Imagine that you, a member of your family or a close friend was suffering from cancer and none of the hospitals in your locality had enough nurses on staff to provide safe, quality care. Now multiply that scenario by millions of Americans and you have a full-scale national emergency in the making.
Oncology nursing is a specialty that is currently facing a grave shortage of workers—a shortfall that could increase to crisis proportions over the next 10 years. According to a study published in the September/October 2001 issue of Nursing Economic$, oncology practitioners fear that the shrinking cancer nursing work force will not be sufficient to meet the demands of America’s 80 million baby boomers as they age.
The study, led by Peter Buerhaus, RN, PhD, FAAN, associate dean for research at Vanderbilt University School of Nursing in Nashville, warns that “nurse executives report great difficulty retaining experienced RNs, a lack of qualified applicants for open positions, and virtually no one believes there will be enough RNs in total, and oncology RNs specifically, in 10 years.”
Combine this alarming trend with the fact that cancer is one of the six critical target areas of the Department of Health and Human Services (HHS) initiative to eliminate racial and ethnic disparities in health outcomes by the year 2010, and the result is a field where minority nurses are not only urgently needed but can also make a life-or-death difference in their communities.
“Oncology nursing is a great field to get into, especially if you want to be involved in improving the health of minority populations,” says Mylene Perez, RN, OCN, BSN, head of the Oncology and Renal department at Dekalb Medical Center in Decatur, Ga. “People of color are at a disproportionately high risk for nearly all types of cancer.”
Perez, who is Filipino American, says she would strongly encourage minority nursing students to look into careers in cancer nursing. “If you are someone who has a strong need to help your own people, this is the right field for you,” she emphasizes. “In oncology nursing, you can really make a difference in the entire community–not just by caring for patients but also by providing screening and preventive education to the people around them.”
A Deadly Disparity
While cancer is a serious health threat for all Americans, this deadly disease is not an equal opportunity killer. Numerous studies have confirmed that racial and ethnic minorities are at a far higher risk of developing cancer than their Caucasian counterparts. Consider these chilling examples from HHS’ Office of Minority Health:
- The incidence rate for lung cancer is about 50% higher for black men than white men.
- Native Hawaiian men have elevated rates of lung cancer compared to Caucasian men.
- Alaska Native men and women suffer disproportionately higher rates of colo-rectal and gastric cancer than do whites.
- Vietnamese women in the U.S. have a cervical cancer incidence rate five times greater than that of white women. Hispanic women also suffer elevated rates of cervical cancer.
This trend of unequal outcomes is even more starkly revealed when looking at cancer mortality rates. For example:
- For men and women combined, blacks have a cancer death rate about 35% higher than for whites, and black men are 50% more likely to die from the disease than white men.
- The death rate for lung cancer is about 27 percent higher for blacks than whites.
- The prostate cancer mortality rate for black men is more than twice that of white men.
- Native Hawaiian and Alaska Native women have the highest breast cancer death rates in the U.S. And while African-American women have a lower risk of developing breast cancer than white women, they are 20% more likely to die from the disease.
What’s the reason for these shocking disparities? Eula Keen-Woods, RN, MHSM, CCRP, believes one of the key factors is that minority cancer patients are less likely to seek treatment early compared to Caucasians. “Sometimes they are in denial,” explains Keen-Woods, who is African American. “If they don’t have a family history of breast cancer, for example, they think they are probably not going to get the disease.”
Perez, who is president of the Philippine Nurses Association of Georgia, adds that underserved minority populations’ lack of access to information about cancer, combined with socioeconomic issues such as lack of insurance coverage, also create significant barriers to equal opportunity in cancer treatment.
“Because many minorities live in poverty, as I did when I was growing up, we don’t always get the screenings and preventive measures that we need,” she says. “And then when we do find out [we have cancer], we often don’t have the financial resources to go out and get treatment for it.”
Still another factor that tilts the balance of equal cancer outcomes unfairly towards Caucasians is the historical underrepresentation of minorities in clinical trials for new cancer treatments. As a result, says Bertie Ford, RN, MS, AOCN, an African-American clinical research nurse who works for the pharmaceutical/biotechnology firm Amgen, there is a serious lack of clinical data about which therapies are effective or not effective for patients from minority populations.
“We need more diversity in these trials,” asserts Ford, who is involved in STAR (Study of Tamoxifen and Raloxifene), a first-of-its-kind large-scale national clinical trial of breast cancer treatments that is actively recruiting minority women.
The low numbers of minority patients who participate in trials of experimental cancer treatments may be a reflection of a lack of diversity among the researchers who recruit participants for these studies, Ford adds. “One reason a lot of [minorities] don’t enter clinical trials is because they don’t see many recruiters who look like them.”
However, this research gap is beginning to narrow, she reports. Over the past few years, leading cancer research organizations have been developing strategies to increase the representation of minority patients in major studies like STAR, which is part of the National Interest Research Group’s National Surgical Adjuvant Breast and Bowel Project.
The National Cancer Institute (NCI) has recently launched a new $60 million program, Special Populations Networks for Cancer Awareness Research and Training (SPN), designed to specifically address minority cancer disparities and encourage greater minority enrollment in clinical trials. The federal agency says its ongoing efforts have already increased minority participation to nearly 20%.
Culturally Competent Cancer Care
Many nurses of color in the oncology field agree that increasing the number of nurses who not only look like their minority patients but also share their cultural and linguistic heritage can play a big part in eliminating some of these unequal health outcomes. Rustica “Rusty” Aujero, RN, BSN, a Filipino-American nurse who works on the GYN/Oncology floor at Duke University Medical Center in Durham, N.C., feels that culturally sensitive care is key in cancer nursing.
“Sometimes [minority] patients do not respond to the nurses or they are not cooperative, because they are afraid to do what you are telling them,” Aujero explains. “Often this is due to cultural misunderstandings, such as the patient’s lack of experience with Western-style medicine, so it is very important to know about, and be sensitive to, their background.”
Karen Taoka, RN, MN, AOCN, a case manager for cancer patients at the Queen’s Medical Center on the island of Oahu, Hawaii, holds a similar view. “The concept of caring for the whole person is basic to nursing,” she says. “As the U.S. population becomes more and more multicultural, the concept that a minority patient would benefit from having a nurse of the same ethnic background care for him or her is becoming increasingly important.”
Taoka, who is a third generation Japanese American, admits that this could be seen as a very narrow viewpoint, and she stresses that each patient should be treated as an individual. “But I think that if a nurse has some sense of, or at least some appreciation of, the patient’s cultural and ethnic identity, background and values, it can often make a world of difference,” she maintains.
Perla Torres, RN, BSN, AONC, CPON, a native of the Philippines, agrees that minority cancer patients often feel more comfortable being cared for by a minority nurse. A former pediatric oncology specialist who is now retired, Torres still volunteers at Operation Samahan, Inc., a family health and social services center that has two sites in the San Diego area and serves many Filipino patients.
Working with her own people is particularly rewarding for her, she says, because it is an opportunity to help the patients through a process that often terrifies them. “Some of them are not knowledgeable about cancer treatments,” she notes. “They come to the center knowing very little about medical issues and some of them really need help.”
For immigrant patients with limited knowledge of English, having a nurse who speaks their native language can also help break down barriers to effective cancer care. “This can make it much easier for both the patients and their families to communicate with their care providers,” says Torres, who also speaks Spanish. “These types of patients really need me.”
Rosario Nievera, RN, BSN, a Filipino-American nurse from Ballwin, Mo., who specializes in cardiology, knows first-hand how crucial it is for minority cancer patients to receive culturally competent care. She lost a brother to thyroid cancer and a sister-in-law to stomach cancer. Immigrant patients often have specific customs and traditions that can impact their receptiveness to care, Nievera points out.
“Cancer patients have many emotional needs,” she adds. “If their disease is terminal, they know they are going to die sooner or later. Psychologically, just the mere presence of someone who shares their cultural background makes them feel better. They can relate to us.”
In response to these needs, the Oncology Nursing Society (ONS), a national association that represents over 30,000 RNs and other cancer care professionals, is taking steps to help cancer nurses provide culturally sensitive care to minority patients. In 1995 the society convened a Multicultural Outcomes Team to provide its members with information and resources to help them gain cultural competence in practice, education and research. The team’s first project was the development of ONS Multicultural Outcomes: Guidelines for Cultural Competence, which was published in 1999.
To help nurses translate these guidelines into practical applications, ONS offers Multicultural Tool Kit, designed to give users “fundamental knowledge for providing culturally competent care to individuals, families and communities from various ethnic, religious, cultural or social settings.” Available through the Education section of the society’s Web site, www.ons.org the kit offers such resources as a PowerPoint slide presentation that can be used for classroom instruction, questionnaires for pre-assessing students’ cultural knowledge and a Transcultural Nursing Assessment Guide.
How many minority cancer nurses are there? According to Hank Walshak, the Oncology Nursing Society’s public relations manager, nurses of color comprise approximately 9% of >the society’s membership as of October 1, 2001 —but the actual percentage is probably higher. “That’s because our member surveys allow people to respond [to the question about their race or ethnicity] by checking the categories of ‘Other’ or ‘Do not care to respond,’” he explains.
Many of the nurses interviewed for this article say the number of minority nurses in the oncology field reflects the percentage of minorities in the total RN population—i.e., about 13%–and that the shortage of oncology nurses parallels the national nursing shortage. As a result, job opportunities for nurses of color who have specialized oncology knowledge and skills are readily available—and not just in the clinical setting.
“Many people still think that nurses only work at the bedside or teach,” says Amgen’s Ford. “But now [the health care and pharmaceutical] industry has really started to flood the market with jobs for nurses. For instance, my company is planning to hire several more nurses in the near future, and they will be looking at the top nurses in the field.”
Sandra Millon Underwood, RN, PhD, FAAN, an African-American cancer researcher and educator who recently received the National Black Nurses Association’s Nurse Researcher of the Year award, agrees that oncology nursing offers a wide variety of career opportunities on many different levels. For example, she says, there are many clinical positions currently available in hospitals—including those that specialize exclusively in cancer care–as well as in community health facilities that focus on acute care. Nurses are also urgently needed to fill positions in community education, cancer prevention and early detection programs. Nurses with master’s degrees have more options, Underwood adds, and those with PhDs and beyond can work in research, management, education and policy.
Underwood is the American Cancer Society Harley Davidson Oncology Nursing Professor at the University of Wisconsin in Milwaukee. Part of her role in this professorship, which was established to enhance the care of cancer patients, their families and those at risk of developing the disease, is to advance the ACS’ mission through professional and public education, and to promote cancer research and prevention.
Preventing cancer before it strikes is the area where the need for oncology nurses is greatest, Underwood believes. “In fact, you don’t even need to be an oncology nursing specialist to do this,” she says. “My feeling is that all nurses, however they are employed, can take advantage of opportunities to present information about cancer prevention and screening to the patients and communities they serve.
“This isn’t to say we don’t need skilled nurses to provide cancer treatment in clinics and hospices, because we do,” she continues. “But I think the greater good can be accomplished by reducing the risk of cancer in the first place, through prevention and early detection.”
Bettina Willis, RN, MS, associate director of nursing for Medicine (which includes the oncology department) at the University Hospital of the Downtown Medical Center in Queens, N.Y., also sees this community outreach function as an important need that minority nurses can fill. Willis, who is African American, has worked as a cancer prevention educator in the Arthur Ashe Institute of Urban Health’s Black Pearls: Health and Beauty Outreach for Black Women program, which uses hair salons as sites for providing health education and screening to black women in inner city neighborhoods.
The Black Pearls program uses community residents, local health professionals and participating salons to teach women about health issues like breast cancer, sexual health, smoking cessation, heart disease, high blood pressure, nutrition and organ donation. The participants watch a film while they are getting their hair or nails done, then listen as the educators discuss information about disease prevention and early detection.
“We are fortunate that the institute has asked black nurses to participate in this program, because it is a very effective way we can reach our own people with this important information,” says Willis. “There are many young people who don’t really know about cancer screening and the importance of early detection. Every time I have helped them learn about it, it’s been a very gratifying experience.”
Whether they choose to focus on treatment, prevention, research or teaching, minority nurses can make important contributions in virtually every aspect of oncology nursing. “We need more nurses in areas like bone marrow transplant, chemotherapy and radiation, and genetic counseling,” Willis emphasizes. “Our country’s population is getting older, the baby boomers are getting older. We need that new wave of nurses to come into the field. There is a vast number of opportunities for them.”
“An Incredible Experience”
When Bertie Ford was a new graduate 18 years ago, she started off in oncology nursing and has never left the field. But that doesn’t mean that nurses without previous work experience in cancer nursing can’t break into this specialty.
“Really, you can come into oncology nursing with just about any background,” she says, “except maybe ER or trauma nursing, because cancer units prefer to hire nurses who are used to having a longer relationship with the patient. You need to have a good background in med/surg and have good clinical skills, because cancer patients often have a number of co-morbidities. You also have to have the ability to offer psychological support.”
Keen-Woods, who lost a sister to breast cancer, believes there are certain characteristics that are necessary for a successful career in oncology nursing. “You have to be a compassionate and caring person with the ability to assist others and help make their lives more comfortable. You have to be willing to give a part of yourself to the patient, to make them feel like they have someone they can turn to who is concerned about them and cares about their well-being.”
For Keen-Woods, the greatest reward is feeling she has made a difference in a cancer patient’s life. “What makes it really worthwhile is when you are able to care for a patient when they are at their weakest moment and then see them respond to the treatment,” she asserts. “You see that your patient did make it and they are able to go home, live a nice life and come back to show you their wedding pictures and pictures of their babies.
“Even when the outcome isn’t as positive and the patient dies, you can be there to console the patient’s family and help make their loss a little easier for them,” she adds. “That can be rewarding in its own way. You also know you did everything you could to make that patient’s life more comfortable as they prepared for the end.”
Taoka says she find oncology nursing a very challenging field, but one that also provides great personal satisfaction. “It is not static. It is a very dynamic and exciting field where things are constantly evolving,” she explains. “The other thing that’s so rewarding about oncology is the opportunity to work so closely with your patients and their families. It is just an incredible experience. You learn so much about yourself and you definitely learn not to take life for granted.”
Resources for Cancer Nurses
For more information on careers in oncology nursing, contact the following organizations:
Oncology Nursing Society (ONS)
501 Holiday Drive
Pittsburgh, PA 15220
The association’s Web site, ONS Online, is a particularly valuable resource for prospective oncology nurses as well as other health care providers, cancer patients and their families and friends. Its vast menu of information includes everything from job listings and news about the latest developments in cancer treatment to funding sources for cancer research.
Association of Pediatric Oncology Nursing (APON)
4700 W. Lake Avenue
Glenview, IL 60025-1485
If you are particularly interested in caring for kids with cancer, pediatric oncology nursing is a field that offers many career opportunities. APON is an association of more than 1,900 RNs and other pediatric hematology/oncology health care professionals dedicated to providing care for children and adolescents with cancer or blood disorders.
Intercultural Cancer Council (ICC)
Houston, TX 77030
The ICC’s goal is to promote policies, programs, partnerships and research to eliminate the unequal burden of cancer among racial and ethnic minorities and medically underserved populations in the U.S. and its associated territories. The council offers such resources as a biennial symposium and cancer fact sheets for specific minority populations.
National Cancer Institute (NCI)
Building 31, Room 10A31
31 Center Drive, MSC 2580
Bethesda, MD 20892-2580
One of the National Institutes of Health and the nation’s primary federal agency for cancer research, the NCI offers information on cancer treatments, risk factors, cancer screening/testing, minority health disparities, current clinical trials and research funding. The NCI’s Cancer Information Service, a free national information and education network, is an invaluable resource for both oncology nurses and cancer patients.
American Cancer Society
Headquartered in Atlanta with more than 3,400 local offices, the ACS provides a wealth of information, including culturally competent print and online patient education materials and information for cancer survivors. For nurses and other cancer care professionals, ACS offers a cancer drug guide, treatment decision tools, books and publications, as well as numerous resources for cancer researchers.
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