As more hospitals, clinics,

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1 Essential Steps in Super User Education for Ambulatory Clinic N u r s e s Shannon McIntire Te resa Clark As more hospitals, clinics, and other health c a re facilities begin to implement electro n i c medical re c o rds (EMRs), there is a growing need to determ i n e strategies for successful implementation. One strategy is having nurses as super users. Super users are defined as a class of h i g h e r-level EMR software users who help with software customization and assist clinician end-users with its use. This experience is shared to help others employ possible strategies with implementing an EMR. Implementing an EMR is an important yet time-consuming task. Once implemented, the EMR Shannon McIntire, M S N, R N, is an IT Specialist, Iowa Ve t e rans Home, Marshall - t own, IA Teresa Clark, M S N, R N, U n i versity of Iowa Hospitals & Clinics, Iowa City, Iowa A ck n ow l e d g m e n t s: The authors wish to a ck n owledge the continued support and guidance of Jane M. B r o kel, PhD, RN, Assistant Professor at the University of Iowa College of Nursing, throughout this project. This study was conducted as the lead a u t h o r s final project for her MSN degree at the University of Iowa College of Nursing in I owa City, IA. Without the support of the U n i versity of Iowa Hospital and Clinics (UIHC) this study would not have been pos - s i bl e. Additional support from Ja n e t W i l l i a m s, PhD, RN, FAAN, from the U n i versity of Iowa College of Nursing, and K i rk Phillips, PhD, from Iowa Health Systems are appreciated in telling this story. Statement of Discl o s u r e : The authors r e p o rted no actual or potential conflict of interest in relation to this continuing nu r s i n g education art i c l e. N o t e : O b j e c t i ves and CNE Evaluation Fo rm appear on page 343. Pre-implementation and education steps for ambu l a t o ry care nu rs e s chosen as super users are described in this art i cl e. Those chosen as super users supported a new electronic medical record (EMR) within a large academic medical center with more than 200 health care spe - cialty cl i n i c s. Essential steps prepared these super users to integrate the EMR into their daily wo r k f l ow s. O b j e c t i v e s 2009 Society of Urologic Nurses and Associates U rologic Nurs i n g, p p Key Wo rd s : Electronic health record (EHR), electronic medical record (EMR), education, adoption methods. 1. Discuss the role and responsibilities of super users during the education process of an electronic health system. 2. List objectives for pre-implementation education of an electro n i c health system. 3. Describe the education intervention method for implementing an electronic health system in a medical facility. can be used to improve patient care, promote patient safety, improve documentation, and reduce costs (Brown, Rudman, Hughes, Rogers, & Smith, 2002; B u rt & Sisk, 2005; McCain, 2008; Rouf, Chumley, & Dobbie, 2008; Simon et al., 2008). When it comes to the provision of health care, the recognition of an EMR s value is escalating. EMRs have the ability to address health care pro v i d e r s need for information, increase collaboration among members of care teams, and provide decision-supp o rt functions that enhance the quality of health care (Anderson, 2000; Houser & Johnson, 2008; Te rry et al., 2008; Townes, Benson, Johnston, & Vaughn, 2000). EMR software is not pre - s e t exactly to how most disciplines or o rganizations will want to document. Every organization has unique services, policies, and proc e d u res that dictate the need for i n f o rmation based on their stand a rds of care and workflows. For this reason, there will be a cert a i n amount of content set up in the s o f t w a re by the organization prior to implementation. Groups within the organization must consider all documentation processes, care requirements, and information needs prior to educating clinicians on the new system. There f o re, each different specialty area, including all disciplines using the system, need to identify their doc- UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 337

2 umentation needs for the EMR. E v e ry health care facility has state, federal, and pro f e s s i o n a l s t a n d a rds with which they must comply re g a rding documentation. A c c reditation standards, such as The Joint Commission, or special c e rtification standards, such as National Cancer Institute (NCI) designation, are other standard s that can impose needs. Identifying and coordinating all complete documentation re q u i rements for specialty areas, such as uro l o g y s e rvices, can be a challenge. F i g u re 1 provides essential objectives for pre-implementation education of a new electronic health s y s t e m. Once the initial set up of the EMR software has occurred, a plan needs to be established by the project management team within the organization for who will be responsible to educate the nurses on the new system, and how and when this will occur. Nurse educators, nurse informaticists, training teams from the s o f t w a re company, or even hire d consultants are possible choices as educators. Implementation of an EMR at a large hospital with the complexity of multiple outpatient clinics will re q u i re many nurses using the system. Each nurse will have to be educated prior to full implementation, as well as participate in the continuing education associated with system updates. B a c k g r o u n d A 680-bed comprehensive academic medical center and regional re f e rral center located in the Midwest embarked on an extensive journey toward transitioning to an EMR system. A c c o rding to the medical center s annual re p o rt, there were more than 200 health care specialties available, with many outre a c h clinics accessible throughout the state. In one fiscal year, the medical center re c o rded over 850,000 outpatient visits. The medical center employed more than 500 Figure 1. Three Essential Objectives for Pre-Implementation Education of an Electronic Health Information System 1. Introduce the electronic health info rmation system early to nurses chosen as super users to foster a comfo rt level with software prior to implementation. 2. P r ovide nurses with a more productive acceptance testing ex p e rience using patient scenari o s. 3. Allocate time to rev i ew / a n a l y ze wo rk f l ow to gather input from super users and all clinical EMR users during pre-implementation. This will enable customization of the system and sufficient process improvement to ensure minimal wo rk f l ow disruptions to nurses during and after implementation. a m b u l a t o ry nurses; among those nurses, more than 100 were considered super users for the EMR. Super users were in a class of higher-level EMR users who w e re more knowledgeable in their ability to operate the EMR softw a re and could help others with the system. Pre f e r a b l y, super users had some experience with using a mouse, keyboarding, and possibly some Microsoft Wo rd skills, such as copying and pasting. At this medical center, a p p roximately 7000 employees re q u i red EMR software training. This number included both inpatient and outpatient staff from all health care disciplines. Of the approximate 7000 employees, roughly 3000 were employed as a m b u l a t o ry staff (University of Iowa Hospitals and Clinics, 2009). In January 2007, the medical center officially initiated the plan to implement a new enterprise clinical information system that would be used in both the inpatient and outpatient settings (University of Iowa Hospitals and Clinics, 2009). They had previously used a combination of both paper and electronic medical re c o rds. Intere s t i n g l y, t h roughout the medical center, m o re than one type of electro n i c re c o rd was utilized. Some are a s had a home-grown electro n i c re c o rd that had been in place for a round 20 years, while other a reas had newer software purchases from a commercial vend o r. Since there was a combination of re c o rd types being used, t h e re was a great variety of computer skills and attitudes among nurses for switching from existing products and methods. The medical center had implemented s o f t w a re in previous years, and the nursing informatics department was already well established. They had prior experience of successful techniques for educating nurses. This art i c l e discusses the initial education of outpatient or ambulatory care clinic nurses in the role of super users on the new electronic medical re c o rd software. Purpose The purpose of this article is to describe the education pro c e s s utilized at the medical center as it pro g ressed toward the implementation of the EMR, specifically the planning and implementation of overview sessions designed to educate ambulatory clinic super users on the use of new EMR software. The aim of these overview sessions was to teach basic functionality of EMR s o f t w a re to a smaller group of nurses before education was provided to all nurses thro u g h o u t each ambulatory clinic. Introducing the system early during the pre-implementation phase to a super user group was an attempt to provide a smoother transition during and after golive of the EMR. The overv i e w 338 UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5

3 sessions provided the nursing i n f o rmatics department and the nursing super users with time to identify which pieces of clinical content for documentation or other functions within the EMR still needed to be added to the EMR design. Since overview sessions were conducted appro x i- mately six months prior to the go-live date, there would be time to make changes before educating all clinicians. Initial set-up of the vendor s EMR software was basic, and content was minimal, much of which was meant for all users in general rather than specifically for each specialty area. The system at the time of the overv i e w sessions did not have all the documentation features that each nurse from every possible clinic would need on the day of golive. Much of the final documentation re q u i rements were being collected from each of the a m b u l a t o ry clinics by the nursing informatics depart m e n t. S u b s e q u e n t l y, the inform a t i o n collected was being built into the system before, during, and after the overview sessions being o ff e red to super users. The dynamic changes to the EMR w e re seen by super users who could provide feedback on the design prior to formal testing and general training. The intent was to have all EMR documentation ready for the final education provided to all clinicians. The o v e rview sessions were basic functionality only. This new software came equipped with both a training module and a playground module. The training module allowed nurses to be educated on the basic functionality of the EMR s o f t w a re in a classroom enviro n- ment. The playground module p rovided nurses the ability to continue practicing after the o v e rview sessions, thus pro v i d- ing them the opportunity to become more proficient at using the software. Past software programs did not have a playgro u n d module in which to practice, so this was an important new feat u re to assist with education and on-going practice. S t a ff identified as super users by their ambulatory clinic nurse managers would help identify any missing documentation areas not c u rrently in the EHR but seen as beneficial. Super users re p o rt e d those documentation items to nurse informatics staff, who then worked to reduce as many content gaps as possible prior to go-live with the EMR developers. Content would continue to be developed before, during, and after go-live as necessary. Super users needed to be proficient at basic computing skills, such as using a mouse and keyboard, and have the willingness to help assist others in learning how to use the s o f t w a re later. Education Intervention Method The first step for setting up o v e rview sessions was to create a lesson plan with scenarios that would fit into a specified timeframe allotted for each session. In the case of overview sessions, the education was to last appro x i- mately two hours. This would allow super users a first glance at the software without overw h e l m- ing them. From past educational experiences with software, nursing informatics staff had found that training worked best if no m o re than 10 to 15 nurses were in a computer session at once. To o many nurses with varying levels of computer skills in one class f rustrated those who were pro f i- cient with the computer and those who were not as proficient. Keeping the class size small can p revent the participants from feeling like the session is moving too fast or too slow. The goal was to make sure the entire lesson plan was covered within the time constraints, while at the same time, giving nurses the confidence for understanding the information at the end of the session. Scenarios would include basic outpatient skills, such as how to locate a patient; change the login clinic; view upcoming appointments, demographic inform a t i o n, notes, or labs on scheduled patients; document telephone encounters when someone calls in with questions or concerns; document information during a clinic visit, such as allergies, patient hist o ry, and vital signs; administer and re c o rd immunizations; and re c o rd the administration of medications. These scenarios were basic and not focused on any one p a rticular type of clinic. The next step included having a staff person from the Health C a re Information System (HCIS) D e p a rtment set up 30 patient re c o rds in the system that could be used during the overview sessions. Thirty temporary user IDs and passwords were created by HCIS to provide access to this i n f o rmation. The training user IDs and passwords ensured that the c o rrect clinic and patient scenario re c o rd could be accessed for training purposes. These re c o rds simulated real patient re c o rds by having similar personal, demographic, and health history inform a t i o n. The simulated re c o rds would be used to educate super users on the new system to develop skills for working with the new electro n i c re c o rd. Super User Role and R e s p o n s i b i l i t i e s Nurse managers within each clinic area were contacted by the nursing informatics depart m e n t and requested to identify nurses and other staff who were willing and able to be a super user. Super users would have a re s p o n s i b i l i- ty to attend the initial overv i e w session for the EMR and then commit to attend future testing sessions, attend a final educational session before all other nurses would be educated, participate as facilitators during f u t u re educational sessions for the rest of the nurses, and serv e as an on-going re s o u rce for nurs- UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 339

4 es once the software was implem e n t e d. B e f o re any overview sessions w e re scheduled, the nurse managers from each ambulatory clinic determined how many nurses they wanted as super users. Nurse managers also identified times and days that would allow staff to p a rticipate in the educational sessions. The nursing inform a t i c s d e p a rtment then consulted with HCIS to re s e rve computer labs for the three weeks needed to pro v i d e o v e rview educational sessions. The number of sessions to be implemented was directly determined from the amount of nurses and the available seating in the computer lab. Computer training labs consisted of classrooms with 10 to 15 computer terminals. Each nurse would have his or her own c o m p u t e r, while the designated trainer demonstrated EMR functionality by projecting an image of the EMR screens on the wall and giving step-by-step instru c t i o n s. Seating availability for each computer lab within the hospital varied. Computer lab rooms that seated no more than 15 to 20 staff and were available during the days, and timeframes needed were reserved. Sign-up sheets stating the days, times, and computer lab locations of the trainings w e re made available to the nurse managers so that super users could sign up to attend an o v e rview session. One nurse inform a t i c i s t s e rved as the primary educator along with 1 or 2 facilitators for the first day s overview sessions. This p rocess worked well, and theref o re, was continued for the remaining sessions. As the nurse i n f o rmaticist discussed how to complete diff e rent steps in the EMR software, a view of the EMR was projected onto the wall at the same time. Facilitators were available if individual instruction or s u p p o rt was requested or needed during the sessions. Facilitators w e re of great benefit to assist nurses should they miss any steps during the overview sessions. Super User Tr a i n i n g The medical center had 142 a m b u l a t o ry super users sign up to attend overview sessions. Tw o d i ff e rent computer labs were utilized. One computer lab held 10 computers, while the other held 20 computers. A total of 12 o v e rview sessions were held over a 3-week period. Days and times of the week for overview sessions w e re determined by the nurse managers from each clinic s first or second choices, and also by when the computer labs were available. As a result, overv i e w sessions were scheduled in the a f t e rnoon on We d n e s d a y s, Thursdays, and Fridays, with Thursdays allowing for two afternoon sessions. Of the 142 super uses attending the sessions, at least 64 were s t a ff nurses, 17 were medical assistants, and 28 were nurse managers. Other super users included advanced practice nurses, clinical nurse specialists, and other ambulatory care personnel. Educators and facilitators arr i v e d at least 15 minutes early to unlock the computer room door, s t a rt each computer so that computers were ready at the login page, have a sign-in sheet available to re c o rd who attended the training sessions, and ensure that hand-outs were printed and available for those attending the session. The initial 30 to 40 minutes of each session was used for a review of the timeline for implementing the EMR, and explaining the purpose and i m p o rtance of the roles of super users. Super users pro v i d e d assistance within the clinical a rea, answered questions fro m other users, and identified documentation needs for their specific clinic service that were not p resent within the EMR. In the remaining 80 to 90 minutes, patient scenarios were pre s e n t e d, and the super users were allowed to use the system and ask questions. O v e rview sessions also allowed the nursing inform a t i c s d e p a rtment an opportunity to see which super users were catching on quickly and which were going to need a little extra help to learn the system to help teach others. The sessions allowed the educator to identify positive and any potential negative attitudes super users had toward the system. Super users who struggled more with learning the system needed remedial education and additional guidance to learn the new softw a re. Those who were less positive about the system needed extra encouragement to embrace the organizational change. Both knowledge and a positive attitude w e re beneficial to teach other clinicians new EMR skills. Knowing the super user s abilities and attitudes gave the nursing inform a t- ics staff an idea of which clinic a reas would potentially re q u i re m o re help on the first and following days of go-live. Since the medical center chose to utilize the big-bang method of implementing the system (meaning everyone starts using the system the same day), it was very important to make sure super users were ready and available on the day of go-live. There w e re not enough nursing informatics and HCIS staff available to cover all shifts and all areas on the day of go-live without the help of the 142 super users. Super users were encouraged to practice on the system in the s o f t w a re s playground enviro n- ment as soon as possible and as often as possible. Instru c t o r s acknowledged that time is a p remium on the units and in the clinics. There were few opport u- nities available while working to practice on the computer. For this reason, several short training patient scenarios were developed so that nurses could get online and practice individual scenarios for 5 to 10 minutes at a time. Super users were also ins t ructed to utilize the e-learn i n g modules located on Share p o i n t, a M i c rosoft intranet tool used by the medical center to manage 340 UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5

5 s h a red educational documents. The e-learning modules were an interactive way to learn via the computer and provided both review and additional training in computer skills. The e-learn i n g modules reviewed basic functionality of the system but also included short interactive training modules showing staff how to use basic computer functions, such as a mouse or keyboard. Some of the modules were cre a t- ed by the software vendor, and others were created by the medical center s HCIS staff. Once super users were comf o rtable with the basic functionality of the EMR software, they contacted the nursing inform a t i c s d e p a rtment to have a competency checklist signed off. The checklist was a method to ensure that the EMR functions covered in the o v e rview sessions were exhibited by the super user, who would be able to demonstrate to other staff the basic functionality of the system. This allowed for more involved participation of the clinic nurses and super users in the l e a rning process. To decrease the amount of hours spent in final EMR instruction, super users w e re to review certain functions with all clinic staff and then sign o ff a competency checklist for each clinician in their clinic are a. Some competencies known prior to final EMR instruction included the login process; finding a patient on a clinic schedule; finding a patient in the EMR not on the schedule; perf o rming a chart review to view pro g ress notes, labs, or other miscellaneous documents; and the logout pro c e s s. Competency checklists needed to be signed off prior to final EMR instruction approximately six weeks before the actual go-live d a t e. D i s c u s s i o n P roviding overview sessions to super users at least six months prior to go-live was a new tactic for the medical center and has been used by others (Halbesleben, Wakefield, Wa rd, B rokel, & Crandall, 2009). In the past when overview sessions w e re not off e red, nurses were not well pre p a red to be critical evaluators in testing their workflow of the system prior to actual implementation for acceptability. Nurses were too busy trying to access screens and understand basic functionality rather than identify how the system was used to document care for the patient. Patient scenarios for testing acceptance identified what was successful or what import a n t documentation pieces were still m i s s i n g. S t rengths of Overv i e w Sessions Identifying super users early and having overview education sessions early provided a nont h reatening way to become familiar with the system before attending sessions used to test functionality of the EMR for acceptability. The goal of this method was to allow super users to gain experience with the system, thus providing for a more productive acceptance testing process later on. Super users were encouraged to provide input into the customization of the system for their p a rticular practice enviro n m e n t. Any questions regarding how each super user s clinic or ambul a t o ry workflow would fit into the system was necessary to make the testing sessions productive to finding any remaining deficiencies before implementation. Having a nurse experienced with technology provide the training sessions to other nurses was important and of great benefit. Non-clinical inform a t i o n technology staff could pro v i d e o v e rview sessions but were unable to answer the clinical workflow questions. An ambulat o ry or inpatient nurse is much better suited to answer nursing documentation questions re l a t e d to electronic charting to capture the nursing process completely. O v e rview sessions also provided a mock experience for the educators to identify what worked and what did not work during sessions for super users. This made subsequent education sessions flow more smoothly. Individuals who re p o rted previous exposure to electronic records systems a p p e a red to have an easier time c o m p rehending the material and transitioning to the EMR system. Limitations of Overv i e w Training Sessions A limitation to pro v i d i n g o v e rview sessions for super users included the numerous personnel and time re s o u rces necessary to have and attend the sessions. Education sessions increased the operational expenses, primarily associated with session salary re q u i rements. Beginning the education process six months in advance of go-live re q u i re d early commitment of staff time, thus reducing available clinic s t a ff. To appropriately select super users, nurse managers needed training and assistance to understand the re s p o n s i b i l i t i e s of super user and what the ro l e encompassed. O p p o rtunities for Future O v e rview Training sessions T h e re are always ways to i m p rove education sessions, and p roviding super user overv i e w sessions is no diff e rent. For future EMR education sessions, it would be beneficial to have e-learn i n g modules available earlier within the medical center s educational course management application located in Sharepoint. This would allow super users to become comf o rtable with the system s feature s earlier and across the communities with affiliated clinics having smaller staff. The ability to collect data and analyze how many nurses a re practicing on the playgro u n d module would have been useful to determine the level of use for these re s o u rces. The usage re p o rts from the playgro u n d UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 341

6 module would be a method to identify where the clinic nurses used the system to practice, and t h e re f o re, would be better prep a red for the testing sessions and final EMR education sessions for all clinicians, and skilled as a re s o u rce on the day of go-live and after. Conclusion The adoption rate of EMRs in health care settings varies widely, and there are many barriers and risks involved with implementation. One major challenge has been the time commitment involved to learn and use EMRs. Because people learn by diff e re n t methods and at diff e rent rates, some nurses will learn faster and others more slowly. In order for the implementation of an EMR to be effective, there has to be buy-in f rom the top administration down to each employee (Fullerton, Aponte, Hopkins, Bragg, & B a l l a rd, 2006; Houser & Johnson, 2008; Te rry et al., 2008). How much the nurse manager support s and buys into the importance of the EMR correlates with how well super users attend EMR educational sessions and how well prep a red clinicians are when competency checklists are signed off. Without the support of management, nurses would not have the time to attend educational sessions nor practice afterw a rds. If a nurse has limited computer experience, the need for additional time for learning is important and must be set aside. A key factor in how EMR implementation moves forw a rd is dire c t l y related to the level of computer experience the nurse has (Te rry et al., 2008). This article highlighted the importance of super user o v e rview sessions for ambulatory c a re nurses, provided guidance on how to set up overview sessions, and explained the early role of a nursing super user to pre p a re a clinic or ambulatory care setting for an EMR. Those considering implementing EMRs in ambulatory clinic settings should reflect on the following issues: identifying a method to create lesson plans utilizing patient scenarios, building the practice playground environment, identifying the time table with location and dates of training opportunities, soliciting help from nurse managers in re c ruiting super users well in advance, and promoting buy-in f rom nurse managers to encourage their nurses to attend training and practice afterw a rd. This implementation strategy indicates that super user overv i e w training sessions is one method that provides education on the use of electronic health re c o rds to help with a smoother transition with a new system at the time of go-live. Future studies should examine the contribution of super user responsibilities in the overall impact of EMR usage and ongoing training of new employees. R e f e re n c e s Anderson, J.G. (2000). Computer- b a s e d a m b u l a t o ry information systems: Recent developments. The Journ a l of Ambulatory Care Management, 2 3(2), B rown, A.C., Rudman, W.J., Hughes, G.D., Rogers, H., & Smith, J.M. (2002). A d d ressing ambulatory medication e rrors in Mississippi. Topics in Health Information Management, 2 3(2), B u rt, C.W., & Sisk, J.E. (2005). Which physicians and practices are using e l e c t ronic medical re c o rds? H e a l t h A ffairs, 24(5), F u l l e rton, C., Aponte, P., Hopkins, R., III, Bragg, D., & Ballard, D.J. (2006). U rologic Nursing Editorial Board Statements of Discl o s u r e Lessons learned from pilot site implementation of an ambulatory electro n- ic health re c o rd. Baylor University Medical Center Proceedings, 19( 4 ), Halbesleben, J., Wakefield, D., Wa rd, M., B rokel, J., & Crandall, D. (2009). The relationship between super users attitudes and employee experiences with clinical information systems. Medical Care Research & Review, 6 6(1), Houser, S., & Johnson, L. (2008). Perceptions regarding electronic health re c o rd implementation among health information management professionals in Alabama: A statewide s u rvey and analysis. Perspectives in Health Information Management, 5, McCain, C. (2008). The right mix to supp o rt electronic medical re c o rd training. J o u rnal for Nurses in Staff Development, 24(4), Rouf, E., Chumley, H., & Dobbie, A. (2008). Electronic health re c o rds in outpatient clinics: Perspectives of t h i rd year medical students. B M C Medical Education, 8, 13. Simon, S., McCart h y, M., Daushal, R., J e n t e r, C., Volk, L., Poon, E., et al. (2008). Electronic health re c o rd s : Which practices have them, and how are clinicians using them? J o u rnal of Evaluation in Clinical Practice, 14, Te rry, A., Thorpe, C., Giles, G., Brown, J., H a rris, S., Reid, G., et al. (2008). Implementing electronic health re c o rds. Canadian Family Physician, 5 4, Townes, P., Benson, D., Johnston, P., & Vaughn, C. (2000). Making EMRs really work: The Southeast Health Center experience. The Journal of A m b u l a t o ry Care Management, 2 3(2), University of Iowa Hospitals and Clinics. ( ). University of Iowa Health C a re. Retrieved July 30, 2009, fro m w w w. u i h e a l t h c a re. c o m In accordance with ANCC-COA gove rning rules Urologic Nursing E d i t o rial Board statements of disclosure are published with each CNE offe ri n g. The statements of disclosure fo r this offe ring are published below. K aye K. G a i n e s, M S, A R N P, C U N P, disclosed that she is on the Speake r s Bureau fo r P f i ze r, Inc., and Nova rtis Oncology. Susanne A. Q u a l l i ch, A N P - B C, N P - C, C U N P, disclosed that she is on the Consultants Bureau for Coloplast. All other U rologic Nurs i n g E d i t o rial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education art i c l e. 342 UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5