Oncology Nursing: Quo Vadis? A 30-Year Perspective

ABSTRACT: "From My Viewpoint" features essays by experts on vital issues in cancer care. This month, Pearl Moore, RN, provides a thoughtful perspective on the impact of advances in cancer medicine on the practice of oncology nursing. She discusses how treatment and management innovations have deepened and enriched the field, but also have posed new challenges. In 1975, Ms. Moore cofounded the Oncology Nursing Society (ONS), a professional organization that has grown to include more than 32,000 registered nurses and other health care providers. She currently serves as the society's chief executive officer, but will retire from the ONS in January 2007.

The myriad changes that oncology physicians have experienced in the last 20 years are certainly applicable to oncology nurses, in particular, the technology explosion and its effects on diagnosis, treatment, and survivorship; the emergence of cancer as a disease of the elderly; challenges posed by shortages of health care workers; and the fact that almost all cancer patients today are treated as outpatients. Recent therapeutic innovations and management approaches have been keenly felt by oncology nurses, who typically play a major role in patient education.

When I was doing clinical work about 23 years ago, patients receiving cisplatinum often would be in the hospital 2 to 3 days for hydration, followed by a couple of days for their treatment and then a few more days for post-therapy hydration. Many were patients with brain tumors and were inpatients for the entire 6 weeks of their course of radiation, and that's unheard of today.

Of course, treatment choices have changed radically, with increasing attention given to chemotherapy (even for cancers that used to be treated primarily with radiation), as well as biotherapy and molecular-targeted and genetics-based treatments, and new challenges have emerged as a result of these improvements in care.

Many medical advances over the last few decades have occurred in areas in which oncology nursing has traditionally been strongest: symptom management, survivorship, and detection and prevention. In symptom management the oncology nurse has tremendous influence on outcome, by using a variety of techniques to improve patients' functional status, keep them moving, and ease them back into family or community roles, while providing psychological support.

The relatively recent availability of agents to manage nausea and vomiting, as well as anemia and fatigue, has enabled us to significantly improve cancer patients' quality of life.

Better Informed Patients

Another dramatic change is that patients are much better informed, because they have used the Internet to educate themselves about their disease. You can talk with patients at length, and they ask intelligent questions about their treatment options. This is very positive.

The other side of this, however, is that often patients have received some bad information, so the oncology nurse has to help them wade through all of it and direct them to good resources. Patients also ask about clinical trials, and often they have thoroughly researched the various available studies. Here is where patient advocacy groups have had a major influence, again, with patients being much more knowledgeable about appropriate treatment.

The trend toward oral chemotherapy poses a huge challenge for us, because it means less time spent with the patient and, therefore, less time to educate patients about a treatment and its side effects. When patients were receiving intravenous chemotherapy, the nurse might be with them for an hour, or at least for a period of time sufficient to convey important outcome-related information.

The irony is that, today, much more patient education is needed regarding oral agents, to ensure that patients are in compliance with their treatment, understand the side effects, and know when to contact the oncology nurse.

Yet these patients may not be coming into the office or the clinic. As a result, nurses whose patients are on oral chemotherapy will have to do more telephone work. Every office visit with the patient will have to be maximized. Nurses are also increasingly using patient-education tools as aids.

Increased survivorship presents a challenge for oncology nurses because of comorbidity issues, late effects of treatment, and second cancers. When one factors the current nursing shortage and limited time with patients into the equation, the difficulty is compounded. The oncology nurse of today must be a capable patient navigator to prevent patients from getting "lost" in the system, because follow-up is essential and we want patients to get reconnected with their primary care physicians or to stay on schedule with follow-up visits to their oncologists.

In addition, oncology nurses are beginning to play an important role in prevention and detection; we really haven't done as much as we could do, but I think nursing efforts will be key in areas such as tobacco cessation. There is a new cervical cancer vaccine that will eventually be in the marketplace, and I expect we will be very active in education about that. We have always talked about the importance of diet and nutrition in cancer prevention, and have encouraged patients to be screened for breast, prostate, and colorectal cancer, and that role is likely to expand as well.

Financial and health care economic factors, as well as expanded career options, have contributed to the current shortage of nurses, including nursing school faculty, and the Oncology Nursing Society (ONS) has campaigned aggressively to turn this around. Critical care units and emergency units have experienced worse declines in staff numbers, but oncology nursing has also seen a shortfall. The average age for nurses in the ONS is 45, so many are not far from retirement. Retention has also been a problem; oncology nursing is very challenging and the work schedule can sometimes compound the problem, so sometimes nurses choose to leave the field.

The ONS has spearheaded a variety of outreach efforts to bring people into the specialty. These have included masses of printed material, films about oncology nursing, projects with our chapters, and job shadowing and mentoring programs in which nurses can get a good feel for the day-to-day aspects of the work while pairing with experienced mentors who can help them through the rough times.

We have a partnership program with the National Student Nurses Association (NSNA) so that nurses with some interest in oncology can become members of ONS at reduced rates; we have a virtual page directed at these students on the ONS website (www.ons.org), and we disseminate a newsletter to encourage students to enter the field of oncology nursing. We send extensive mailings about all of our conferences, publications, and distance learning programs to nursing schools and hospitals across the country.

We are constantly marketing the Society and all it offers, not only to bring people into the field but perhaps more important to retain nurses who are already working in our specialty, by keeping them up-to-date and reinvigorated.

Although huge numbers of nurses attend our conferences, many nurses may not be able to participate in person because of understaffing at their institutions, so the ONS has been proactive in providing regional programming, as well as a variety of distance learning courses, webcasts, virtual sessions from our annual Congress, teleconferences, and print-based materials.

Advanced Practice Roles

As the practice of cancer medicine has evolved, so have the job functions of the oncology nurse diverged into a variety of advanced practice roles. Our membership includes clinical nurse specialists and nurse practitioners, for example. Oncology nurse certification, which began through the Oncology Nursing Certification Corporation in the mid-1980s, has expanded exponentially. We now have more than 21,000 oncology certified nurses as well as advanced oncology certified nurses and certified pediatric oncology nurses. Our newest areas of advanced certification are advanced oncology certified nurse practitioners and advanced oncology clinical nurse specialists. This process is an essential indicator of competency and illustrates the ever-growing diversity of expertise within the field of oncology nursing.