Oncology Nurse Shortage ‘Will Get Worse Before It Gets Better’

PITTSBURGH—Two recent reports by the Health Resources and Services Administration spotlight a difficult situation in health care today, both for providers and patients. The agency’s 2000 "National Sample Survey of Registered Nurses" found a significant decline in the rate of increase for people entering nursing—from 14.2% between 1992 and 1996, to 4.1% between 1996 and 2000—at a time of greater population growth and aging.

Its study "Nurse Staffing and Patient Outcomes in Hospitals," based on data from 1997, found a strong and consistent relationship between a higher number of nurses and a reduction in adverse outcomes in five areas—urinary tract infection, pneumonia, shock, upper gastrointestinal bleeding, and length of stay. The message: Fewer nurses will mean poorer outcomes.

Oncology has not been spared from the problem, as Oncology Nursing Society (ONS) chief executive officer Pearl Moore, RN, MN, FAAN, details in this interview with Patrick Young, ONI’s Washington Bureau Chief.

Ms. Moore, adjunct assistant professor at the University of Pittsburgh School of Nursing, helped to pioneer her field as one of the nation’s first oncology clinical nurse specialists. She later served as the first coordinator of the Brain Tumor Study Group, and was one of the 250 nurses who founded ONS in 1975. In the early 1980s, she became the Society’s first executive director.

ONI: Is there a shortage of oncology nurses?

Ms. Moore: There is a shortage in all of nursing that is becoming very severe. We first saw it in emergency room and critical care units, but now we are definitely hearing about it in oncology.

One of our board members recently attended a meeting of comprehensive cancer center directors of nursing, and many of them were even talking about taking nurses right out of school. Oncology units used to be able to get more experienced nurses, but now they really have a severe problem. We are hearing more and more of this.

ONI: What are the major factors behind the problem?

Ms. Moore: For all of nursing, there are several factors. First of all, there are a lot of opportunities now for young people, especially young women, other than nursing. So young people are not entering nursing the way they used to do.

Another factor is that early in the 1990s, we saw major changes in health care—the managed care movement, the movement out of hospitals and into the ambulatory setting, and financial cutbacks. With that, many oncology units closed, and a number of nurses were out of work or had problems getting employment, particularly those who were clinical specialists or master’s-prepared nurses.

So, with that happening, schools of nursing began to cut back enrollment, and some even closed. Now, we have a shortage, but we can’t accept additional young people into nursing programs because there are not enough spots.

ONI: Why can’t the nursing schools simply expand and hire more faculty?

Ms. Moore: You have to have a certain level of education to be in a faculty position. Usually faculty members have doctorates, and many have now moved into other fields. We need to increase nursing faculty so that we can improve nursing education, but that is going to take some time.

Another thing about the shortage is that the average age of the nurse now is 44. We can predict that 15 years from now there will be a lot of people retiring, and we are not going to have the nurses to replace them. It is a much older workforce, and we haven’t seen that before.

So, to recap, you don’t have people entering nursing, you have an aging workforce, and retention is a severe problem.

ONI: Why is there a problem with retention?

Ms. Moore: Because staffing levels are so low, most cancer centers require severe mandatory overtime, which is causing great consternation and stress. Salaries and benefits are still issues that affect retention. Oncology then compounds all that with severely ill patients who require a great deal of nursing care.

ONI: Is it a problem of respect between oncologists and oncology nurses?

Ms. Moore: You often hear about difficulties between physicians and nurses in other areas, but that is not true in oncology nursing. We have a great collegial relationship. In fact, our physician colleagues are very concerned about the nursing shortage.

ONI: If you would, go back and talk about the problems that managed care and cost containment programs have had on oncology nursing.

Ms. Moore: First, a number of dedicated oncology units closed because it was thought that the beds weren’t needed. Administration of chemotherapy, for which patients once had to be admitted, is now done on an outpatient basis.

Sometimes patients were admitted for a course of radiation therapy or for part of the treatment, but now it is all outpatient. So without those beds, there wasn’t as much need for oncology nurses.

Second, as reimbursement changed, hospitals looked to save dollars, and nursing salaries suffered.

Third, in cancer care, we had many master’s-prepared nurses, clinical specialists, who are the key to good nursing care. They do staff and patient education; they do assessments; they coordinate care.

Clinical specialists are important to the care of cancer patients, but expensive. Administrators weren’t getting reimbursements as much as formerly, so they cut down on clinical specialists. Now we need the clinical specialists back. But because the shortage is acute at every level, there are not enough nurses to hire.

ONI: What are some of the opportunities that have opened up for oncology nurses outside of the traditional hospital setting?

Ms. Moore: Certainly, there are opportunities in ambulatory settings and as office or clinic nurses. Home care and hospice are other areas. Many nurses, particularly the ones with doctorates, are working in the pharmaceutical industry or doing nursing research. Some have gone into business for themselves or have taken management positions.

You name it, the opportunity is there. When you get discouraged enough and unhappy enough, you leave the field totally, and we are seeing that happening, sad to say.

ONI: What is being done to alleviate the problem?

Ms. Moore: We know there are some bills being written at the federal level that should help with issues such as mandatory overtime, scholarships for nurses, and loan forgiveness. There may be legislation related to staffing patterns and the appropriate number of nurses per patient. There is even talk of developing a nurse corps. The federal government is going to have to step in, and we are going to actively support appropriate federal legislation.

We are also active in a coalition called "Nurses for a Healthier Tomorrow," in which about 20 nursing organizations are pulling together to encourage people to go into nursing.

In oncology, ONS is working on a job-shadowing program for young people to get them to go into nursing and to tell them about oncology nursing.

ONI: Sort of an early mentoring program?

Ms. Moore: Yes. We are also seeking funding to bring people enrolled in nursing programs to our annual meeting to get them thinking about oncology nursing.

We have completed a huge workforce study that we will release soon, which will give hard data about what is going on in oncology nursing. The survey went to administrators, nurses, and oncologists, who had the best return rate.

When we have these data, the next stage will be to look at outcomes. What, for example, do these data actually mean in relationship to outcomes when you have certain staffing levels?

We are also going to have a retreat for administrators and educators to look at the results of this workforce study, and to put our heads together in a collaboration between ONS and the folks in the trenches to address the issues: "What can we do?" "How can we get people to come into oncology and stay?" We are talking about taking specific actions.

ONI: What do you see as the prospects for oncology nursing over the next 5 to 10 years?

Ms. Moore: I think it is worrisome, and it is going to get worse before it gets better. A lot of steps are being taken, and it will turn around. But there will be some tough times for a while.