Oncology nursing under pressure

Cancer remains a major health challenge of our time. Despite many advances in cancer science, early detection and more targeted treatments, the pressures on colleagues in oncology nursing practice are rising and are unrelenting. Cancer remains the second cause of premature mortality in most countries meaning that health systems need educated and experienced oncology nurses at their core to deliver safe and humane care. However, it is not always possible to recruit or retain nurses working in such highly pressurised clinical situations. Two thirds of nurses leaving the NHS in the UK are under 45 years, and in the US the American Nurses Foundation and Joslin Insight claim that 45% of Generation Z (born after 1995) are considering leaving with better work–life balance, pay, enhanced support and improved working conditions being common expectations that are not being met by employers (Bean et al., 2022; James et al., 2024). Those nurses who do stay face rising expectations, both from the public and from themselves as they share an ambition to deliver the best cancer care possible. Those of us who have enjoyed long and varied careers as oncology nurses now enjoy the benefit of hindsight but have a responsibility to call out the pressures placed on practice colleagues, especially when patient safety, or their own well-being, is at risk of being compromised. With the frequent exposure that oncology nurses have to loss, suffering and intense clinical workloads, it is little wonder that the core qualities of compassion and empathy are tested on a daily basis. This may result in an increased risk of burnout, occupational stress, emotional distress and compassion fatigue. By the very nature of nursing work, by witnessing the impact of cancer, nurses suffer too. Studies have reported significant levels of burnout among all oncology professionals, including clinical oncologists, although the way this is experienced may differ depending on professional backgrounds, geographic region and personal characteristics (Gribben & Semple, 2020; HaGani et al., 2022). For oncology nurses, the emotional burdens placed on the workforce can be exemplified when we consider care needs across the human lifespan, with a brief recognition here of the unique pressures on those who work with children and adolescents/young adults (AYA) with cancer, and their families. When caring for AYA groups, oncology nurses may identify more closely with them if they are the same age as themselves, or if have children of a similar age, adding a further dimension to the emotional labour involved in contemporary cancer nursing. In a study of younger oncology nurses caring for young cancer patients (Cable et al., 2023), it was revealed that these nurses not only shouldered a significant emotional burden, but that this was compounded by the age and stage of life of AYA patients. This deeply resonated with the nurses involved. For reasons of empathy, their communication style altered at times, sometimes risking professional boundary violation, and leading to further emotional pain for them. The experiences of these early career nurses were intensified as they might be the most senior nurses available during a 24-h period, meaning they are delivering complex clinical care with only limited clinical experience, leaving them vulnerable to patient safety errors. They also reported supporting even more junior colleagues alongside vulnerable AYA patients and parents, which tested their emotional resilience even further. The powerful emotions and relationships that could be encountered with patients and families may never be managed appropriately without adequate support and supervision (Mazzella Ebstein et al., 2019). As the incidence of cancer increases, with newer and more complex treatment options available, the emergence of specialist roles and oncology sub-specialisms to improve the quality of care for patients and families across the cancer continuum, and the urgency to recruit and retain early career oncology nurses is ever-present. However, this requires investment in education, structured workplace support models and an acknowledgement of the needs of cancer patients across the age span. Also, being aware of generational differences in relation to nursing recruitment, retention, communication, continuous professional development and succession planning should also be kept in the frame. Global projections on the need for nurses and the incidence of cancer intersect and suggest a future in which an adequate pipeline of well-prepared and motivated oncology nurses will be essential. As low- and middle-income countries build infrastructure for cancer prevention, detection, and treatment, the demand for oncology nurses will increase there also and these countries will start to look for ways to retain their own nurses to work locally. Too often countries in the West look to developing countries to recruit oncology nurses, but this may quickly change as these countries develop their own ambitions. Building the infrastructure for each nation's national oncology nursing workforce must be a priority if a reduction in cancer burden is to be achievable. Cancer Nursing career structures should be a central workforce target in all National Cancer Plans. Closing beds or chairs due to lack of nurses, as has happened in the UK, can only have negative impacts. Advancements in healthcare services, innovative technologies and a steady flow of novel cancer treatments are transforming oncology in a positive manner but also introduce new stressors and new challenges for oncology nurses. This includes a higher throughput of patients with many now receiving oral chemotherapy at home, including those who are older and living with multiple co-morbidities. For the increasing numbers who also now survive cancer, there is a need to assess and manage late effects of treatment. Monitoring and supporting this rising number of people, including the use of remote assessment clinics, will become an even more important role in the future. The COVID-19 pandemic exacerbated pre-existing system issues and led to staffing shortages in the United States as nurses retired early or left the profession. As mentioned previously oncology nursing has always been emotionally draining but the turnover rate in newly graduated nurses is particularly worrisome. Travel nursing is attracting younger nurses due to the higher compensation and less organisational demand. Recruitment of oncology nurses from one country to another continues to be a global pattern but does not address why local strategies for the retention of the existing workforce fail. [Correction added on 27 Feb 2024, after first online publication: The previous sentence has been revised.] Interventions to prepare and retain the nursing workforce do exist. Specific to oncology nursing, the prelicensure/undergraduate curriculum needs to include more content on oncology topics; past reports have shown limited attention is being paid to cancer, despite it being such a prominent health concern for all nurses in the future. The transition from undergraduate to registered practitioner also needs well-designed residency programs as other healthcare professions already have. To enhance retention, using experienced oncology nurses as mentors or coaches, a role beyond that of preceptor, could help support new graduates as they acclimatise to the work environment and the emotional demands of caring for oncology patients. Several papers and position statements have outlined the importance of oncology nurses in reducing the burden of cancer for individuals and countries and multiple strategies have been outlined (So et al., 2016; Yates et al., 2021). Interventions from various sectors of the healthcare environment will be needed to ensure the pipeline of oncology nurses that we call for here. Governmental and nongovernmental organisations have a role to play in increasing and optimizing the oncology nursing workforce. Governments can implement policies and allocate funding to build and sustain the nursing workforce, agree and adhere to staffing standards for all care settings and support the specialisation of nursing in oncology. This requires investment and bold leadership. In those countries that do not yet recognise oncology nursing as a specialty, national nursing leaders must support the designation of oncology nursing as a professional specialty and advocate for the necessary education and accreditation resources. Education leaders can help by ensuring that there is sufficient content about cancer care in the curriculum, developing innovative pathways into nursing and increasing advanced oncology education options. Nurse executives can also be allies by helping to address system issues such as staffing, education opportunities, nurse well-being and workplace bullying. A critical component here is that shared decision-making will be needed between frontline oncology nurses and those in leadership positions. This editorial is written by colleagues representing the European Oncology Nursing Society https://cancernurse.eu/about-eons/ and the Oncology Nursing Society (https://www.ons.org). We joined forces here to emphasize the urgency of the challenge facing oncology nursing and to suggest ways forward. There is a saying, think global, act local. Many countries are facing similar challenges to our own with their nursing workforce and are trialling solutions that could also benefit other parts of the world. Global collaborations between national and international oncology nursing societies can facilitate connections, advance the exchange of best practices and build the unique specialism of oncology nursing. Joint working between EONS and ONS are good examples of this in action. Clinical exchanges offered by cancer centres can also foster clinical innovations, evidence-based knowledge and innovative role development. Advocates for oncology nursing acting on a global, national and local scale will help ensure that we have a well-prepared oncology nursing workforce for the future. We will all need these oncology nurses and in terms of action the time is now, and the challenge is ours. DK & BN conceived, designed and edited this editorial. MC & CJ contributed content and agreed the final structure. We have no conflict of interest to declare.