Nursing Sub-specialization: What Makes Oncology Nursing Different from All the Rest?

"Why would anyone want to be an oncology nurse?”

It’s a question I’ve been asked more than once and is often followed by: “The treatments make people puke,” or “Everyone loses their hair,” or ultimately, “Don’t they all die?” Yes, I’ve heard them all. Sometimes even from other nurses.

Nursing is one of the rare professions that allows for (and some may argue even encourages) specialization, yet that may not be the general perception. Talk to a room full of high school students as I did not long ago, and their view of nurses comes directly from Hollywood, where women are preoccupied with sex and the token males are unabashedly gay. Perhaps television has progressed since the days when nurses were depicted as coff ee-making handmaidens for physicians, though perhaps it depends on how progress is measured.

Despite the public perception, nurses know how specialized we’ve become. Just as medical science has evolved and produced specialists whose knowledge and on-the-job training makes them experts in a given field, so has the nursing profession. And while there are still generalist nurses who “do it all,” today there are more specializations than ever before.

With all of these specialties to choose from, why did I choose oncology? I confess oncology was not my fi rst choice, my second, or even my third. In fact, it was one of the last specialties I would have selected. Unfortunately, the nursing shortage that loomed like an employment tidal wave when I first entered the program had evaporated upon graduation. Throughout college, I knew I wanted to be an ER nurse. My best friend was a paramedic and I went on rides with him while in school. The adrenalin rush was habit forming and the unpredictability was exhilarating. I decided that there would never be a shortage of patients, because the ER was always busy. After discovering that the job market had collapsed, I was suddenly faced with only two options: an evening shift position in surgery as a scrub nurse or a night shift position on the cancer fl oor. Was it too late to change my profession? Of course, little did I know that interviewing with the head nurse of the oncology unit would be the first step in a 25-year journey.

New perspectives

I quickly discovered my ignorance of oncology was blatant (we’d barely touched on it in school), and my misconceptions were staggering. Alopecia, I learned, did not occur with all treatments, and after a while it even began to look “normal.” Nausea and vomiting in 1983 was still a major side effect of treatment, and even the newly approved drug metoclopramide was only marginally more eff ective than prochlorperazine for some chemotherapy. Yes, many patients died. But I learned from books, lectures, and heart-to-heart, tear-fi lled meetings with our head nurse that death was a natural part of life and that my role was not necessarily to be the heroic “Annie, Annie are you all right?” I-can-save-you nurse.

Learning how to manage death—for both the patient who was dying and for the family—was every bit as challenging as maintaining a patient’s blood pressure in the ER after a major trauma, but the goals were diametrically opposed. I soon learned there were “good deaths” and there were “bad deaths.” I cared for a former 1940s big band conductor, whose death was as peaceful as a well-orchestrated song. There was another patient with leukemia whose massive hemorrhage made her look as though we’d been torturing her with sharp objects; I never wanted to experience that again.

Many of our small group meetings were about managing death—not preventing it. They centered on our own feelings, as it became obvious that I would not be able to help a dying patient come to terms with his or her impending death if I was terrifi ed of being diagnosed with oat cell cancer the next time I coughed more than two times.

A different type of success

Unlike my colleagues working in other areas of the hospital, my measure of success as a nurse was not governed by cure, and my care plans did not focus on early discharge planning. My role included administering toxic therapy that would sometimes cure patients or sometimes buy additional time, and taking steps to eliminate or minimize the treatment side effects. We might not have been able to prevent mucositis, but we understood the important components of patient and family education designed to reduce symptoms and minimize complications.

It took a while, but I developed relationships with our “frequent flyer” patients who were admitted every three or four weeks for treatment. I realized that if I had been working in the ER, these relationships would have never developed.

After 25 years, I still remember a patient I cared for when I was a new oncology nurse. Richard was dying from renal cell cancer. I was his night shift nurse, and while managing his pain, we spent a fair amount of time talking about his family. I had never met them—the drawback of starting your shift at midnight—but I knew his daughter. She would call me every night at 4:00AM when she fi nished work, to check on her dad. I would give her an update from what the evening shift nurse told me, and give her my assessment. Richard died during the day shift a couple of weeks later, and that night, his daughter came to the hospital to see me and thank me for taking care of her father. I told her I did not really do much, but she insisted I had. This conversation was the fi rst time I realized that the rewards of being an oncology nurse were not easily measured or described.

Quality of care

When people learn that I am an oncology nurse, they often ask, “Isn’t that depressing?” No, not usually. Yes, I have cried when patients died because it seemed so unfair, particularly with the kids, but those have been the exceptions. I believe oncology nurses—and there are well over 30,000 of us in the US—have an unusual perspective when compared with many other health professionals.

Oncology nurses wear multiple hats when treating our patients. I wear the aggressive treatment hat when the goal is to cure. When my patient finishes the last cycle of chemotherapy and tells me that his or her scans are clear, I know I helped him or her to get this far. Maybe I even helped provide the cure, helped give this patient a second chance at life, or maybe I helped provide some additional time—hopefully quality time. The outcomes are not always foreseen, but I’m always amazed when a patient comes back to visit years later and remembers me like I’m some long-lost nephew; that’s when I know I made a diff erence.

Sometimes I wear the symptom management hat, when a cure is no longer an option. We move from quantity of life to quality of life, and the question becomes “What can I do to make the patient feel better?” Maybe it’s helping the patient fi nd another medication to control his or her symptoms better, whether it’s pain, nausea, or constipation; or perhaps helping him or her work through their anger. There are times when I collaborate with other specialists to create a plan to enhance quality of life. The hats can change quickly and unexpectedly. At the end of the day, I know my “success” as a nurse is based on a diff erent set of parameters, measured in a less objective way.

I’m thankful nursing has become so specialized and varied. Not everyone wants to be an ICU nurse, a geriatric nurse, a pediatric nurse or, yes, an oncology nurse. I did not choose oncology, but looking back, I would not have it any other way.

Mr. Eisenberg is the Professional Practice Coordinator for Infusion Services at Seattle Cancer Care Alliance, Seattle, WA.