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"Nurses select oncology because of the relationships they are able to build with patients and families, and the clinical challenges. The acuity of patients is such that it's very complex care, so the nurse's role is really critical for positive patient outcomes," she said.

In the survey, nurse executives reported a small pool of qualified applicants as the biggest hiring obstacle.

John Crossley, RN, associate vice president for patient care operations at the University of Texas M.D. Anderson Cancer Center in Houston, agreed. He said the 456-bed hospital has 120 vacancies out of 1,800 RN positions.

"Vacancies do affect patient care to a point," but the level at M.D. Anderson, about 6 percent, is manageable, he said.

Striking a balance

To handle the deficit, the center uses agency and temp oncology RNs, and "we have to be careful not to overload our people with additional responsibilities," Crossley said.

That means trying to even out surgery admissions so demand is even from day to day, installing computerized patient records to reduce nurse time spent on documentation, working on timely delivery of supplies and developing smoother discharge processes.

"We're trying to preserve nursing resources so RNs are used for nursing instead of other tasks," Crossley said.

When care settings are short on staff, oncology nurses perceive worse working conditions, declining quality of care and greater difficulty in keeping experienced RNs, the survey showed. "When you're operating at a shortage, you are so strapped just trying to get basic physical care done that you don't have time to do the extra things that make nursing rewarding, like teaching patients how to manage their chemo and symptoms and giving psychosocial support," Culhane said.

While the survey found shortages across care settings, staffing problems were most severe in inpatient settings: 19 percent of inpatient oncology RNs said they worked on adequately staffed units, compared to 33 percent in hospital-based outpatient clinics and 39 percent in nonhospital clinics and offices.

Now that 80 percent to 90 percent of cancer care occurs in hospital-based outpatient settings, general hospitals have moved the remaining few inpatients from oncology-specific units to mixed units with other types of patients.

"That's a dissatisfier for oncology nurses-they prefer all the oncology patients on one unit," Buerhaus said.

Certified oncology nurse Laura Solano, RN, agreed. She followed her patients and switched within her hospital from the mixed inpatient unit where she was a charge nurse to the outpatient radiation clinic at Sequoia Hospital in Redwood City, Calif.

Oncology nurses in the community general hospital work in a 40-bed inpatient unit that includes oncology, medical, surgical, orthopedic and detox patients, she said. "You have to know a little bit of everything. It's very challenging and the workload is [heavy]. That's why you get burned out."

Solano is happy in the outpatient radiation clinic at Sequoia Hospital. "I really like it. Patients come in every day for about 28 days. I enjoy talking to them and getting to know them," she said.

Solano reflects a positive statistic in oncology and general nursing. Across three recent national surveys-including the oncology survey and the 2002 NURSEWEEK/AONE survey [www.nurseweek.com/survey]-"about three-quarters of nurses say they would recommend nursing as a career to others. That's a pretty important finding," Buerhaus said.

It means there's hope for recruiting new people, including more men and minorities, into the field.

Meeting the challenge

Increasing the pool of all nurses is good for oncology nursing, too, Culhane said. The Oncology Nursing Society and a coalition of RN organizations worked tirelessly on the Nurse Reinvestment Act, signed into law in the summer (although no money has been appropriated as yet). The bill covers recruitment (public service announcements, public education programs, ads), retention (hospital programs) and promotion of more education for the nursing workforce (advanced degrees, nursing faculty, LVNs to RNs, loan forgiveness for working in underserved places).

Hospitals also are working on recruitment, retention and education to solve the problem.

Farquhar credits the 2-year-old Seattle Cancer Care Alliance with creating a positive work climate-good staff, excellent facility education and training, encouragement to become certified in oncology-that is encouraging nurses to stay.

Devine says she has an advantage in recruiting and retaining oncology nurses because "it's an all-oncology unit here. That makes a difference, especially in staff satisfaction," she said.

Devine is also president of Denver's metro ONS chapter, which participates in the national ONS mentorship program with area elementary, junior high and high schools, and provides educational opportunities for nursing students, "so they get an idea of oncology nursing as a specialty," Devine said.

"I feel we're very visible and vibrant as an organization that supports oncology nursing excellence."

Nurses agree that solving the oncology nursing shortage will require many actions-most of them similar to dealing with the overall shortage-by people game for challenge.

Fortunately, those are the type of people oncology nursing attracts.

Contact Heather Rock Woods at hrwoods@earthlink.net