Urology Nursing Practice Educational Preparation, Titles, Training, and Job Responsibilities Around the Globe

Research
Urology Nursing Practice
Educational Preparation, Titles,
Training, and Job Responsibilities
Around the Globe
Jeffrey A. Albaugh
P
rior to defining the scope
of urology nursing practice, data that describe
how urology nurses in
different geographic regions are
prepared for practice, the titles
they claim, and the job responsibilities they perform need to be
collected. Obtaining an understanding of how urology nurses
describe their practice assures
that the commonalities and differences in training are identified. These data can then be used
to guide the establishment of
standards, providing excellence
in training in urology nursing
practice. The lack of consistency
in the use of urology nurse titles
makes it difficult for health care
professionals, urology patients,
and family members to understand the role of the urology
nurse and the urology advanced
practice nurse (APN).
Jeffrey A. Albaugh, PhD, APRN, CUCNS,
is an Advanced Practice Urology Clinical
Nurse Specialist, NorthShore University
Urology, and an Assistant Research
Professor, the University of Illinois at
Chicago, Chicago, IL.
Acknowledgment: This study was funded
by the Society of Urologic Nurses and
Associates, Inc. (SUNA) Foundation. Special
thanks to all who participated in the study, to
the leaders of the Global Alliance of Urology
Nurses for the idea of this study, and to the
University of Illinois at Chicago College of
Nursing for their support. Thank you to the
many people who helped with conception
and timely editing of this manuscript, including (but not limited to) Peggy Ward-Smith,
Barbara Broome, Jo Ann Kleier, Jane
Hokanson Hawks, and Trish White.
© 2012 Society of Urologic Nurses and Associates
Albaugh, J.A. (2012). Urology nursing practice educational preparation, titles,
training, and job responsibilities around the globe. Urologic Nursing, 32(2).
A descriptive study of urology nursing titles, educational preparation, and job
functions revealed more than 80 titles, varied educational preparation, and some
common and varied job functions. The results also indicated that urology
advanced practice nurses continue to expand their independent roles.
Key Words:
Urology nurse, nursing titles, nursing education, nursing
roles, job functions.
As urology APNs around the
globe continue to take on more
independent roles and engage in
more complex procedures, it will
become even more important to
identify how advanced practice
urology nurses are trained for
these job functions. A review of
the literature failed to identify
any global studies that described
urology nursing education, titles
used by urology nurses, or specific clinical responsibilities of urology nurses at both the basic and
advanced practice level.
White, Crowe, and Papps
(2009) used survey data from
Australian and New Zealand
nurses to describe their roles, professional titles, educational
preparation, and clinical practice
responsibilities. Results of this
study identified more than 35 job
titles used by urology nurses.
Preparations for various advanced clinical practices by nurses varied and ranged from selftaught to formal competency
training. Thompson and associ-
UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 / Epub Ahead of Print
ates (2007) surveyed urology
nurses working in the United
Kingdom. This study concluded
that there were 44 different job
titles being used by urology nurses and a variety of clinical
responsibilities, including bladder scanning, catheter insertion,
changing catheters, and bladder
irrigation. Some advanced skill
procedures included cystoscopy,
protocol development, reviewing
test results, triaging outpatient
referrals, performing and interpreting urodynamics, urethral
dilatation, and performing urology and gynecology assessments.
In the United States (U.S.),
Kleier (2009) studied procedural
competencies and job functions of
urology APNs who were members
of the Society for Urologic Nurses
and Associates (SUNA). The
results of this survey identified 71
job functions, which included
evaluation and management of
new and established patients,
ordering and interpreting diagnostic studies, teaching patients and
1
Research Summary
Background
Describing urologic nursing practice is an essential step
in determining how urology nurses are prepared for practice,
the titles they claim, and the job responsibilities performed by
urology nurses around the globe to identify commonalities and
differences, and to work toward establishing consistency and
excellence in care.
Purpose/Aim/Objective
The purpose of this study was to determine the training
preparation for urology nurses at all levels of practice, the titles
used by urology nurses, and the clinical responsibilities of
urology nurses.
Methods
The study used a prospective descriptive survey design.
The questionnaire was distributed via the Internet with a link
to an online survey that was anonymously completed by urology nurses around the world.
Results
There were 709 valid responses from urology nurses representing 34 different countries around the world. A total of 82
different titles were identified by urology nurses around the
health care staff, and telephone
communication with patients.
Procedures and functions most
commonly performed by APNs
included suture/staple removal,
bladder irrigation, bladder scanning, post-operative wound care,
drain
removal,
suprapubic
catheter insertion/change, bladder training, and microscopic
examination of urine. While the
results of these studies (Kleier,
2009; Thompson et al., 2007;
White et al., 2009) provide insight
into urology nursing practice, no
international survey has been performed. Thus, at the request of the
Global Alliance for Urology
Nurses (GAUN), this survey was
performed.
Purpose of the Study
The purpose of this internationally based survey study was
to obtain data that can be used to
describe and understand the different educational preparation of
urology nurses who provide care
at a basic and advanced level,
titles used by nurses at each of
these levels, training in urologic
procedures at the advanced level,
and clinical responsibilities of
urology nurses at the basic and
APN level.
2
world. The most common title was registered nurse/staff nurse.
The most common age group of urology nuses in the study
was 51 to 60 years of age (38.7%), with the next most common
age being 41 to 50 years of age (36.3%). The most common
certification held by urology nurses was urology certification
(34.8%, n = 247), with nurses in North America most commonly certified (n = 124), followed by Europe (n = 66) and the
United Kingdom (n = 33). The urology nurses identified 98 distinct roles, and the most common activities performed by the
entire group were patient/family education, catheterization,
intermittent catheterization, bladder ultrasound, change/manage suprapubic catheters, medication administration, uroflow,
and assist urologist with procedure.
Conclusions
Nursing titles vary greatly around the globe. The lack of
continuity in titles may lead to confusion among nurses and
the public at large. Nurses around the world reported many
roles, and although there were many common roles shared by
many nurses, nurses are taking on advanced roles, such as
performing cystoscopy, circumcision, and prostate biopsy.
Level of Evidence – VI
(Melnyk & Fineout-Overholt, 2011)
Research Design and Methods
Data were collected using a
prospective descriptive survey
design. Study data consisted of
responses to a 22-item survey and
8 additional questions specific to
APNs. The answers to each survey item were categorical, and
when applicable, a choice of
“other” was offered with an
option to write in a response.
The investigator-initiated survey was developed specifically
for this project, with face validity
provided by leaders and scholars
from multiple professional urology nursing organizations, including SUNA, the British Association
of Urological Nurses (BAUN), the
Australian and New Zealand
Urological Nurses Society, and
the European Association of
Urology Nurses (EAUN) who are
all participants in GAUN (an
organization created by the previously listed organizations to share
information and glean knowledge
from any urology nursing organization around the globe). Several
survey items were adapted from
the survey used by White et al.
(2009) with permission.
Institutional Review Board
(IRB) approval was secured from
the University of Illinois at
Chicago. Study participation was
solicitied via an e-mail from the
membership rosters of the professional organizations mentioned
previously. These individuals
were identified as potential participants based on the assumption that they worked in a urology health care setting at least
part-time on a regular basis, were
able to read and understand
English, and were able to respond to questions.
Data were collected using
SurveyMonkeyTM, which provides anonymity of the responses,
including encryption. No identifiable data were collected, including no IP addresses. As an exempt
study, consent was assumed upon
submission of the survey.
Procedures
An invitational e-mail was
sent to all members of the professional organizations identified
previously. This e-mail described
the study purpose, aim, time
required for participation, and a
link to the survey. Each organization was encouraged to send a
reminder two to three weeks after
the initial notice, a time identified by Hennings (2010) as when
response rates slow down. Each
UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 / Epub Ahead of Print
organization was encouraged to
send a second reminder two to
three weeks hence when the
response rate slowed. Data were
collected over a three-month
period; enrollment ceased when
no responses were received during the previous two weeks.
Results
Responses were obtained
from 715 individuals. After
reviewing these data, six were
determined to not meet study
inclusion criteria (not registered
nurses, retired). Thus, data were
analyzed on 709 responses.
Estimating that e-mails were sent
to each of the 4190 potential participants, this represents a 17%
response rate. Response rates for
Web-based surveys vary, with a
standard response rate yet to be
determined. Polit and Beck (2012)
report that Internet questionnaires
generally receive a 50% response
rate. In a meta-analysis of online
survey research, Hamilton (2011)
determined that reported response rates ranged from 32.52%
to 41.21%, with a standard deviation of 29.40%. Given this discrepancy, the demographic characteristics of the respondents
become a better determining variable with response to the validity
of these data. Assuming that the
study population is homogeneous, and the results of this
study are not intended to be
applied to other populations,
while people are not identical, a
representative sample is sufficient
(Engel & Schutt, 2005).
Responses were obtained
from urology nurses practicing in
34 countries. A total of 82 titles
were identified by respondents,
with the most common titles
being registered nurse/staff nurse
(20.6%),
nurse
practitioner
(17.8%), urology nurse specialist
(15.4%), and clinical nurse specialist (10.6%). The majority were
from North America/United
States (50.2%), female (92%), and
between 51 to 60 years of age
(38.7%). These individuals worked 31 or more hours a week in a
urology health care setting
(73.1%). Most respondents work-
Table 1.
Demographic – All Respondents
Characteristic
n
%
Age (Years)
18 to 30
21
3.0
31 to 40
103
14.5
41 to 50
258
36.4
51 to 60
274
38.6
Over 60
53
7.5
654
92.2
Asian
23
3.2
African-American/Black
12
1.7
8
1.1
11
1.6
Race/Ethnicity
White/Caucasian
Hispanic/Latino
Other
Gender
Female
652
92
57
8.0
0 to 4
106
15
Male
How Long Worked in Urology (Years)
5 to 10
181
25.5
11 to 15
164
23.1
16 to 25
171
24.1
87
12.3
0 to 10
45
6.3
11 to 20
50
7.1
21 to 30
96
13.5
31 to 40
277
39.1
More than 40
241
34.0
North America/United States
353
49.8
Europe
151
21.3
United Kingdom
108
15.2
Australia/New Zealand
87
12.3
Asia
10
1.4
0 to 11
165
23.3
12 to 17
225
31.7
18 to 65
671
94.6
Older than 65
580
81.8
More than 25
Hours Worked per Week in Urology
Region
Ages of Patients (Years) (Check All Applicable)
UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 / Epub Ahead of Print
continued on next page
3
Table 1. (continued)
Demographic – All Respondents
n
Characteristic
%
APN Results
Work Setting
Hospital-based clinic
232
32.7
Hospital
153
21.6
Private practice clinic
107
15.1
Multi-practitioner clinic
76
10.7
Other
53
7.5
Government institution
49
6.9
Surgical center/Perioperative center
24
3.4
Independent APN Clinic
15
2.1
General urology
465
65.6
Incontinence
408
57.5
Urology/Oncology
355
50.1
Areas of Urology Practice
Urodynamics
315
44.4
Kidney stones
276
38.9
Sexual health/Dysfunction
236
33.3
Women’s health
147
20.7
Operating room
131
18.5
Andrology/Infertility
163
14.5
Neurology
92
13.0
Pediatric
89
12.6
Table 2.
Educational Preparation of All Nurses by Region
HospitalBased (%)
Bachelor of
Science
Degree (%)
Master of
Science
Degree (%)
Post-Graduate
Degree (%)
Australia/
New Zealand
(n = 87)
27.6
25.3
12.6
29.9
North America
(n = 359)
12.0
29.5
28.1
10.3
United Kingdom
(n = 108)
25.9
39.8
22.2
5.6
Asia (n = 10)
20.0
30.0
30.0
10.0
Europe (n = 151)
41.7
18.5
16.5
9.0
ed in the hospital or clinic setting
in the areas of general urology,
incontinence, and urology/oncology. Most respondents were baccalaureate-educated (28.5%), and
the most common certification
among them was urology certification (34.8%, n = 247). The demographics of the study population
are displayed in Table 1, while
4
respondents (n = 702, 99%)
reported practicing safely within
their scope of practice.
Table 2 describes the educational
preparation of the urology nurses
by region. Ninety-eight distinct
roles and/or procedures were
identifed (see Tables 3 and 4).
Many urology nurses were
involved in research (n = 303,
42.7%), with the most common
type of research described as medically initiated (36.5%). Almost all
A total of 245 respondents
identified themselves as APNs.
Repondents identified 33 distinct titles, with the most common being a nurse practitioner of
some form (55.2%). Forty-nine
percent of these APNs reported
having independent prescriptive
privileges, while almost onethird (29.4%) of the APNs said
they do not prescribe at all.
Invasive procedures were being
performed by APNs more commonly in the United Kingdom
and Europe (see Table 5 to compare regional responses for these
procedures). APNs were asked
about training for advanced procedures. Most of the advanced
roles and procedures done by
APNs were learned through
informal training, with the
exception of prescriptive privileges (71% formal competency
training), cystoscopy (50% formal competency training), and
prostate biopsy (52.6% formal
competency training).
The most common minimum
requirement for the APNs was a
master’s degree (68.2%); continuing education credit was secondary (51.8%), followed by certification (45%). A minimum number of APN practice hours were
reported by 31.4% of these participants. The most common perceived barriers to practice identified by participants were legislation limiting practice (34.8%),
lack of training available for skills
(34.8%), and physician resistance
(24.6%). Some respondents
(24.6%) did not perceive any barriers to advanced practice. Of
those certified (n = 175, 71.4%),
the most frequent requirement for
certification was continuing education hours (70.9%), followed
by board examination (60.1%)
and mandatory minimum hours
in clinical practice (54.7%).
APNs do a variety of different
procedures; the most commonly
reported procedure was evaluation and management of urologic
problems (n = 252, 95.1%).
UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 / Epub Ahead of Print
Table 3.
Urology Nursing Procedures
n
%
Patient/family education
630
88.8
Catheterization
567
80.0
Intermittent catheterization
504
71.2
Bladder ultrasound
491
69.2
Change/manage suprapubic
433
61.1
Medication administration
421
59.6
Uroflow
411
58.0
Assist urologist with procedure
388
54.8
Check vital signs
386
54.7
Telephone triage
369
52.2
Bladder training
367
52.0
Intravesical medication administration
357
50.2
Assist with prescription renewal
317
45.0
Urodynamic testing
266
37.8
Pelvic floor muscle training
262
37.1
Pre-op surgery evaluation
262
37.1
Oncology surveillance
255
35.9
Blood draw
190
27.0
Intracavernosal injections
142
20.1
Metabolic stone evaluation
108
15.5
Biofeedback-assisted pelvic floor muscle training
89
12.9
Pessary fitting and application
80
11.2
Role/Procedure
Other Procedures Identified
Continence management, continence assessment, skin care, fitting of
clamps and external catheters, fecal incontinence, post-op care, operating room
nurse/scrub/circulate, first assist in operating room, patient navigator/liaison/case management surgery scheduler, staff education, quality management, administrative/management, accreditation activities, patient and family
support, giving diagnosis/breaking bad news, develop standards, teaching
colleagues/nursing academics, androgen deprivation therapy, testosterone
therapy, neuromodulation evaluation and programming/interstim, highlight
abnormal EKG/cardiology consults, telephone follow up post-procedure, lower
urinary tract symptoms (LUTS) clinic, oncology support, urostomy/stoma
care/ostemy care, rapid access clinic, intravenous (IV) therapy, pain management for interstitial cystitis (IC), pediatric dysfunctional voiding clinic, catheter
flush, research care of drains, bladder irrigations, lithotripsy operator, postprostatectomy penile rehabilitation, in-office erectile dysfunction treatments,
coordinate/schedule appointments, order labs, and voiding trials.
Note: Bolded text denotes more than one similar response.
Discussion
All notices for the study were
sent through the different nursing
organizations to their members.
Although 709 responses were validated, and the response rate was
only 17%, there is no way to determine if all e-mail addresses are
accurate/functioning and if all
recipients were nurses. Non-nurses, such as physician assistants,
medical assistants, industry affiliates, and other individuals may be
members of these organizations. A
few non-nurses completed the survey, and those responses were
eliminated because they did not
meet inclusion criteria. There may
UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 / Epub Ahead of Print
also be some overlap with some
nurses having membership in
more than one association (for
example, a nurse in Europe may
be a member of both the European
and British Associations and
would therefore receive e-mails
through both organizations). The
survey was done in English, and
this may have deterred some nurses who do not use English as their
first language from participating.
Only one organization was able to
track if e-mails were accessed, and
through that tracking, it was determined that less than half the emails sent were opened.
The nurses in this study primarily worked in the hospital
setting; many urology clinics
exist within the hospitals themselves throughout the world.
Urology nurses are an aging population, with the majority 50
years of age or older. Just as the
nursing population is aging, urology nursing is following that
trend with the smallest number
of respondents being the younger
nurses. Only 3% of respondents
were 30 years of age or under.
Urology Nursing Titles
Results of this study support
previous research (Thompson et
al, 2007; White et al., 2009) documenting multiple titles for urology nurses. These many-varied
titles may reflect urology nurses’
creativity to define themselves in
their unique roles within urology,
but the lack of continuity in titles
may lead to confusion among
nurses and the public. In the U.S.,
Australia, and New Zealand,
some titles, such as registered
nurse and nurse practitioner, are
protected by law/statute, but
many titles are not. Registered
nurse is a common title that is
often protected in different countries, and the public is familiar
with that title. Urology registered
nurses could use that title, and if
they are certified, they could use
the title of certified urology registered nurse (CURN).
The confusion with advanced
practice nursing titles is a greater
issue in terms of identity for the
public and other health care pro-
5
fessionals. There were 33 distinct
titles, but 93% of the titles contained either nurse practitioner or
clinical nurse specialist. These
titles are accepted APN titles, and
would be further defined and protected through acceptance of the
APRN Consensus Model and the
Institute of Medicine (IOM) Report
on the Future of Nursing in the
U.S. and other countries (IOM,
2010; Partin, 2009; Stanley,
Werner, & Apple, 2009). The APRN
Consensus Model seeks to standardize APRN licensure, accreditation, certification, and education,
Table 4.
Urology Nursing Advanced Procedures
Role/Procedure
Suture/staple removal
Remove drains
Evaluation and management urology problems
Bladder irrigation
Digital rectal examination (DRE)
Prescriptions
Suprapubic catheter insert
Urodynamics interpretation
Treat sexual dysfunction
Treat prostatitis/benign prostatic
hypertrophy/prostate cancer
Stent removal
Microscopic urinalysis
Image interpretation
Stricture/urethral dilation
Subcutaneous pellets placed
Cystoscopy
Priapism treatment
Prostate biopsy
Aspirate hydrocele
Bladder biopsy
Circumcision
Vasectomy
Penile Doppler
Genetic testing/Kerotype interpretation
n
328
316
262
190
172
155
149
145
145
145
%
46.3
44.6
37.0
26.8
24.3
21.9
21.0
20.5
20.5
20.5
143
135
118
114
92
69
56
42
23
17
17
16
14
10
20.2
19.0
16.6
16.1
13.0
9.7
7.9
5.9
3.2
2.4
2.4
2.3
2.0
1.4
Some other procedures identified:
– Anesthesia pre-assessment
– Specialty catheterization
– Bladder instillations
– Pessary fitting/training
– Fecal incontinence evaluate and manage
– Patient conferences
– Trigger point injections
– ABG draw and interpret
Note: Bolded text denotes multiple responses for that procedure.
in addition to standardizing APN
titles. The consensus model
(APRN Consensus Work Group &
the National Council of State
Boards of Nursing APRN Advisory
Committee, 2008) and the IOM
(2010) both call for uniformity in
acceptance of these two advanced
practice titles (along with two other
titles encompassing midwives and
nurse anesthetist). Further work is
needed to delineate the titles of
nurse practitioners and clinical
nurse specialists as APNs.
Education and Preparation
Of Urology Nurses
Most of the urology nurses in
the study were educated at a baccalaureate (BSN) level or higher,
but no standard exists for educational preparation. Educational
preparation for APNs at the graduate level has become standardized in the U.S., Australia, New
Zealand, and the United Kingdom; it is not standardized worldwide. Minimum standards in
terms of education and accreditation provide important guidelines
for how APNs must be educationally prepared for practice, but
guidelines are needed to determine urology core curriculum
necessary to gain appropriate
knowledge for practice in urology.
In addition, training programs
need to be implemented worldwide to specifically educate urology nurses at the basic and
advanced levels in urology
because lack of training was identified by APNs as a barrier to practice. Although urology certification was the most common type of
certification, less than half of
these respondents were certified
in urology. Urology certification is
one way to determine expert
knowledge in urology.
Table 5.
Advanced Practice Nurse Procedure comparison Across Regions
Prescriptive (%)
Cystoscopy (%)
Bladder Bx (%)
Prostate Bx (%)
All (N = 194)
72.1
21.7
8.7
10.2
Australia/New Zealand (n = 16)
25.0
28.6
0.0
0.0
United Kingdom (n = 22)
47.8
47.0
28.0
12.0
North America (n = 118)
96.3
11.9
3.4
9.4
Europe (n = 38)
27.5
22.5
13.2
13.2
6
UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 / Epub Ahead of Print
Job Responsibilities and Roles
Nurses around the world
reported many roles, and although there were many common roles shared by these nurses, some APNs are assuming
diverse advanced roles, such as
performing cystoscopy, circumcision, and prostate biopsy. Patient
and family education remain a
common activity of all urology
nurses. The most common
advanced procedures performed
by the respondents were suture/
staple removal and removal of
drains; these procedures were
reported as being done by both
urology nurses and APNs. The
most common procedure performed specifically by APNs was
evaluation and management of
urology patients, which is similar to previous research findings
in the U.S. (Kleier, 2009).
The role of the APN varies; if
APNs perform invasive procedures, comprehensive training
needs to be developed to promote excellence in delivering
safe patient care. Formal training
was not identified by many of the
APNs who participated in this
study. Nurses in urologic nursing
organizations worldwide are
working on some training guidelines for procedures such as cystoscopy, according to Lucinda
Pulton and Heather Schultz,
Cystoscopy Training Guidelines
Task Force members for BAUN
and SUNA, respectively (personal communication, October 28,
2011). Work is also underway in
most of the urology nursing
organizations involved with this
study to establish a urology core
curriculum, and that work is
being done in conjunction with
GAUN according to GAUN Vice
Chairperson Bente Thoft Jensen
(personal communication, October 30, 2011).
The Global Alliance of
Urology Nurses met in San
Antonio in 2011, and leaders from
urology nursing organizations discussed the issues of core competence in urology, certification,
education, titles, roles, and training. In the study, the APNs identified the lack of adequate training
as a barrier to practice. Training
programs in urology should be
developed to fill this void.
Implications
The findings herein combined with previous research recognizes the need for globally
accepted urology nursing titles for
nurses at all levels to minimize
confusion. Training and educational programs are not standardized, and urologic nursing organizations around the globe continue
to work toward standardization in
terms of education in the specialty of urology. As roles expand in
urologic nursing, the need for
standardized training for those
roles will continue to be an issue,
and this study provides information about those roles and current
training for APNs.
Limitations
This study was limited to the
convenience sample of nurses
who belong to urology-specific
professional nursing organizations worldwide. The study was
done via e-mail through a link to
an online survey, and this method
may not capture all urology nurses globally. The study cannot be
generalized to all urology nurses,
but it does provide information
about urology nurse respondents
around the world. There may be
access concerns around the globe
with SurveyMonkey.
Future Research
Further research is needed to
clarify titles and roles of urology
nurses and APNs worldwide. The
use of multiple titles may cause
confusion among those for whom
care is provided and should be
assessed in future studies.
Further research is needed to
determine the best training to prepare urology nurses for practice
in urology and to perform invasive procedures. This study offers
beginning research about titles,
education, and the profesisonal
roles of urology nurses. Further
studies may need to be conducted
using paper and pencil and/or
phone or in-person interviews in
UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 / Epub Ahead of Print
addition to online studies. Based
on the results of this study, further research is needed to separate the APN from the RN role. As
APNs continue to expand their
scope of practice, research studies to evaluate the efficacy of
APN care as compared with other
providers would be valuable.
References
APRN Consensus Work Group & the
National Council of State Boards of
Nursing APRN Advisory Committee.
(2008). Consensus model for APRN
regulation: Licensure, accreditation,
certification and education. Retrieved
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