Workforce Issues Linked to Crisis in Cancer Care

By Debra Wood, RN, contributor

September 17, 2013 - Declaring a crisis in America’s cancer care delivery system, the Institute of Medicine (IOM) cited workforce issues as among the many contributing factors, including an aging population, rising costs and the complexity of care. Their report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” was released on September 10, 2013.

Eric Magnussen: Cancer care is impacted by workforce issues and shortages.
Eric Magnussen expects the cancer workforce shortage will increase in the years ahead.

“We definitely are seeing workforce shortages,” said Eric Magnussen, vice president of talent at Cancer Treatment Centers of America in Schaumburg, Ill., who added that his organization is not currently experiencing challenges finding good employees, who they refer to as “stakeholders.” But with projections of fewer nurses and physicians, “We know there is going to me more and more of a war for talent in the years to come.”

More than 1.6 million new cases of cancer are diagnosed each year in the United States, the IOM report says. By 2030, cancer incidence is expected to rise by 45 percent to 2.3 million new diagnoses annually. Another challenge is the cost of cancer care, which is rising faster than other sectors of medicine, having increased from $72 billion in 2004 to $125 billion in 2010, according to the report. At the current rate, it will increase another 39 percent to $173 billion by 2020.

Additionally the complexity of cancer care has grown recently and new therapies are introduced regularly. Incorporating this new information into clinical care is challenging, the report says.

The oncology workforce may soon be too small to care for the rising number of people diagnosed with cancer, and training programs lack the ability to rapidly expand, the report adds.

“[The shortages are] a result of a combination of the challenge of schooling employees, for physicians that is a 12-year time horizon through fellowship, and the uncertainty around the future of healthcare,” Magnussen said. “That is causing people to pause.”

In January 2013, the American Society of Clinical Oncologists (ASCO), one of 14 IOM report sponsoring organizations, published a paper stating that oncologists aged 64 and older represented 18.2 percent of the workforce, while those younger than 40 years represented 15.8 percent. The median age of oncologists is 52 years, one year older than the median age of all physicians. A 2007 study by ASCO projected a shortage of up to 4,080 oncologists by 2020.

ASCO President Clifford A. Hudis, MD, FACP, praised the IOM report and said, “The recommendations offer a solid framework for achieving that goal by helping us improve the quality of care today while developing evidence for safe and effective treatments for tomorrow.”

A study by the American Academy of Hospice and Palliative Medicine estimates the country has a shortage of up to 7,000 full-time and 18,000 part-time palliative care specialty physicians.

Additionally, nursing shortages and nursing faculty shortages persist. The Oncology Nursing Society (ONS) attributes the problem to the workplace environment, education and public policy.

Brenda Nevidjon projects a nursing shortage during the next 10 years in cancer care.
Brenda Nevidjon, MSN, RN, FAAN, projects a nursing shortage during the next 10 years.

“Although shortages of nurses are rare today due to the economy, the projection for the future, given the aging RN workforce, is that we will have a nursing shortage in the next 10 years,” said Brenda Nevidjon, MSN, RN, FAAN, professor of nursing and health care leadership at Duke University in Durham, N.C., past president of ONS, and president-elect of the International Society of Nurses in Cancer Care. “What needs to be clearly understood is that nurses outside of the specialty of cancer nursing are and will be caring for people with cancer. They too need to be considered as part of this coordinated workforce, and the Oncology Nursing Society has developed resources for these nurses.”

Nevidjon added that the IOM report “The Future of Nursing: Leading Change, Advancing Health” also has important recommendations for the cancer care team of the future, including that nurses practice to the full extent of their education and training.  For example, nurse practitioners have the education and training to provide services, such as survivorship clinics.

In a position statement, ONS suggests more oncology content be included in school curricula, and that employers ensure oncology nurses learn the latest techniques and emerging therapies. Additionally, it recommends improving the work environment and resolving negative issues, such as mandatory overtime, low salaries and low staffing.

The IOM also cited job dissatisfaction and job-related stress as deterrents to people considering an oncology career. Studies show high levels of burnout among professionals working in oncology.

“Some of the things we do are to create a culture that empowers stakeholders to make changes to the work environment,” Magnussen said. The organization has trained nurses and other staff in Lean Six Sigma principles and encourages them to apply that knowledge to make changes and eliminate waste, things the customers do not value. It also has developed wellness and well-being programs.

“Healthcare workers traditionally give the most of themselves and do not take the time to take care of themselves and reenergize,” Magnussen said.

Cancer Treatment Centers’ mind–body medicine team of PhD-prepared psychologists also are available to meet with staff members, particularly when working on a troubling case.

In addition to simply having enough clinicians to provide cancer care, quality care requires adequate staffing with a properly trained and coordinated workforce. The IOM maintains that high-quality cancer care needs clinicians with core competencies and recommended professional organizations define core competencies for all those providing cancer care and then ensure their clinicians have those skills.

The IOM also stated that the “cancer care team, in coordination with primary/geriatrics teams and specialist care teams, should implement patients’ care plans and deliver comprehensive, efficient, and patient-centered care.” It acknowledged barriers exist to team-based care, including regulatory and policy issues. But nevertheless, patients benefit from more coordinated, team-based care.

Cancer Treatment Centers already employs an integrated team model, with specialty oncologists, chiropractors, nurses, nutritionists, naturopathic doctors, psychologists and other professionals. The Patient Empowered Care Teams meet daily to review inpatients’ medical data and progress and discuss and refine plans of care.

“It’s a way to ensure you have experts from each discipline talking together about the best way to deliver care to the patient,” Magnussen said.

The IOM recommended that federal and state legislative and regulatory bodies should promote such teams through the elimination of reimbursement and scope-of-practice barriers to team-based care. It also indicated that the U.S. Congress should fund the National Health Care Workforce Commission, which was created by the Affordable Care Act in 2010 but is still unfunded.

Furthermore, it suggested academic institutions and professional societies should establish education programs to train the existing healthcare workforce in team-based cancer care.

“Through that team-based approach, we think our outcomes stack up to any of the other cancer players in the industry,” Magnussen said. “The team-based approach to care is the wave of the future, not just for oncology, but in a variety of different disciplines.”

Read the full IOM report: “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.”

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