January 26, 2024
10 min read
By 2030, all members of the Baby Boom generation will be aged 65 years or older.
If current workforce trends continue, the supply of nurses available to care for this aging population will fall far short of demand.
A 2022 nursing workforce analysis published in Health Affairs showed that the number of registered nurses in the United States dropped by more than 100,000 between 2020 and 2021 — the largest 1-year decline in the past 4 decades. A substantial proportion of the nurses who left the field were younger than age 35, and most worked in hospitals.
Another report published by analysts at McKinsey & Company estimated that the shortfall of nurses needed to provide adequate patient care in the U.S. may reach 450,000 by 2025.
The nationwide nursing shortage has been profoundly felt in oncology, which presents unique challenges and requires specialized skills from practitioners.
Sarah Currie
“The current challenges for staffing in nursing are unlike anything we have seen in a generation, and strategies we have used previously to solve shortages are likely not to work moving forward,” Sarah Currie, RNC, MSN, NEA-BC, chief nursing executive and senior vice president at St. Jude Children’s Research Hospital, told Healio. “Given the national nursing shortage and the impact of COVID-19, with nurses leaving the profession, it is more important than ever to support and retain experienced oncology nurses, recruit experienced nurses and have a strong transition-to-practice program for graduate nurses.”
Healio spoke with leaders in the oncology nursing field about the factors contributing to the workforce shortage, what health care organizations can do to retain current staff, and what can be done to encourage and recruit nurses to join the specialty.
Convergence of factors
The reasons for the broad nursing shortage are multifaceted, and the complexity and stresses associated with oncology nursing compound the problem.
Historically, nursing school graduates gained work experience before transitioning to cancer care. Additionally, nursing school graduates often have limited exposure to oncology during their schooling, according to Vicki Caraway, RN, BSN, MBA, NE-BC, vice president and chief nursing officer at Miami Cancer Institute, part of Baptist Health South Florida.
“There has been a thought process for a long time that you don’t take new graduates into oncology,” Caraway told Healio. “That’s changed now, and we have lots of programs to support new nurses and bring them into oncology sooner rather than later.”
Danya Garner, PhD, RN, NPD-BC, OCN, CCRN, president of Oncology Nursing Society (ONS), agreed that earlier educational exposure to oncology should be a priority to strengthen the specialty’s nursing workforce.
“Turnover is an ongoing challenge, and first and foremost in developing the pipeline is educating prelicensure nursing students about the opportunities in oncology nursing,” Garner told Healio. “There is little oncology content in the curriculum and limited oncology faculty. Yet, over the course of a nurse’s career, there is a high likelihood of caring for someone with cancer.”
National nursing shortage projections may not reflect reality in every area of the country.
According to the Health Resources and Services Administration, the extent of the shortage varies substantially across states. The administration projects a 26% projected shortage in Washington by 2035, but an estimated 48% oversupply in North Dakota at that same time.
The 10 states expected to have the greatest shortfall in 2035 are Washington (26%), Georgia (21%), California (18%), Oregon (16%), Michigan (15%), Idaho (15%), Louisiana (13%), North Carolina (13%), New Jersey (12%) and South Carolina (11%).
The COVID-19 pandemic has had a considerable impact on nursing overall and specifically in oncology. For oncology nurses who already felt overwhelmed by staffing challenges and burnout, the global pandemic exacerbated this situation.
Burnout and related issues have led to nursing attrition across generations, according to Misty Evans, DNP, APRN, CPNP-AC, BMTCN, associate professor in the pediatric nursing practitioner acute care program at Vanderbilt University School of Nursing and an advanced practice provider at Sarah Cannon Pediatric Transplant & Cellular Therapy Program At TriStar Centennial.
“We saw a huge decline during COVID, with young nurses leaving the workforce due to burnout and other challenges,” Evans told Healio. “We’ve also had experienced nurses — who we thought might continue working until 2030 — who have decided to go ahead and retire early.”
The pandemic also presented opportunities for nurses to take traveling positions, transitions that have come at the expense of full-time institutional nursing jobs.
“The pandemic obviously created these opportunities for oncology nurses to travel,” Caraway said. “Some of them decided to travel and maybe found another niche, or maybe just decided to keep traveling.”
The shortage also exists at a faculty level, leading some nursing schools to limit enrollment due to an inadequate number of instructors.
A 2022 special survey on vacant faculty positions published by American Association of Colleges of Nursing identified 2,166 full-time faculty vacancies across 909 nursing schools with baccalaureate and/or graduate programs in the United States.
“There’s [an] issue [with] having enough educators to fill faculty positions to teach students in order for them to become trained nurses,” Evans said.
Impacts on patient care
As the population ages, and as the profession contends with new challenges engendered by the COVID-19 pandemic, the nursing shortage likely will have a profound effect on the delivery of oncology care.
“We’re all aware that health care occurs in an interprofessional environment,” Garner said.
“For example, [the shortage] can be felt by the provider or physician writing orders for admission for an oncology patient. If you don’t have enough nurses there to carry out those orders, this can delay admission of that patient to start receiving their cancer treatment,” Garner added. “You need the nurses to be there, working in tandem with the physician.”
Additionally, the rapid evolution of cancer treatment requires nurses who are aware of and trained in the use of novel therapies, Evans said.
“Oncology care is becoming more complex, with therapies such as [chimeric antigen receptor T cells] and new indications for transplant. Specialized hematology/oncology nursing care is important in every step along that continuum of care, from diagnosis through survivorship,” Evans said. “We have had to get very creative in educating the nurses we have. We always want to deliver high-quality, high-standard care, so we have to make sure we’re providing the education those nurses need to do that.”
A nursing shortage would be especially challenging in the context of pediatric oncology, “taking burnout to the next level,” Currie said.
“A lack of skilled nurses within our St. Jude nursing workforce could impact the delivery of care within our hospital walls, which is critical to [our] mission,” Currie told Healio. “Danny Thomas built St. Jude to discover cures and save lives, and you cannot undergo any of the research unless you have highly qualified nurses to physically administer the medicines, assess for tolerance, monitor for side effects and care for the patients.”
ONS efforts
ONS has made concerted, multifaceted efforts to address the projected shortage of nurses, Garner said.
“One of our most important goals is to increase and retain the number of nurses in the profession,” he said. “Some of our chapters have participated in high school career days to educate students about nursing. Chapters also connect with the schools of nursing in their area to engage students who may be interested in learning more about oncology.”
Garner discussed ONS’s Learning Extension Activities Plan (LEAP), which provides an opportunity for nursing students to further refine their knowledge of topics included in the society’s Cancer Basics course. The educational offering is an introduction to caring for patients with cancer throughout the disease course.
The LEAP curriculum includes four modules with activities through which instructors can encourage additional oncology training. These modules feature the basics of cancer, treatment modalities, symptom management, cancer treatment and more.
“LEAP is a bridge to help nursing faculty who may not be oncology nursing faculty to expand their oncology knowledge and impart that to nursing students, as well,” Garner said.
Additionally, the Oncology Nursing Foundation arm of ONS offers scholarships for nurses looking to complete their initial licensure or obtain advanced degrees to pursue careers as nurse practitioners.
“We consistently hear that there is an insufficient number of nurse practitioners with a foundation in oncology,” Garner said. “According to the Bureau of Labor Statistics, approximately 30,300 new advanced practice nurses will be needed each year through 2031 to meet the rising demand for care.”
To address this need, ONS offers competencies and standards of practice for oncology nurse practitioners, with a certification exam for the role.
“We have tailored resources to support the training of oncology nurse practitioners,” Garner said.
Early exposure to oncology
During Caraway’s tenure as chief nursing officer at Baptist Health, she has been dedicated to attracting and retaining quality nurses.
Within a year and a half, she reduced the hospital’s nursing turnover from about 28% to between 8% and 10%.
She said she achieved this “through a lot of hard work and teamwork.”
She emphasized the importance of exposing nursing students to oncology as early as possible and bolstering this training through a strong oncology nursing residency program.
“The idea is to get [new graduates] connected early with really strong preceptors, have a great onboarding and orientation program, and then have residency programs with people there to support them,” Caraway said. “You’ve got to expose people to oncology in school to get them to understand what it is. Then they fall in love.”
Although St. Jude did not experience the same loss of nurses as other institutions during the pandemic, the institution was “impacted by nurse turnover and dwindling applicant pools,” Currie said.
The organization decided to revise its residency program, established in 2012.
The revamp began in 2021, and St. Jude enrolled its first residents into the new model in 2022. The revision included program expansion, a new structure, and incorporation of enculturation activities that has “all but eliminated” attrition and turnover at St. Jude among early-career nurses, Currie said.
“Noting both the institutional and national trends, our organization and nurse leaders have kept nurse retention as a primary focus,” she said. “Revision of our residency program was a strategic initiative to stay relevant amidst a volatile nurse hiring environment.”
Evans agreed that, given the need for trained nurses and the availability of specialized training, new graduates should have the opportunity to work in oncology as soon as possible.
“It used to be that new graduates had to spend a couple of years in general medicine or surgery, and really hone in on and master those clinical skills before they could move into oncology-based units,” she said. “Now we have nurse residency programs that have increased the specialized training for new graduates.”
As new graduates, these nurses can be hired into pediatric oncology, adult oncology or transplant units, and they have dedicated classroom time during their residencies to learn more about patients, treatments, outcomes and supportive care, Evans said.
Institutions also must understand the importance of acquiring and retaining oncology nursing faculty. Evans cited the Health Resources and Services Administration’s Nurse Faculty Loan program.
“This program provides opportunities for nurses to receive financial support for continuing education, as long as they agree to teach afterward,” she said. “I think nursing schools recognize the need to retain faculty.”
Culture of support
Caraway emphasized the value of establishing an atmosphere of respect and communication in her role as a leader.
“The foundation is important. You have to set that culture as a leader by being transparent and available,” she said. “I do CNO town halls, and quarterly CNO coffee meetings, where I randomly invite 10 to 15 nurses, and we have conversations about what’s important to them, what’s working, what’s not working. What they bring up drives my work.”
Caraway also participates in “culture labs” as part of her nursing team’s regular activities. These 15-minute online sessions are dedicated to discussing issues around teamwork and collaborative spirit.
“This helps to level the playing field for all levels of the organization to work together,” Caraway said. “Nurses do not work in a silo, and it is key to develop relationships across the organization that serves our patients.”
“We started out with our leaders in charge of these culture labs, but we decided that the staff needed to lead these,” she said. “It’s usually two people who lead it every week, and our executive leaders log in, as well. Every level of the organization is there. We get to know each other, and we all walk away feeling enthusiastic.”
St. Jude also has invested time to create a workplace culture that engages and values its members, Currie said. St. Jude adheres to the concept of whole-person care and seeks to help nurses with their professional and personal development, she added.
“We know life exists outside our walls, and we want to make sure our nurses are successful at work and at home,” Currie said.
“These new strategies have created a strong community within our residency cohorts, where they have significant shared experiences and get the support they need,” she added. “The result of our work has been a reduction in turnover from 25% to less than 5% among our new graduate nurses.”
Engaging with professional societies
Another valuable way to promote retention of oncology nurses is by connecting them to professional organizations and resources, Evans said.
Professional societies offer valuable educational opportunities and chances to network with colleagues from across the country.
“We have the Oncology Nursing Society, and we have nursing organizations specifically for pediatric oncology nurses,” she said. “We also have other kinds of professional medical organizations, such as ASCO and Association of Science and Technology Centers, that are supporting our nurses. I think that kind of support and professional growth is going to increase nursing satisfaction in the job.”
Institutions also can support nurses as they pursue additional oncology certification. Evans said Sarah Cannon, the cancer network of HCA Healthcare, supports nurses as they earn additional oncology credentials, such as certification as a blood and marrow transplant nurse or Oncology Nursing Certification Corporation certification.
“HCA Healthcare supports them by paying for the test, and they get a bonus if they pass the exam,” she said. “That’s job satisfaction. That’s knowledge and professional growth, and it’s a demonstration of competency in taking care of this population, which is wonderful.” – by Jennifer Byrne
References:
For more information:
Vicki Caraway, RN, BSN, MBA, NE-BC, can be reached at Miami Cancer Institute and Baptist Health Cancer Care, 8900 Kendall Drive, Miami, FL 33176; email: [email protected].
Sarah Currie, RNC, MSN, NEA-BC, can be reached at St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678; email: [email protected].
Misty Evans, DNP, APRN, CPNP-AC, BMTCN, can be reached at Vanderbilt University School of Nursing, 461 21st Ave. South, Room 306, Godchaux Hall, Nashville, TN 37240; email: [email protected].
Danya Garner, PhD, RN, NPD-BC, OCN, CCRN, can be reached at Oncology Nursing Society, 125 Enterprise Ave., Pittsburgh, PA 15275; email: [email protected].
Sources/Disclosures
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Disclosures:
Caraway, Currie and Garner report no relevant financial disclosures. Evans reports a consultant role with Vertex Pharmaceuticals.