed to evaluate the KAPs of HCPs regarding CAUTI prevention. The first questionnaire, adapted from Balu et al. [10], was administered to doctors and nurses and included four sections: (i) demographic characteristics (five items), (ii) knowledge (11 items), (iii) attitudes (seven items), and (iv) perceived practice (seven items) (Supplementary data A).

The second questionnaire, developed by the research team, was designed specifically for nursing assistants and comprised four sections: (i) demographic characteristics (four items), (ii) knowledge (10 items), (iii) attitudes (12 items), and (iv) perceived practice (16 items) (Supplementary data B). Both instruments underwent rigorous content and face validity assessment by a panel of four subject-matter experts. To assess the feasibility of the data collection process, a pilot study involving 16 participants was conducted. The newly developed questionnaire for nursing assistants was re-tested following a two-week period to assess its stability through test–retest reliability. Internal consistency was evaluated using Cronbach's alpha.

Ethical considerations

This study received ethical approval from the Faculty of Health Sciences Research Ethics Committee at the University of Malta (reference no: FHS-2022-00302). In addition, approval was granted by the Research Committee of the rehabilitation healthcare facility. Prior to data collection, permission to utilize the research instrument developed by Balu et al. [10] was secured. Participants were provided with an information letter outlining the study's purpose and procedures. To maintain anonymity, no personally identifiable data were collected. Participation was voluntary, and informed consent was inferred through the completion of the online questionnaire.

Statistical analysis

The completed questionnaires were exported from Google Forms and analysed using the Statistical Package for Social Sciences (SPSS) version 28.01. Responses were systematically coded: items with response options ‘agree’, ‘I do not know’, and ‘disagree’ were coded as 1, 2, and 3, respectively. Binary response items (‘agree’ or ‘disagree’) were assigned values of 1 and 2. For questions employing a five-point Likert scale, responses ranged from ‘strongly agree’ (coded as 1) to ‘strongly disagree’ (coded as 5). Negatively worded items were reverse-coded to ensure consistency across scales.

For both questionnaires, a total score for each KAP section was computed by summing each participant's responses within the respective section, provided that all items were completed. Internal consistency of each KAP section for both questionnaires was assessed, yielding Cronbach's alpha values above 0.5, indicating satisfactory reliability (see Table I).

Table I.

Descriptive and reliability statistics on the total scores for each knowledge, attitudes, and practices (KAP) section

	Doctors and nurses			Nursing assistants
	Knowledge total	Attitude total	Practice total	Knowledge total	Attitude total	Practice total
Mean score	14.91	16.50	11.23	15.83	13.61	18.39
Standard deviation	3.35	3.55	3.16	3.62	2.11	2.33
Lowest (best) possible score	11	7	7	10	12	16
Lowest (best) achieved score	11	7	7	12	12	16
Highest (worst) possible score	33	35	35	30	24	32
Highest (worst) achieved score	31	28	19	26	20	24
Adequate range, frequency	11–18, 89.6%	7–16, 47.9%	7–16, 92.7%	10–16, 74.8%	12–15, 84.3%	16–21, 86.2%
Moderate range, frequency	19–25, 8.3%	17–25, 51.0%	17–25, 7.3%	17–23, 18.5%	16–20, 15.7%	22–26, 13.8%
Inadequate range, frequency	26–33, 2.1%	26–35, 1.0%	26–35, 0%	24–30, 6.7%	21–24, 0%	27–32, 0%
Items' Cronbach's alpha	0.604	0.518	0.597	0.744	0.776	0.711

Descriptive statistics, including frequencies, means, and standard deviations, were employed for dataset summarization (Supplementary data C, D). Given that normality tests indicated non-normal distribution, non-parametric statistical tests were used. Inferential analyses were conducted using the Kruskal–Wallis, Mann–Whitney, and Spearman's rank correlation tests to identify significant associations between total KAP scores and to explore the impact of demographic variables on these scores.

Results

The study population comprised 23 doctors, 130 nurses, and 162 nursing assistants. Of these, 12 (52.1%) doctors, 84 (64.6%) nurses, and 119 (73.5%) nursing assistants completed the questionnaire, resulting in an overall response rate of 68.3% (N = 215). The majority of respondents were aged between 26 and 35 years (n = 97, 45.1%) and most were female (n = 161, 74.9%). Nursing assistants represented the largest subgroup of respondents (n = 96, 44.7%), and 28.8% (n = 62) of participants reported having more than 10 years of professional experience. A high proportion of participants had received training in IPC (n = 180, 83.7%) as well as specific training on the prevention of CAUTI (n = 171, 79.5%) during their professional education. Most participants (n = 185, 86%) reported receiving IPC training at their current workplace (see Table II for demographic results).

Table II.

Healthcare professionals' demographic characteristics

Demographic characteristics	Doctors		Nurses		Nursing assistants
	Frequency (n)	Per cent (%)	Frequency (n)	Per cent (%)	Frequency (n)	Per cent (%)
Age (years)
18–25	1	0.47	3	1.4	19	8.84
26–35	8	3.72	55	25.58	34	15.81
Over 35	3	1.4	26	12.09	66	30.6
Gender
Male	3	1.4	19	8.84	32	14.88
Female	6	2.79	65	30.23	90	41.86
Nationality
Maltese	12	5.58	60	27.9	39	18.14
Non-Maltese	0	0	24	11.16	80	37.21
Designation
Care worker	-	-	-	-	96	44.6
Nursing assistant	-	-	-	-	23	11
Staff nurse	-	-	41	19	-	-
Senior staff nurse	-	-	28	13	-	-
Practice nurse	-	-	5	2.3	-	-
Charge nurse	-	-	10	4.6	-	-
Foundation year doctor	2	0.9	-	-	-	-
Basic specialist trainee	2	0.9	-	-	-	-
Higher specialist trainee	5	2.3	-	-	-	-
Consultant	3	1.4	-	-	-	-
Professional experience
<6 months	0	0	1	0.47	22	10.23
6 months to 2 years	2	0.93	2	0.93	31	14.42
3 years–6 years	3	1.4	24	11.16	25	11.63
7–10 years	4	1.86	26	12.09	13	6.05
>10 years	3	1.4	31	14.42	28	13.02
Educational level
Certificate	-	-	-	-	64	53.8
Diploma in care	-	-	-	-	55	46.2
Diploma in nursing	-	-	24	25	-	-
Undergraduate degree	1	1.04	21	21.88	-	-
Postgraduate degree	11	11.46	39	40.62	-	-
Award location
Malta	-	-	-	-	63	52.9
Abroad	-	-	-	-	56	47.1
Course duration
0–3 months	-	-	-	-	20	16.8
3–6 months	-	-	-	-	38	31.9
6 months to 1 year	-	-	-	-	61	51.3
Received IPC Training during the course to qualify as an HCP	10	83.3	77	91.7	92	77.3
Received CAUTI prevention training during the course to qualify as a HCP	9	75	76	90.5	86	72.3
IPC training received at the current workplace	10	83.3	78	92.6	97	81.5
IPC training last received
Never	1	8.3	4	4.7	13	11
0–3 months ago	3	25	13	15.5	37	31.1
7 months to 1 year ago	0	0	14	16.7	23	19.3
1–3 years ago	6	50	39	46.4	26	21.8
>3 years ago	2	16.7	14	16.7	20	16.8

CAUTI, catheter-associated urinary tract infection; HCP, healthcare professional; IPC, infection prevention and control.

Knowledge regarding indwelling catheter care practices

The mean knowledge score regarding CAUTI prevention for doctors and nurses was 14.91 ± 3.35 (standard deviation, SD), reflecting an adequate level of knowledge (see Table I). A majority of doctors and nurses correctly identified females and elderly patients as high-risk groups for CAUTI (n = 77, 80.2%). Essential preventive measures, such as timely removal of urinary catheters (n = 70, 72.9%) and securing catheters to prevent displacement (n = 94, 97.9%), were widely recognized. Additionally, 81.3% (n = 78), acknowledged the importance of daily hygiene of the urethral meatus and urinary catheter, while 78.1% (n = 75) were aware that the risk of CAUTI increases with prolonged catheter duration. There was a limited emphasis on the use of lubricants from Supplementary Table C1).

For nursing assistants, the mean knowledge score was 15.83 ± 3.62, indicating an adequate level of knowledge overall (see Table I). A large proportion (n = 115, 96.6%) demonstrated awareness that CAUTIs are among the most prevalent HAIs and recognized the importance of maintaining urinary catheter bags below the level of the bladder. Low awareness of specific guidelines for urinary catheter care was identified (n = 82, 68.9%) (Supplementary Table D1).

Perceived attitudes toward CAUTI prevention

Attitudes toward CAUTI prevention were predominantly positive across all groups of HCPs (see Table I). The majority of doctors and nurses (n = 72, 75%) affirmed that urinary catheter renewal reminders are advantageous in reducing catheter days. Conversely, only 32 respondents (33.3%) disagreed with the practice of performing routine urine cultures for asymptomatic bacteriuria in patients with indwelling catheters (Supplementary Table C1).

For nursing assistants, 97 participants (84.3%) demonstrated favourable attitudes (score 12–15), while 18 (15.7%) showed moderately favourable attitudes (score 16–20). Almost all nursing assistants (n = 117, 98.3%) identified CAUTI prevention as an integral component of their professional responsibilities, and 97.5% (n = 116) acknowledged the critical importance of hand hygiene in reducing the risk of CAUTI. However, a small proportion of respondents (13.4%) reported that time constraints posed a barrier to consistently changing gloves between patients (Supplementary Table D1).

Self-reported practices in CAUTI prevention

The mean practice score for doctors and nurses was 11.23 ± 3.16, indicating an adequate level of adherence to recommended practices (see Table I). Almost all respondents (n = 95, 99%) reported consistent use of catheters with the smallest feasible diameter to minimize urethral trauma, and 93 (96.9%) adhered to the guideline of positioning the urinary catheter bags below bladder level. Only 71 respondents (74%) consistently maintained a sterile, continuously closed urinary catheter drainage system. A high majority (n = 114, 95.8%) of nursing assistants agreed with the routine changing of urinary drainage bags (Supplementary Table C1).

For nursing assistants, the mean practice score was 18.4 ± 2.3, also indicating an adequate level of adherence to recommended practices (see Table I). Hand hygiene before and after managing indwelling urinary catheters was reported by 86.2% (n = 100), while almost all nursing assistants (n = 117, 98.3%) ensured that gloves were changed between patients (Supplementary Table D1).

Figure 1 illustrates the distribution of KAP scores among doctors, nurses, and nursing assistants. It is important to interpret these comparisons with caution, as different instruments were used for data collection across the groups.

Figure 1.

Total scores of healthcare professionals' knowledge, attitudes and practice towards catheter-associated urinary tract infection prevention total scores.

Analysis of knowledge, attitudes and practices by demographic variables among healthcare professionals in CAUTI prevention

The analysis revealed no statistically significant differences in the knowledge and practice scores of doctors and nurses across demographic variables. However, their attitude scores varied significantly based on nationality, professional designation, and educational level (Table III). The Mann–Whitney test (Table IV) showed that Maltese doctors and nurses reported more favourable attitudes compared with their non-Maltese counterparts. Bonferroni-adjusted pairwise comparison tests (Table IV) indicated that professionals with a diploma had less favourable attitudes than those with undergraduate or postgraduate degrees. Pairwise comparisons for professional designation did not reveal statistically significant differences between groups.

Table III.

Results for tests of significant differences by demographic variables (bold P-values are significant)

Variable	Doctors and nurses						Nursing assistants
	Knowledge total		Attitude total		Practice total		Knowledge total		Attitude total		Practice total
	Test statistic	P	Test statistic	P	Test statistic	P	Test statistic	P-value	Test statistic	P	Test statistic	P
Age	3.959	0.138	3.013	0.222	0.492	0.782	30.559	<0.001	39.072	<0.001	38.438	<0.001
Gender	3.224	0.073	0.294	0.588	3.131	0.077	0.363	0.547	0.725	0.394	0.105	0.746
Nationality	0.015	0.901	6.547	0.011	0.482	0.487	2.327	0.127	4.502	0.34	2.889	0.089
Designation	6.436	0.490	18.544	0.010	12.984	0.073	0.781	0.377	0.911	0.340	0.367	0.545
Educational level	2.337	0.294	13.638	0.001	5.074	0.079	4.540	0.033	6.631	0.010	4.952	0.026
Job experience	3.002	0.557	5.624	0.229	3.391	0.495	30.975	<0.001	39.042	<0.001	25.888	<0.001
Was infection prevention and control included in your education and training to qualify as a HCP?	0.079	0.779	0.329	0.566	0.251	0.617	20.594	<0.001	16.821	<0.001	17.441	<0.001
Have you ever received education and training related to CAUTI as part of your qualification as a HCP?	0.337	0.561	0.129	0.720	0.891	0.345	0.683	0.409	1.796	0.180	1.264	0.261
Have you received education and training on IPC in your current job?	1.721	0.190	0.032	0.857	1.524	0.217	1.626	0.202	0.154	0.694	0.191	0.662
When did you receive the last training on IPC?	0.745	0.946	5.566	0.234	2.734	0.603	18.336	0.001	19.758	<0.001	13.520	0.009

CAUTI, catheter-associated urinary tract infection; HCP, healthcare professional; IPC, infection prevention and control.

Table IV.

Results for pairwise comparison tests (only significant results are presented for clarity)

Variable	Groups	Doctors & nurses			Nursing assistants
		Attitude total			Knowledge total			Attitude total			Practice total
		Mean rank	Test statistic	P	Mean rank	Test statistic	P	Mean rank	Test statistic	P	Mean rank	Test statistic	P
Gender	Male Female
Nationality	Maltese Non-Maltese	44.33 61.02	563.5	0.011
Educational level	Certificate Diploma				54.03 66.95	1378.0	0.033	50.97 66.23	1207.0	0.010	49.56 62.57	1101.0	0.026
	Diploma Undergraduate	66.08 41.95	24.128	0.010
	Diploma Postgraduate	66.08 42.46	23.620	0.001
IPC training received	Yes No				52.57 85.31	1925.5	<0.001	51.29 79.87	1778.5	<0.001	48.42 78.29	1579.0	<0.001
Age (years)	18–25 26–35				97.95 56.34	4.407	<0.001	99.42 49.65	5.456	<0.001	94.84 48.88	5.130	<0.001
	18–25 36–45				97.95 50.81	5.111	<0.001	99.42 51.22	5.366	<0.001	94.84 44.98	5.564	<0.001
	18–25 46–60				97.95 51.19	4.737	<0.001	99.42 48.09	5.411	<0.001	94.84 45.75	5.257	<0.001
Course duration	0–3 months 3–6 months							85.95 55.16	3.502	0.001
	0–3 months 6 months to 1 year				80.88 49.85	3.652	0.001	85.95 50.17	4.356	<0.001	70.83 47.27	2.817	0.015
Job experience	<6 months 6 months to 2 years							93.17 62.07	3.426	0.006	83.70 51.48	3.626	0.003
	<6 months 3–6 years				89.25 57.18	3.328	0.009	93.17 46.68	4.958	<0.001	83.70 52.66	3.328	0.009
	<6 months 7–10 years				89.25 55.35	2.940	0.033	93.17 35.46	5.162	<0.001	83.70 43.00	3.666	0.002
	<6 months >10 years				89.25 37.68	5.491	<0.001	93.17 47.61	4.943	<0.001	83.70 41.88	4.666	<0.001
	6 months to -2 years >10 years				63.63 37.68	3.019	0.025
IPC training date	0–6 months 7 months to 1 year				79.22 52.28	3.077	0.021				70.32 44.60	0.291	0.029
	0–6 months 1–3 years				79.22 50.35	3.422	0.006	76.94 47.83	3.572	0.004
	0–6 months >3 years				79.22 50.43	3.147	0.017	76.94 44.86	3.509	0.005

IPC, infection prevention and control.

For nursing assistants, significant variations were observed in knowledge, attitude and practice scores across several demographic factors, including age, educational level, course duration, job experience, receipt of IPC training during their studies, and the timing of their most recent IPC training (Table III). Pairwise comparisons (Table IV), demonstrated that nursing assistants aged 18–25 years had significantly lower knowledge, less favourable attitudes, and poorer practices compared with those aged 26–35, 36–45, and 46–60 years.

The Mann–Whitney tests indicated that nursing assistants with a certificate had significantly higher knowledge, more favourable attitudes, and better practices compared with those with a diploma. Those who completed a six-month to one-year course outperformed those with zero-to three-month courses in all domains, including KAPs. Furthermore, nursing assistants who completed a zero-to three-month course had less favourable attitudes than those completing a three-to six-month course.

Job experience significantly influenced the scores of nursing assistants. Those with less than six months of job experience showed lower knowledge, less favourable attitudes, and poorer practices compared with those with three to six years, seven to 10 years, and over 10 years of experience. Nursing assistants with six months to two years of experience had lower knowledge compared with those with over 10 years of experience. Additionally, those with less than six months of job experience demonstrated less favourable attitudes and poorer practices compared with those with six months to two years of experience.

Receipt of IPC training significantly impacted the scores of nursing assistants. Those who received IPC training demonstrated higher knowledge, more favourable attitudes, and better practices compared with those who did not receive training. The timing of IPC training was also a key factor. Nursing assistants who attended within the past zero to six months had lower knowledge scores compared with those who attended training seven months to one year ago, one to three years ago, or more than three years ago. Similarly, those trained within the past zero to six months exhibited less favourable attitudes than those trained one to three years, or more than three years ago, and poorer practices compared with those trained seven months to one year ago.

Intercorrelations among knowledge, attitude, and practice scores in CAUTI prevention

A significant positive correlation was observed between knowledge and practice scores among doctors and nurses (r = 0.309, P=0.002), indicating that greater knowledge was associated with better adherence to practices for CAUTI prevention. No other significant correlations were identified for doctors and nurses.

For nursing assistants, significant positive correlations were identified between knowledge and attitudes (r = 0.471, P<0.001), knowledge and practices (r = 0.383, P<0.001), and attitudes and practices (r = 0.403, P<0.001). These results suggest that higher levels of knowledge are positively associated with more favourable attitudes and improved practices, emphasizing the interconnected nature of these domains in CAUTI prevention.

Discussion

This study evaluated the knowledge, attitudes, and perceived practices of HCPs regarding CAUTI prevention in a rehabilitation facility. The evolving healthcare landscape, with shorter acute hospital stays and increased reliance on rehabilitation and long-term facilities, has introduced new challenges. Rehabilitation facilities now care for patients with higher medical complexity, often requiring acute care interventions and invasive devices such as indwelling urinary catheters. This shift increases the risk of HAIs, including those caused by antimicrobial-resistant pathogens [11,12].

The study findings revealed moderate to adequate KAP levels among HCPs, with demographic variables significantly influencing scores. Positive correlations were observed between knowledge and practice among doctors and nurses, and between all three KAP domains for nursing assistants. However, the strength of these correlations was modest to moderate (r = 0.309 to r = 0.471), suggesting that knowledge acquisition alone is insufficient to drive adherence to best practice. These results underscore the need for a comprehensive approach that integrates both organizational and individual strategies, including ongoing continuous development [13,14]. Saint and colleagues suggest that implementation of structured organizational protocols and the regular auditing of CAUTI outcomes are more effective in improving prevention practices than individual educational interventions alone.

We found limited awareness of guidelines for urinary catheter care management among participants. This finding aligns with previous research demonstrating that organizational context and systemic barriers, particularly limited access to guidelines and recommendations, play a role in shaping CAUTI prevention practices, extending beyond individual knowledge [5,13]. Structural and organizational challenges identified in previous studies include limited access to evidence-based guidelines at the point of care, inadequate systems for monitoring catheter duration, lack of standardized protocols for assessing the presence and the necessity of an indwelling catheter, and insufficient feedback mechanisms for CAUTI outcomes [15,16]. These organizational factors significantly impact process outcomes. Ongoing auditing and monitoring of CAUTI outcomes, with results visible to both staff and leadership, has been shown to be an effective strategy for preventing HAIs [17,18]. Educational efforts, while valuable, cannot address systemic issues such as leadership deficiencies or lack of evidence-based guidelines and infection prevention programmes [19,20].

We found gaps between evidence-based recommendations related to urinary catheters and HCPs KAP. For example, while most nursing assistants acknowledged the importance of maintaining a closed drainage system to prevent CAUTIs, 95.8% agreed with the routine changing of urinary drainage bags, which contradicts current guidelines recommending against this practice unless clinically indicated. Our findings mirror those of other institutions, reporting a lack of awareness of HCPs to maintain a closed drainage system [11,12,21]. Disrupting a closed urinary drainage system increases the risk of urinary tract infections and poses a threat to patient safety [13,14]. The deficiency in maintaining closed drainage systems, despite adequate knowledge scores, suggests organizational barriers to implementation [15].

Hand hygiene remains a cornerstone of IPC strategies and is widely recognized as an essential measure to prevent HAIs and combat antimicrobial resistance [[22], [23], [24]]. The findings showed a general awareness of hand hygiene recommendations among participants, indicating that this measure is well-integrated into urinary catheter care practices. Future research should focus on evaluating effectiveness of multi-modal approaches, particularly in rehabilitation or long-term-facility settings where extended urinary catheterization periods may be necessary. Investigation of the specific organizational barriers in the rehabilitation context could provide valuable insights for improving CAUTI prevention practices.

This study had limitations that require consideration when interpreting the findings. The cross-sectional design captured only a snapshot of KAP, preventing the establishment of causal relationships between the variables and understanding of how knowledge influences practice over time. The self-reported nature of data collection introduces potential social desirability bias, as participants may have overestimated their compliance with best practices. The absence of observational data to validate self-reported practices further limits the reliability of our findings. Data collection from a single rehabilitation hospital and the moderate response rate (68.3%) limit result generalizability. The use of different instruments for doctors/nurses versus nursing assistants complicated direct group comparisons. Further research is crucial to understanding the mechanisms of infections associated with urinary catheter care and management in long-term-care facilities, as well as to identifying optimal strategies for translating research into practice within these settings.

In conclusion, this cross-sectional study explored the knowledge, attitudes, and practices of healthcare professionals regarding CAUTI prevention in a Maltese rehabilitation hospital. Of the 315 HCPs invited, 68.3% responded. The findings demonstrated moderate to adequate KAP levels among participants. The modest correlations between knowledge and practice (r = 0.309 to r = 0.471) suggest that knowledge improvement alone may be insufficient for improving CAUTI prevention practices. Demographic variables such as educational level and professional experience showed an association with KAP scores, yet these relationships must be considered within broader organizational factors within healthcare facilities. Key recommendations include implementing systematic auditing processes, establishing clear organizational guidelines, promoting adherence to these guidelines, developing automated reminder systems, and ensuring leadership engagement in prevention efforts. Future research should evaluate the effectiveness of integrated approaches that address both individual competency and systemic barriers to CAUTI prevention in rehabilitation settings, particularly focusing on the development and implementation of sustainable organizational frameworks for infection prevention.

Sample CRediT author statement

Donatella Catania Muscat: Conceptualization, Methodology, Software Donatella Catania Muscat.: Data curation, Writing- Original draft preparation. Monique Sciortino: Visualization, Investigation. Ermira Tartari: Supervision.: Monique Sciortino: Software, Validation.: Donatella Catania Muscat; Ermira Tartari; Monique Sciortino: Data curation, Writing- Original draft preparation.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Appendix A. Supplementary data

The following are the Supplementary data to this article: