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Geriatric urology and the evolving role of the nurse practitioner.

Nurses at all levels provide frontline care for older adults in numerous settings that range from primary care to acute care to long-term care. The United States (U.S.) population continues to age, and it is estimated that by the year 2030, the percentage of the population over age 65 will reach at least 20.3% (Ortman, Velkoff, & Hogan, 2014), making the role of nurses in caring for older adults increasingly vital. As the population continues to age and live longer, the incidence of chronic disease and the need to manage chronic illness rises. Not only does this imply an emerging need for expert care in geriatrics in general, but this population growth has important implications for the intersection of urology and geriatrics. Urology is a specialty that will continue to see growth; this includes the domains of clinical care, access to care, care of genitourinary (GU) malignancy, education of other providers, and research focused on the urologic needs of older adults. There will be an increasing need for providers at all levels who are proficient in the care of voiding dysfunction, urinary tract infection, genitourinary malignancies, and urogynecology issues.

According to Bardach and Rowles (2012), there is a lack of geriatric-specific content across healthcare disciplines, influenced by the belief that the care of older adults does not require specific educational content. This includes within current nursing curricula, with many programs admitting to the challenge of including additional geriatric material, in part due to already busy curricula and few faculty members with geriatric expertise. Of the 222,000 nurse practitioners (NPs) in the U.S., gerontological NPs account for only 2.7% of all nurse practitioners, while adult-gerontology primary care NPs account for an additional 4% (American Association of Nurse Practitioners [AANP], 2016).

The Section for Enhancing Geriatric Understanding and Expertise Among Surgical and Medical Specialists (SEGUE) and American Geriatrics Society (AGS) discussed the projected need for education specific to the care of the geriatric population. Their 2011 white paper outlined the need for all healthcare specialties to adopt competencies appropriate to their specialty; it also highlighted the specialty care required by older adults (SEGUE & AGS, 2011). This geriatric patient population is characterized by the presence of simultaneous chronic diseases, multiple hospital admissions, polypharmacy, increased health service utilization, and the potential for reduced personal autonomy. The challenge in effective care for an aging population requires teamwork and an interdisciplinary approach.

The Nurse Practitioner and Expanded Specialty Practice

The Institute of Medicine (IOM) (2010) supports NPs working to the full extent of their training and NP expansion into specialty practice (such as urology or geriatrics), including support for the development and implementation of residencies or fellowships for APRNs across all practice settings. The IOM recommends examining metrics that measure expanded competencies and improvements to patient outcomes. The National Governors Association (NGA) (2012) created a position document that supports this ongoing expansion of NP scope of practice and unified licensing standards throughout the 50 states. This NGA document recognizes that the demand for primary care services in the U.S. is expected to grow and keep pace with the aging population. The increased demand is also as a result of the 2010 Patient Protection and Affordable Care Act (PPACA).

Recent estimates place approximately one-third of NPs in specialty clinical environments (i.e., specialty practices that are not solely based on the population-based focus of their primary certification) (Chattopadhyay, Zangaro, & White, 2015; Coombs, 2015; Health Resources and Service Administration [HRSA], 2014). Chattopadhyay et al. (2015) reported that 8.8% of NPs work in surgical specialties; however, specifics regarding individual specialties were not provided. These authors stated that NPs work in collaboration with physicians in a variety of practice environments, and were generally satisfied that "the duties of their principal position reflected the full scope of their NP capabilities and allowable scope of practice" (Chattopadhyay et al., 2015, p. 174) for the state in which they worked. The number of NPs in specialty environments, such as urology, is likely to rise significantly as the aging population continues to demand additional specialty services and facilities seek options to increase access.

Traditionally, the education of NPs has covered populations from an age-based perspective, but lacked attention to specific disease states while offering the added value and perspective of the nursing model. Recent literature suggests that due to the rapidly changing nature of contemporary health care, residency and fellowships for NPs will have increased significance (Bush & Lowery, 2016; Chaney, Harnois, Musto, & Nguyen, 2016; Harris, 2014), especially for areas that are not the focus of present NP curricula or the advanced practice registered nurse (APRN) consensus model, such as urology. Postgraduate fellowships may offer an option for formal education in specialty areas and may promote increased job satisfaction (Bush & Lowery, 2016), while respecting the boundaries of the generalist certification and original APRN consensus model population focus.

The Urology Nurse Practitioner

The division of advanced nursing practice into population foci occurred to meet the anticipated healthcare needs of the public. It resulted in the standardization of graduate-level curricula, but this has been to the detriment of specialties that concentrate on particular disease categories, such as urology. Primary care NPs provide care that focus on the whole person across his of her life span. NPs focusing on urology take their population focus one step further, providing patient care throughout the urology continuum, maintaining their expertise in assessment, diagnosis, and treatment, while focusing efforts toward GU symptom management and supportive care within the context of GU conditions. This is a natural expansion of the NP role: to focus on providing high-quality care not just to one specific population focus, but to provide that same high-quality care within an overlapping specialty population focus. In this context, it permits NPs to have a vital role in meeting both current and projected needs of patients needing GU care.

In an ideal scenario, graduate programs or post-graduate certificate programs would include didactic and clinical preparation in urology and qualify the NP to take the urology certification examination offered by the Certification Board for Urologic Nurses and Associates (CBUNA), which is not currently a requirement for employment in any urology clinical environment. Movement toward a standardization of urology education for NPs could occur through additions and specializations within current graduate education programs, but it can also happen through targeted continuing education programs or workshops. NPs will be a vital piece toward meeting the GU care needs of the aging population; their contribution and expertise can be guaranteed through both structured education and increased efforts of collaboration with urologists.

Urology is considered a "nontraditional setting" for nurse practitioners because there is no formal training or degree for urology nurse practitioners; most are family NP or adult NP certified (Quallich, 2011, 2016). This implies that additional education, "on the job" training, and continuing education are necessary in order to fill this specialty NP role. A focus in urology permits the NP to continue to be populationfocused within the care of GU patients and maintain consistency with the APRN model, while still adding the value and discipline of the nursing model. This implies the need for the ongoing partnership and innovation between advanced nursing education and advanced nursing practice to assure that NP curricula keep pace with the changing healthcare population as it ages.

Supporting the NP Role In Urology

The movement of NPs into urology is a function of acknowledging that the burden of urologic diseases in the U.S. continues to rise with its aging population. This is coupled with the fact that urologists as a group are older than other surgical specialists (Pruthi, Neuwahl, Nielsen, & Fraher, 2013). The average urologist is male and 55 years old; there are 3.9 urologists per 100,000 population; 62.7% of practicing urologists work with one physician extender (NP or physician's assistant [PA]) in their practice, while some report working with three or more (American Urological Association [AUA], 2016). The AUA (2014) estimated there were 3,338 NPs working in urology practices and institutions across the U.S., and the growth of the NP workforce will continue to outpace the growth of the urologist workforce. Urologists outside of academic settings have been slower to embrace inclusion of NPs as providers of high-quality urology care, influenced by the debate over which procedures (e.g. cystoscopy or prostate biopsies) are appropriate for NPs to perform. There is a clear role for NPs in addressing patient care and continuity deficits created by decreased resident and fellow work hours by improving access, continuity of care, and throughput.

The urologist workforce continues to age and retire at a rate that outpaces the number of urology residents that complete their training and achieve board certification. This has created a looming gap in the workforce trained to care for urology patients with both acute and chronic urologic conditions. The AUA, as outlined in a 2014 white paper, supports incorporation of both NPs and PAs into urology practices, with the urologist functioning as leader of the team. While the 2014 AUA white paper recognizes the demand for healthcare services is likely to change over the next decades and endorses the inclusion of NPS and PAs, it maintains the traditional hierarchical model of health care, with physicians as "captains of the ship." This is in conflict with the position of AANP, which states that the role of the NP on the healthcare team can include a leadership position (AANP, 2015).

There is sparse data on outcomes and NPs in surgical environments, but NPs can efficiently bridge the access gap for urology patients, especially in environments where the surgeon is only available one or two days a week. NPs can evaluate, initiate management, order imaging evaluations, and then proceed to manage patients independently once it is determined that surgery is not necessary. NPs have a clear role in autonomously evaluating patients to increase surgeon productivity. This approach is consistent with the IOM (2010) report that stresses interprofessional collaboration, which is directly linked to improved outcomes and states "all healthcare professionals should be educated to deliver care as part of interdisciplinary teams" (p. 48).

The Future and the NP Role In Urology

Undertreatment of chronic urologic conditions creates a risk for decreased quality of life, psychosocial decline, and decreased functional status, and a longer wait for evaluation and management can contribute to decreased outcomes, resulting in higher healthcare costs. Stange (2014) reported that within the context of primary care, provider type (NP, PA, MD) may be less important "than the organizational structure in which their services are delivered" (p. 16). This means identifying the potential needs of a patient population and matching them with the provider with a complementary set of skills and training may be the most effective method of care delivery. Utilizing NPs as the first point of contact for many urologic conditions may improve access. But the strengths of the NP role related to patient education, communication skills, length of visits, and use of evidence-based practice guidelines offer a clear advantage when anticipating the needed expansion of the pool of urology providers.

The current literature is sparse and offers few publications relative to outcome data with NPs in urology settings. There are even less data about NPs working in subspecialties, such as incontinence care and endourology. However, it is not unreasonable to extrapolate from existing data that demonstrate the safety and effectiveness of NP care in the management of chronic conditions. Care provided by NPs and physicians has repeatedly been demonstrated to be equivalent for many chronic conditions (Horrocks, Anderson, & Salisbury, 2002; Newhouse et al., 2011; Poghosayn, Boyd, & Knutson, 2014; Stanik-Hutt et al, 2013), and NP care improves outcomes with geriatric patients (Morilla-Herrera, et al., 2016; Reuben, et al., 2013). It is not difficult to infer the likely quality of urology care anticipated from NPs from these comparison studies because many nonoperative urology conditions benefit from chronic, episodic long-term care, a role uniquely suited to the NP. In the urology context, this suggests that NPs managing chronic GU conditions (e.g. erectile dysfunction, incontinence, benign prostatic hyperplasia [BPH], interstitial cystitis) would show similar success rates to urologists. NPs have previously surpassed physicians in metrics for patient follow-up, consultation time, satisfaction, counseling, and assessment (Naylor & Kurtzman, 2010). Through care coordination and counseling, NPs often create a more trusting relationship with patients (Chattopadhyay et al., 2015), and NPs may be specifically suited to manage non-surgical chronic conditions.

This expansion of NPs into urology clinical practice may have more relevance in terms of division of labor, which has also been termed collaboration or team-based approach. This increased supply of providers focusing on GU conditions may increase the use of urology services, offering opportunities for people who might have gone without GU care to enter into the system in a more timely fashion by having an initial consultation with an NP. This may also help focus GU care on screening and prevention, rather than on urgent or acute treatment, especially because this approach is the focus of nursing and advanced nursing care. The increasing complexity of healthcare demands increased provider collaboration; existing data also suggest that this arrangement will increase outcomes while decreasing cost, and simultaneously, improving access and delivery of services.


Specialty care environments are seeing an expansion of the use of NPs due to the mandated decrease in resident work hours, the influence of the PPACA, physician shortages, and/or retire ment rates. Targeted utilization of NPs in specialty environments, such as geriatric urology, can address multiple needs by encouraging the collaborative team model for patient care. This is consistent with the goals of the PPACA to improve affordability and availability, and promote a partnership for comprehensive care between the patient, family, and provider. This model is a remarkable reflection of the traditional nursing model for care. Health promotion within the context of this model is vital, both across the lifespan and as a trajectory of health and wellness, also calling to mind the constructs of the APRN model.

The well-documented future shortage of urologists allows NPs an opportunity to redefine themselves as specialists in urology, improving access to both routine and acute urologic care. This eventual shortage of trained urologists offers an opportunity for both the discipline of urology and NPs to develop new strategies for care delivery by increasing the numbers of NP providers working with urology patients while expanding their clinical roles.

Urologic health needs reach across all patient populations and often exist with other comorbidities. It is vital to control costs, and identifying the best provider to see particular groups of patients, especially those who are not routinely operative candidates within a surgical specialty, is imperative. This is an arena in which NPs can flourish; subpopulations within urology can benefit from the blending of advanced nursing and medical perspectives on care as NPs work to improve care for older adults.

Instructions for Continuing Nursing Education Contact Hours

Geriatric Urology and the Evolving Role of the Nurse Practitioner

Deadline for Submission: June 30, 2019

UNJ 1703

To Obtain CNE Contact Hours

1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation through SUNA's Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to

2. Evaluations must be completed online by June 30, 2019. Upon completion of the evaluation, a certificate for 1.2 contact hour(s) may be printed.

Learning Outcome

After completing this learning activity, the learner will have an understanding of the important role nurse practitioners have in nonsurgical geriatric urology environments.

Learning Engagement Activity

Download and review:

Health Resources and Service Administration (HRSA). (2014). Highlights from the 2012 National Sample Survey of Nurse Practitioners. Rockvill, MD: U.S. Department of Health and Human Services. Retrieved from files/bhw/nchwa/np surveyhighlights. p df

Articles in the SUNA Online Library are FREE for SUNA Members.

CNE Evaluation Fee - $15

The author(s), editor, editorial board, content reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This educational activity is provided by the Society of Urologic Nurses and Associates (SUNA).

SUNA is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

SUNA is a provider approved by the California Board of Registered Nursing, provider number CEP 5556. Licensees in the state of California must retain this certificate for four years after the CNE activity is completed.

This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, SUNA Education Director.

doi: 10.7257/1053-816X.2017.37.3.114


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Chaney, A.J., Harnois, D.M., Musto, K.R., & Nguyen, J.H. (2016). Role development of nurse practitioners and physician assistants in liver transplantation. Progress in Transplantation, 26(1), 75-81.

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Coombs, L.A. (2015). The growing nurse practitioner workforce in specialty care. The Journal for Nurse Practitioners, 11(9), 907-909.

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Quallich, S.A. (2011). A survey evaluating the current role of the nurse practitioner in urology. Urologic Nursing, 31(6), 328, 330-336.

Quallich, S.A. (2016). Nurse practitioner knowledge and treatment choices for chronic unexplained orchialgia. The Journal for Nurse Practitioners, 12(6), e249-e257.

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Additional Readings

Keough, V.A., Stevenson, A., Martinovich, Z., Young, R., & Tanabe, P. (2011). Nurse practitioner certification and practice settings: Implications for education and practice. Journal of Nursing Scholarship, 43(2), 195-202.

Office of the Legislative Counsel for the Use of the U.S. House of Representatives. (2010). Compilation of patient protection and affordable care act. Retrieved from http://house ppacacon.pdf

Quallich, S.A., Bumpus, S.M., & Lajiness, S. (2015). Competencies for the nurse practitioner working with adult urology patients. Urologic Nursing, 35(5), 221-230.

Susanne A. Quallich

Susanne A. Quallich, PhD, ANP-BC, NPC, CUNP, FAANP, is an Andrology Nurse Practitioner, Division of Andrology and Urologic Health, Department of Urology, University of Michigan Health System, Ann Arbor, MI, and a Member of the Urologic Nursing Editorial Board.
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Author:Quallich, Susanne A.
Publication:Urologic Nursing
Date:May 1, 2017
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