2025 Oncology Nursing Reality Shock

ONCNG Oncology Nursing, June 2008, Volume 2, Issue 02

Just as cancer nursing circa 1990 bears little resemblance to cancer nursing of today, in 2025 our profession will have advanced light years beyond current practice.

Just as cancer nursing circa 1990 bears little resemblance to cancer nursing of today, in 2025 our profession will have advanced light years beyond current practice. Oncology nurses must anticipate the changes and challenges that will confront our specialty and take proactive steps to ensure we are prepared. We need to begin planning for our future now, rather than wait and react to changes imposed upon us. The groundwork has already been laid for some of the outcomes described in this article. Although it’s difficult to predict specifi c results and the extent to which some of these changes may aff ect our profession and transform cancer care, one thing is for sure: the year 2025 will be a landmark for oncology nursing for several reasons, not least of which is that the Oncology Nursing Society will celebrate its 50th anniversary. Let’s look at some possible scenarios that could come to pass in the next 17 years.

  • By 2025, cancer care is totally structured around the provision of nursing care. Nurses’ direct care responsibilities have been dramatically altered; technicians, robotics, and patients administer the therapies. In most instances, oncology nurses assume supervisory roles, as there are an insuffi cient number of nurses to practice as they did in the early 2000s. Nurses’ expert knowledge is primarily indirectly dispensed now, and advice and critical thinking are shared with other providers who render the actual therapies.
  • Ninety percent of all cancer care is delivered at home. Nurse-owned and -run consortiums are geographically located based on where the majority of the population with cancer (the elderly) resides. These consortiums have two primary nursing divisions: one is characterized by a primary nurse model, with longitudinal oversight along the cancer continuum (ie, oncology nurse navigator/ care consultant); and the second addresses more acute patient needs by offering nursing care and supervision in a nurse-run home environment (ie, “healing haciendas;” see below).
  • Oncology nursing is no longer delineated by the medical subspecialty model. The navigator movement in the early 2000s has substantiated patient and family choice to have one consistent nurse professional caregiver throughout their cancer experience. Hence, there are no more medical, radiation, or surgical oncology nurses. The nurse navigator/ care consultant assists oncology patients who require surgery with pre-surgery physical preparation, education needs, and post-surgery symptom management. The same assistance is also provided if the patient requires radiation therapy and chemotherapy. Technicians and sophisticated robotics perform the surgery in Mobile OR suites (MORS)—large vans that enable surgeries to be performed in close proximity to patients’ residences; the patients remain in the MORS for an overnight stay. Although radiation therapy in 2025 remains intransient, community- based vestibules in malls facilitate patients’ easy access to treatment. Remote command centers confi gure therapy specifi cs and perform periodic checks for radiation safety and physics testing. Robotic arms turn the patient and place blocks, molds, and other stabilizing devices. These vestibules appear much like tanning booths, and patients gain access by using their digitalized, credit cardsize, comprehensive EMR disc.
  • The largest generation of Americans—the “baby boomers”—are nearly all older than 65, and although a considerable rise in cancer diagnoses was projected due to the graying of these baby boomers in 2025, two significant breakthroughs negated this projection: cancer vaccinations and genetic development. Cancer vaccine development became widely acknowledged as the primary mode to treat early cancer in 2020; however, vaccines are unable to treat signifi cant tumor volume. Mandatory early detection and mass cancer screening for all Americans is being debated in Congress. Genetic developments have revolutionized the management of cancer. Genetic ability to counter cellular signaling and evolving polymorphic changes can be uniquely customized. Both tumor and host variables are evaluated to specifi cally prescribe “designer” treatment regimens for individual patients. Genetic interventions can also ablate treatment-related toxicities.
  • The dispensation of chemotherapy requires minimal competency in venous cannulation, as this vehicle of chemotherapy administration is rarely used. Of all chemotherapy, 85% is delivered orally, absorbed by buccal or rectal mucosa, relayed transdermally by patch, or is inhaled. A major role for nurses working with patients receiving chemotherapy is assuring adherence to prescribed regimens.
  • Patients make only one initial visit to the consultant’s offi ce. Before treatment starts, nurses schedule a home visit to review the treatment regimen, reiterate key instructions, and set up necessary surveillance equipment. A computer is installed in the home, and the patient and their care companion are taught how to access and use the accompanying monitor. When needed, a vital signs vest is also brought to the home. When the vest is put on, all vital signs (pulse, blood pressure, temperature, O2 sats) are electronically recorded and relayed to the nurse’s modem in her offi ce or car. Microchips in prescription bottles keep track of how often the medication container is accessed. For the majority of chemotherapy agents, assays are available to analyze chemotherapy blood levels, and these are compared with microchip recordings. Based on the degree of patient adherence, nurses are reimbursed for their services.
  • Cancer prevention has become a new subspecialty within oncology nursing. Following decades of high-level, sophisticated analyses, individuals most at risk for obesity and smoking-related malignancies can be identified. The cancer prevention nurses work with high-risk individuals to eliminate these carcinogenic risk factors. Nurses are compensated based on the estimated lifetime cost savings per patient for treating lung, bladder, head and neck, breast, colorectal, and other primary tumors. Nursing interventions range from long-distance, camera-based monitoring that surveys individual shopping behaviors and meal preparation techniques, to tours of pathology labs to view biopsy sampling and frozen section evaluations of smoking-related tumors. Predictive analyses can now inform smokers of their projected life expectancy based on their choice to continue smoking. Incentives are off ered when smokers quit, and future out-of-pocket cost for cigarette purchase is calculated and invested for the ex-smoker into retirement accounts or college funds. This outlay of money remains nominal compared with the cost of treating smoking-related malignancies from diagnosis to death.
  • Clinical nurse specialists (CNS) in bone marrow transplant work from their homes. New nurses in these clinical settings are mentored via earpiece communication hardware. The CNS has visual monitoring linkage to several inpatient units from her living room. This eBMT model allows the new nurse to communicate directly with the CNS in real time as they mutually observe, hear, and evaluate clinical issues as they unfold. Critical thinking is optimized by this approach. Additionally, novice nurses feel less isolated and anxious as they learn new and more complex skill sets.
  • “Healing haciendas” are homes providing 24- hour transition care for elderly leukemia and lymphoma patients following major surgery. Patients stay in MORS or the mobile treatment center (MTC) overnight. MTCs are similar to MORS and mini-critical care units that monitor and determine therapy capabilities for patients beginning complex chemotherapy regimens. Following a 24- hour admission to these units, patients are moved to the haciendas, where oncology nurses partner with families to manage acute post-therapy sequelae. There, nurses can teach, promote critical thinking, and demonstrate care techniques prior to the patient’s return home. Once at home, high-level telephone monitoring is maintained. Patients relay their degree of symptom distress by responding to automated phone inquiries prompting them to dial in the number that refl ects their symptom severity. Normative ranges have been pre-established for each patient, and responses above a specifi c upper margin alert the patient’s nurse navigator/ care consultant. These oncology nurse-owned and -run consortiums were among the first businesses to receive federal funding and now receive 100% reimbursement not only because of their cost savings, but also their clinically signifi cant reduction in adverse events, symptom distress, and infection rates compared with “usual care.”
  • Medical and radiation oncologists are out of a job. Human debate about optimum treatment decision making has been replaced by computerized algorithms, and highly sophisticated programming can accommodate the input of hundreds of patient variables to devise an optimum, individualized treatment regimen. Physicians’ historic aversion to cultivating communication expertise and emotional care, in tandem with their treatment decision making, has made them extinct. Their sole focus of expertise has been replaced with a mechanical analog.
  • Although oncology surgeons are still around, their number has been reduced dramatically. The use of robotics and the ability to perform long-distance surgery allows the patient to be operated on in St. Louis, MO, while the surgeon performing the complete hysterectomy for ovarian cancer sits in Dallas, TX.
  • Nurse practitioners provide expert consultation on unusual cases. For more than 10 years, their patient outcomes have been proven to equal those of physicians. Additionally, patient satisfaction ratings for NP-provided care have far exceeded those of their medical counterparts. Most NPdirected cancer therapy is augmented by complementary approaches, in large demand by baby boomer patients. Foreseeing this trend in 2010, NP providers were quick to integrate consultations by these practitioners into their treatment planning.
  • The 39 NCI-designated Comprehensive Cancer Centers in existence in 2008 have now been reduced to seven. In fact, they no longer are called “Comprehensive Cancer Centers,” as their mission is now a specific focus rather than all-inclusive. These centers target bench research as their primary goal, as well as the development of new systemic therapy approaches. Each center focuses on one specific tumor type so that research is concentrated within one facility.
  • Nursing research group cooperatives are structured around the phenomenon of clusters. These include clusters of symptoms, impediments to quality of life, inducers of family distress, adherence barriers, home care diffi culties, survivor surveillance enhancers, and outcomes of family respite care, to name a few. Patients are accrued to studies from community nursing consortiums. Unique to this model is the presentation to community forums following study completion, in which participating patients are invited to hear the results and to assist with the interpretation of research findings. Patients also assist with the identifi cation of future and/or companion studies based on their personal experiences.
  • There are no formal nursing education structures outside of the hospital setting. Modular, computerized instruction is now the major vehicle for learning, and the classroom is now the home office. Basic knowledge can be relayed in this fashion, because nurse educators have not maintained their own clinical proficiency—which is what they expect of the students. Although an all-BSN nurse work force has been the goal, nursing shortages have prompted the continuation of AD programs; however, a leveling based on education background has been accepted. Major supervisor and oversight positions now require a BSN degree. AD graduates can provide leadership to teams and within consortium confi gurations, yet this is competency-based, rather than tenure-mandated. For both nursing levels, however, a dramatic change in their student preparation has transpired.
  • During the first year of AD nursing student education and the first two years for BSN students, generic, online-required course completion does not require them to physically attend the classes. In tandem with this preliminary coursework, however, clinical placement is required within all nursing subspecialties. At the end of this generic coursework phase and introductory clinical exposure, students must then select their preferred nursing specialty. The remaining year for the AD students and two years for the BSN students are spent in their chosen specialty. This parallels the preparation of lawyers in which law clerks spend signifi cant time in ‘real life’ work settings, being mentored by numerous, seasoned lawyers. Nursing students choosing the oncology nursing career track spend time in each specialty focus, which includes: — Prevention and Wellness Oncology Nursing — Primary Nurse Navigator/Care Consultant Oncology Nursing — Hacienda Home Partner Nursing Practicing oncology nurses within consortiums assume education oversight for students on a yearly basis to keep their license current. So, what do you think? A bit too science fiction for you? For those who entered oncology nursing in the early 1980s, think back for a moment and consider your practice then. Could you have envisioned administering cisplatinum without 24 hours of inpatient hydration? How about the lack of need to monitor patients receiving Taxol every 15 minutes for signs of anaphylaxis? Or discharging patients following surgery with drains in place and expecting patients to empty and record findings? Or inserting radioactive seeds near the prostate to treat prostate cancer rather than performing a radical prostatectomy and all its resultant compromise in quality of life? The influence of technology, the aging of the American public, the nursing shortage, the growing consumer health movement, and the considerable escalating cost of healthcare will most defi nitely continue to drive further change within our specialty. Again, the looming questions are how, and to what degree, will these changes present themselves? Talk about some of the projections presented in this article in journal clubs, at lunch, or other forums. Challenge colleagues to consider the possibilities presented, and just as importantly, contemplate what you need to do to get ready for our evolving practice. In her infinite wisdom in the mid-1800’s, Florence Nightingale proclaimed, “Nursing is a progressive art, such that to stand still, is to go backwards.” Better get your running shoes on. An oncology nurse for over 30 years, Ms. Boyle is a nationally and internationally known leader in cancer care. Currently, she is the Magnet Coordinator at Banner Good Samaritan Medical Center in Phoenix, Arizona, where she also leads a nursing research initiative addressing older adults’ experiences with cancer, needs of cancer survivors, and documentation of outcomes of quality nursing practice.