Utilization of advanced practice providers (APPs), nurse practitioners (NPs) and physician assistants in urology has become common in the past decades. According to AUA Census data, the number of urologists working with APPs increased from 62.7% in 2015 to 72.5% in 2018. By the year 2035, it is predicted the use of APPs in urology will nearly double in the U.S., while the number of practicing urologists is predicted to continue to decline.¹ While this article focuses primarily on NP training and education, physician assistants are also regularly utilized in urology. The curriculum in most NP programs focuses on training students to provide safe and competent care to patients from childhood through late adulthood but does not provide new graduates with training in many surgical specialties, such as urology.² The responsibility of training APPs in urology is, thus, left to the hiring organization. However, as there is no national standardization, this training can vary both in length and quality, and often is heavily dependent on the infrastructure and resources committed to this endeavor by the institution.

Table. APP urology fellowships in the U.S.

Novice NPs may have difficulty transitioning from graduate school to professional practice, with up to 50% reporting feeling underprepared in their first year of practice.³ Mentorship and support are cited as critical aspects of successfully training new APPs, often leading to improved job satisfaction and increased retention rates.⁴ Given the predicted urology physician shortage and increased use of APPs, successful training in urology is vital for APPs to meet role expectations. In this article, we provide some guidance on developing and training NPs in urology.

One option is a postgraduate urology fellowship program. Fellowships are a well-established part of medical training but have only recently been considered as part of postgraduate education for NPs. The first NP fellowship program was established in 2007 and focused on primary care.⁵ The idea of postgraduate NP training gained more attention when endorsed by the former Institute of Medicine’s 2010 report, “The Future of Nursing: Leading Change, Advancing Health” and has since expanded into specialty practices.⁶ To our knowledge, there are currently 9 available APP fellowships in urology (see table). These programs are typically 12 months in length, train 1 to 2 NPs per year, offer reduced pay and benefits compared to novice NP salaries in their region, and expect fellowship graduates to be competent clinicians in their specialty after fellowship completion.^7,8 There is no standardized curriculum for APP fellowships or singular credentialing body. Funding is often a large barrier to development.⁹

At our institution, we established an NP fellowship in 2018 to help meet the need of training NPs to specialize in urology. The curriculum is similar to other APP urology fellowships. We require the NP to rotate through all urology ambulatory subspecialties, the inpatient and consult services, as well as to spend time observing in the operating room. It also includes training in outpatient procedures such as cystoscopy. The NP fellows train with both urologists and experienced APPs, have required didactic coursework, participate in the department’s weekly educational conferences and must complete a scholarly project prior to completion of the program. The NP fellows are fully licensed and credentialed providers who are able to bill independently during the fellowship, which helps cover the fellowship funding. In our experience, NP fellowship training has resulted in increased confidence and competence in the NP’s first year of practice. Ideally, after completing this type of training, an NP would be productive almost immediately when entering any urology practice. However, with the limited number of APP fellowships currently available, participation in such a fellowship is not a feasible option for most NPs entering the field of urology.

With few fellowships available to new NPs in urology, it is critical that employers have an established onboarding plan to ensure NP competency, productivity and retention throughout their first year of practice. If an NP is dissatisfied with a practice’s onboarding process, there is a higher likelihood of that NP leaving the organization, which can drastically increase a health care organization’s cost.¹⁰ At a minimum, 3 months of onboarding is likely needed for NPs entering urology. Training should focus on the area of urology in which the NP will be practicing, whether that be inpatient, outpatient or both. Furthermore, focusing their training on a subspecialty can be helpful if the NP is going to be primarily seeing certain diagnoses. If an NP will be seeing postoperative patients, having them observe those surgical procedures will help them to better understand specific postoperative complications. Structured mentorship and support from their supervising physicians and experienced APP colleagues are also vital throughout their first year of practice to ensure NP job satisfaction, retention and provision of high-quality care.

Our institution created a 90-day onboarding schedule for all new APPs in the urology clinic. This schedule allows the APP to spend time in the clinic and operating room in each subspecialty of urology (oncology, reconstructive urology/pelvic medicine, men’s health, general urology and endourology) with required readings such as the AUA guidelines, AUA core curriculum and specific institutional learning objectives for each week. With this model, we have been able to take a comprehensive approach to training our new APPs in urology.

As the proportion of NPs in the urology workforce is predicted to grow, postgraduate fellowships may prove to be the most effective and efficient way to train new NPs entering the field. Unfortunately, the limited number of available fellowships and lack of available funding for more continue to hamper broader enrollment and training. Creating models where the NP fellow can generate revenue to cover their salary may be a solution to create more fellowships in the future, and thus expand opportunities for specialty-specific training. For most NPs entering the field of urology, their training will be left up to the institution or group they join. Having a well-established onboarding process that includes hands-on learning, didactics and learning objectives is essential, along with continued mentorship/support throughout their first year of practice.