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ONS 2002 Environmental Scan:
A Basis for Strategic Planning
This article is an Oncology Nursing Society report.
Leonard Mafrica, MBA, CAE, Layla G. Ballon,
Bridget Culhane, RN, MN, MS, CAE, Michele McCorkle, RN, MSN,
Cynthia Miller Murphy, RN, MSN, CAE, and Linda Worrall, RN, MSN, OCN
Key Points . . .
Purpose/Objectives: To analyze information about
the environments in which the Oncology Nursing Society
(ONS) operates as a basis for strategic planning.
Environmental scanning is the process of obtaining information
Data Sources: Published reports and ONS internal sur-
about the world that affects an organization.
Data Synthesis: Analysis of internal and external trends
Environmental scanning is used for managing change, avoiding
resulted in a list of implications with regard to managing
mistakes, and identifying critical issues.
change, avoiding mistakes, and identifying critical issues
A general set of implications emerges from the process that
for ONS leadership. The team presented ONS leaders
may be used as a basis for strategic planning.
with a tool that helped to guide the development of the
20032006 Strategic Plan.
Organizations whose planning is based on a sound analysis of
Conclusions: The continuing vitality of professional nurs-
their operating environments are positioned for long-term
ing societies such as ONS is critical to the vitality of the
profession of nursing itself. Monitoring the environment in
which these organizations operate--and effectively using
the knowledge that is gained--contributes to their long-
term viability and growth. A stronger ONS is in a position to
ines internal trends and issues. This covers membership
better serve its members, who ensure high-quality care
characteristics and operational aspects.
to people with cancer.
The association industry environment recognizes the orga-
nizational trends that ONS shares with similar organiza-
tions that serve other members and professions.
nvironmental scanning is a systematic effort to obtain
The final component is the environment in which the
information about the world that will affect an organi-
members operate (i.e., the profession of nursing itself).
zation. Scanning is important in managing change
This information was compiled and analyzed to identify the
and avoiding costly mistakes. Over the years, the Oncology
critical issues facing ONS and to provide a basis for strategic
Nursing Society (ONS) has gathered internal and external in-
formation from various member surveys, literature reviews,
focus groups, and conferences with experts from inside and
Leonard Mafrica, MBA, CAE, is the executive director of communi-
outside the nursing profession.
cations and publisher, Layla G. Ballon is the chief operating officer,
This article builds on ongoing efforts to acquire knowl-
and Bridget Culhane, RN, MN, MS, CAE, is the executive director, all
edge by using a model recommended by the American Soci-
at the Oncology Nursing Society (ONS) in Pittsburgh, PA; Michele
ety of Association Executives (ASAE, 1999). This model has
McCorkle, RN, MSN, is the executive director of Oncology Education
four components.
Services, Inc., in Pittsburgh; Cynthia Miller Murphy, RN, MSN, CAE,
The macro environment is the larger space that is shared
is the executive director of the Oncology Nursing Certification Cor-
poration in Pittsburgh; and Linda Worrall, RN, MSN, OCN, is the
with other organizations and professions. A scan of this en-
executive director of the ONS Foundation in Pittsburgh. This report
vironment examines such things as population and soci-
was written under the direction of Pearl Moore, RN, MN, FAAN, chief
etal trends, as well as trends in industries that can affect a
executive officer of ONS and its affiliated corporations.
The association's immediate operating environment exam-
Digital Object Identifier: 10.1188/02.ONF.E99-E109
MAFRICA VOL 29, NO 9, 2002
eration Y also are less physically fit than older generations,
planning for 20032006. This article is a condensed version
of the complete report.
with only two in three high school students participating
regularly in vigorous physical activity (Society for Human
Macro Environment: Societal Trends
Resources Management, 2001).
The Aging Population
Diversity and Disparity
The United States is an aging nation, and the average life
Indications are clear that the United States is growing in-
expectancy increased by more than 30 years in the 20th cen-
creasingly diverse both racially and ethnically. Although
tury (Robert Wood Johnson Foundation [RWJF] & Institute
the majority of the population remains primarily Caucasian
for the Future [IFTF], 2000); this trend is expected to con-
and non-Hispanic (73%), the Hispanic, African American,
tinue. People older than 65 make up the fastest growing seg-
Asian, and Native American populations are growing at rates
ment of the population (Sussman, 2000). By 2010, the aver-
that far exceed that of the population as a whole (RWJF &
age life expectancy is estimated to rise to 86 for women and
IFTF, 2000). This trend is primarily a result of higher immi-
76 for men (RWJF & IFTF), and 100,000 people in the United
gration and birth rates among these groups. By 2010, minor-
States will be older than 100 (Sussman). By 2050, people
ity ethnic and racial groups are expected to account for 32%
older than 80 are expected to comprise 36% of the popula-
of the population, up from 20% in 1980 (RWJF & IFTF).
tion (Society for Human Resources Management, 2001) and
Non-Caucasians will represent close to half of the popula-
1.1 million people in the United States will be older than
tion by 2050 (Society for Human Resources Management,
than 100 (Brickey, 2001).
2001). The fastest-growing segment of the U.S. population is
The aging of the population is the result of the maturing of
the Hispanic group, which primarily is a result of the large
the largest generation to have lived: the baby boomers. Be-
numbers of immigrants from Latin American countries; the
cause of its tremendous volume, the baby-boom generation
largest single source country for U.S. immigrants in 1997
has had a profound effect on the nation, transforming many
was Mexico, accounting for 18% of all immigrants (Ro-
aspects of American culture and economy.
mano, 2000).
Currently, the U.S. adult population crosses over five dis-
Wagner (2001) reported that despite improvements in the
tinct generations of workers and healthcare consumers. Each
health of the U.S. population overall, striking disparities
generation brings its own challenges to the healthcare system
continue in the burden of illness and death experienced by
(see Table 1).
African Americans, Hispanics, Native Americans, Alaskan
Now nearing retirement, baby boomers are maintaining
Natives, and Asian Americans. Infant mortality among Afri-
the nation's attention on issues of social security and health
can Americans, Native Americans, and Alaskan Natives is
care. They are expected to irreversibly alter the traditional
twice that of Caucasians. Fetal alcohol syndrome is six times
doctor-patient relationship (RWJF & IFTF, 2000). The two
as prevalent among African Americans as Caucasians, and
generations that preceded the baby boomers still comprise
heart disease mortality is 40% higher for African Americans
significant portions of the population. The generation that
than Caucasians (Wagner). Stroke mortality is almost 80%
immediately follows the baby boomers, known as Generation
higher for African Americans than Caucasians. Rates of new
X, is well educated and media savvy and now is a vital part
AIDS cases are greatest among African Americans, Hispanics,
of the family market and workplace (Mitchell, 2000). The
and Native Americans (U.S. Department of Health and Human
millennial generation (i.e., Generation Y) is the first truly
Services, 2000b). African Americans continue to experience
high-tech generation; its members have never lived in a
cancer incidence and mortality rates higher than any other
world without personal computers or cell phones.
racial or ethnic group (American Cancer Society [ACS],
The long-term health of those in Generations X and Y is
yet to be seen; however, indications suggest that Generation
Cancer is a major health concern for all populations. Al-
Y may be one of the least healthy. The largest percentage of
though survival rates gradually have increased to 62% (the
cigarette smokers is ages 1824. Smoking rates among teen-
five-year relative survival rate for all cancers combined), cancer
agers rose steadily throughout the 1990s. Members of Gen-
remains the second leading cause of death in the United States
Table 1. Five Distinct Generations Affecting the Workplace and Health Care
% of U.S. Adult
Health System Issues
World War II
Before 1933
First generation to benefit from
All are age 70 and older, many
Social Security, the GI Bill, and
needing long-term care.
D o m i n a t e s top positions in
Approaching peak ages for many
public and private sectors
healthcare issues
Baby boomer
Largest generation ever
Sheer numbers could overwhelm
the system.
Best educated yet
High service expectations
First to grow up with advanced
Less exercise, more smoking
Note. Based on information from Mitchell, 2000.
ONF VOL 29, NO 9, 2002
Institutions that employ nurses and those that educate nurses
(ACS, 2002). In 2002, approximately 1,284,900 new cases of
may shift their training priorities more toward emergency
cancer are expected to be diagnosed and an estimated 555,500
preparedness and away from specialties, increasing the ur-
people will die of cancer (ACS). Those who predict future medi-
gency of nursing organizations to develop specialty content.
cal breakthroughs surmise that some cancers may be cured;
People in all regions and professions are reexamining what
however, cancer will continue to be a leading cause of death
is most important to them and, in turn, reprioritizing how
worldwide for the foreseeable future (Luther, 2001).
they spend their discretionary time and money. This has
Wider Disparity Between the Rich
potential implications for volunteerism and members' pur-
and the Poor
suit of continuing education.
The changing age structure of the population has greatly
Exactly what this means to ONS is not certain, but it will have
influenced American social and economic trends over the
some impact on members' decision making, which will affect
past several decades and will continue to do so as long as
how ONS delivers content and meaning to its members.
sharp differences exist in the size of various age groups. Pre-
The Healthcare Industry
dicted economic growth is related to the large number of
baby boomers entering their peak earning years. The percent-
Revolutionary Advances
age of households with an income of $50,000 or more will
and Ethical Dilemmas
increase to 52% in 2010, up from 39% in 1995 (RWJF &
IFTF, 2000). Higher income is associated with better health
Technology has revolutionized health care in many ways,
status and access to care.
but it has affected the area of biotechnology profoundly. This
The gap between the wealthiest 25% and the poorest 25%
area has far-reaching social implications and consequences.
of the population is growing (RWJF & IFTF, 2000). This pro-
Advances through 2020 are expected to significantly prolong
jected disparity in income may have negative consequences
human life expectancy and increase productivity as biotech-
on the nation's overall health because research has indicated
nology fuses with information technology (Molitor, 2000).
that when income disparity widens, the overall health status
Genetics will advance at a record pace as disease-associ-
of the population declines (Wilkenson, 1992).
ated genes and related genetic tests are identified and devel-
Single-parent households are considered to be the major
oped. In June 2001, leaders of the Human Genome Project
factor contributing to child poverty. At 19%, the United
announced the completion of initial mapping of the 3 billion
States has one of the highest rates of childhood poverty
base pairs of the human genome (Collins & McKusick, 2001).
among the industrialized nations of the world (Mitchell,
Genetic discoveries will continue to play an important role in
2000). Single-parent households are most prevalent among
complex diseases, such as cancer, diabetes, and heart disease.
minority groups, with 38% of African American, 26% of His-
By 2020, every tumor is predicted to have a precise genetic
panic, and 26% of Native American households headed by a
"fingerprint" and therapy will be targeted directly to specific
single parent (Council of Economic Advisors for the Presi-
fingerprints (Collins & McKusick).
dent's Initiative on Race, 1998).
Microchips containing patients' DNA profiles will be ana-
lyzed rapidly at portable laboratories. Sales at these laborato-
Technology: Faster and Smaller
ries are expected to increase to $40 billion in 2009, up from
Technology will continue to revolutionize every aspect of
$1 billion in 1999 (Molitor, 2000). Genetic identification
American society, from grocery shopping to education to
offers the potential for a more preventive approach as com-
genetic engineering. Changes in technology occur more rap-
pared with a corrective approach. Other genetic advances in-
idly than any other area, and the trend is toward producing
clude using genetic fingerprints to individualize prescrip-
tions (pharmacogenomics) and using site-specific genes to
smaller devices that make things happen faster. In fact, micro-
treat inherited or acquired diseases (Molitor; Wooten, 2000).
processor speeds are estimated to double every 18 months
through at least 2010 (Miller, 2000).
Other medical technology advances of the future that will
Technology has changed the concept of time and bound-
significantly change healthcare delivery include minimally
aries. The Internet and a variety of mobile devices permit
invasive surgery, xenotransplantation, cloning, and artificial
blood (RWJF & IFTF, 2000; Molitor; Wooten).
their users to be "connected" all the time. Around-the-clock
operations are possible because of technologic innovations,
Information technology will continue to affect health care
(RWJF & IFTF, 2000). "Telehealth" (i.e., remote monitoring
and consumers now are demanding services day and night,
of chronically ill patients using video cameras, blood pres-
regardless of widely varying time zones. Globalization has
pushed the trend toward continuous operations and service
sure monitors, and "smart pill boxes" [Molitor, 2000]) will
become a more common practice as the use of electronic
(Society for Human Resources Management, 2001).
monitoring systems is perfected and accepted.
September 11, 2001
These advances in healthcare technologies likely will be
accompanied by ethical dilemmas. The magnitude of ad-
Many people consider the terrorist attacks of September
vances in biotechnology and informatics will have far-reach-
11, 2001, to be one of the most significant events in Ameri-
ing implications that many believe will result in divisive
can history. Regardless of one's view with respect to the scale
moral and ethical dilemmas (Molitor, 2000).
of history, most would agree that its effects on near-term
plans are profound. For example,
Healthcare Costs and Access to Care
Associations' traditional programming formats are threat-
ened by changes in the travel industry, speeding the pace
Healthcare spending is projected to total $2.3 trillion or
at which organizations such as ONS must develop alterna-
15.5% of the gross domestic product in 2008, after having
declined from 13.4% in 1993 to 13% in 1999 (Health Care
tive formats (e.g., distance learning).
MAFRICA VOL 29, NO 9, 2002
Interestingly, in this time of heavy mergers and acquisi-
Financing Adminstration [HCFA], 1999). This represents a
predicted increase of 4.3% per year from 19992010. Health
tions, merged companies actually lose market share. Large
mergers and acquisitions do not help deliver blockbuster
insurance plans are expected to become more restrictive, pri-
earnings and sales. The larger a company is, the higher the
vate health insurance premiums will increase, and employers
will be forced to find ways to control costs (Heffler et al.,
sales it needs to meet its expectations. Smaller companies
hold the strategic advantage in this regard. In 2010, the
typical company will have one-third of the employees it
The most anticipated cause of increased healthcare spend-
had in 2000 and will market twice as many products (En-
ing is prescription drugs. Prescription drug spending in-
gel, 2000).
creased 16.9% in 1999 to $100 billion and is expected to
increase an average of 12.6% per year, reaching 16% of per-
sonal healthcare spending by 2010 (Heffler et al., 2001).
The potential for bioterrorism most certainly made its way
Drug price growth is expected to slow between 20042005
to the American national consciousness. Although the im-
because $427 billion of brand-name drugs will lose patent
pact of the anthrax incidents on ONS may not be immedi-
protection (Heffler et al.).
ately apparent, a number of items must be considered in terms
Senior citizens in the second decade of the 21st century
of planning.
(i.e., the baby boomers) will form what has been called the
The focus of national funding priorities may shift. Con-
"Geri-Boom" generation (Wooten, 2000). By 2005, 38% of
sider that the Centers for Disease Control and Prevention
the U.S. population will be "empowered healthcare con-
(CDC) has developed a five-year plan to support disease
sumers" who will possess at least two of the following three
surveillance and communication in response to the threat
characteristics: a household income exceeding $50,000, at
of bioterrorism (CDC, 2000).
least one year of college education, and a personal com-
Training priorities may shift for institutions that employ
puter (RWJF & IFTF, 2000). These consumers will demand
change in the healthcare system. The remaining 62% of the
Communications technology will become more important
p o p u l a t i o n will consist of working Americans whose
should the postal system come under a renewed or sus-
healthcare benefits are insecure or nonexistent (RWJF &
tained threat or if temporary stoppages occur.
The cost of heightened security at the U.S. Postal Service
By 2005, the number of people covered by health mainte-
is likely to be paid by business mailers, and, as a publisher
nance organizations will increase 25% from 78 million in
of periodicals, ONS could be affected substantially.
1998 to more than 100 million people. Those receiving insur-
ance from employers will decrease from 59% in 1997 to 56% in
Oncology Nursing Society
2010. According to the same report by RWJF and IFTF (2000),
O p e r a t i n g Environment
the number of Medicare recipients will increase from 38 mil-
lion in 1998 to 45 million in 2007 (15.5% of the population).
Member Demographics
In addition, the number of uninsured Americans will continue
In an internal report, ONS (2002a) identified key facts
to be 15% of the population in 2007 (RWJF & IFTF).
about its members. The number of active ONS members has
Delivery Systems
increased an average of 5.25% since 1990. The largest seg-
No one type of healthcare delivery model is anticipated to
ments of ONS member demographics, along with other obser-
dominate by 2005. Rather, organizations will employ a mix
vations, include the following.
of delivery models to meet healthcare needs. Disease manage-
Approximately 19% of ONS members are 4549 years of
ment guidelines will have a significant effect on medical
age. Sixty percent of members are older than 40.
practice and patient management for chronically ill patients,
Twenty-one percent of ONS members earn $40,000
and the use of advice nurses in contact with patients via tele-
$50,000 annually.
phone or the Internet will be common practice by 2005
Patient care is the largest functional area at 67%.
(RWJF & IFTF, 2000).
ONS members' largest patient population is in adult care
Employment opportunities for assistive personnel are
at 85.5%.
growing rapidly. Much of direct patient care is shifting to
ONS members primarily are employed on oncology spe-
lower-cost workers. Four of the highest growth occupations
cialty units, and 52.5% work in direct patient care.
for 19982008 in health care and human services will be
As of January 2002, members' primary specialty is in he-
personal care and home health aides (projected to increase
matology-oncology (33%), with chemotherapy and bio-
by 58%), medical assistants (to increase by 58%), social and
therapy falling second (25.25%). In 1997, these numbers
human service assistants (to increase by 53%), and physician
were reversed.
assistants (to increase by 48%) (Galbreath, 2001).
ONS members work primarily in a hospital or multihos-
pital system (43%). The number of members in this setting
The Pharmaceutical Industry
in 2002 is almost the same as it was in 1997, although the
Through his research, James (2000) determined that the
number of members in physicians' offices has almost
doubled and the number in home care has decreased by
pharmaceutical industry will not be an easy place to earn a
almost half.
living in 2005. Pharmaceutical companies will be forced to
change their traditional business models to meet changing
Currently, ONS members have worked, on average, for 20
years in nursing and 10 years in the field of oncology.
customer demands and newer technologies. The study also
The number of members with more than 20 years in oncol-
suggested that double-digit annual increases in revenues and
profits will cease to exist.
ogy is five times what it was in 1997, and the number of
ONF VOL 29, NO 9, 2002
The Association Industry
members with more than 20 years in nursing is almost
twice what it was in 1997.
As a professional membership society, ONS operates in
Sources of Revenue
what has become known as the association industry. With
more than 140,000 associations operating in the United
Table 2 shows the sources of ONS revenue for 19972001.
States, this industry clearly is a major force in shaping the
Although membership has grown steadily, the portion of to-
view of the world (ASAE, 2001). Consider the following
tal ONS revenue that comes from member dues has de-
creased, whereas the portion of revenue that comes from most
Ninety-five percent of associations offer educational pro-
other sources has remained relatively even or has increased.
grams to their members.
This is seen as a positive trend. In organizations such as ONS,
Seventy-nine percent offer public information and educa-
increases in nondues income keep member dues lower. The
most dramatic increase in ONS's revenue is from Oncology
Ninety-five percent publish at least one periodical, and
Education Services, Inc., which contributed 13.92% to the
39% publish books.
Society's total revenue in 1997 and 36.34% in 2001. This
Associations are the originating source for codes of ethics
reflects not only the actual growth of the for-profit subsidiary,
and professional and safety standards that govern almost
but also the growing importance of seeking common ground
all professions.
with corporate-funding sources.
Seventy-one percent of all associations conduct industry
Knowledge Management
research that businesses and the government depend on
a t the Oncology Nursing Society
heavily, which often is not available elsewhere.
More than 173 million volunteer hours in community ser-
Knowledge management is the use of organizational
vice are documented annually by associations.
knowledge for strategic advantage. The various corporations
Nine out of 10 adult Americans belong to an association,
that comprise ONS receive a substantial portion of their pro-
and one out of four belongs to four or more associations
gram and operational funding through pharmaceutical and
(ASAE, 2001).
corporate grants, advertisement and exhibit purchases, and
Associations can learn a great deal from other associations
other funding (e.g., educational sponsorship). To obtain
about the most successful ways to operate. Observing trends
these funds, a cross section of ONS staff members call on and
among the organizations in this business environment pro-
interact with multiple representatives from sponsoring com-
vides ONS with tools to use in its own planning.
panies. ONS recognizes that many staff members have devel-
ASAE (1999) identified major trends that most likely will
oped substantial knowledge and insight regarding these
affect the future of the association industry. A recent trends
company relationships. Ensuring that ONS's organizational
study investigated emerging issues that are likely to trans-
knowledge is preserved and effectively shared is vital in a
form associations (Olson & Dighe, 2001). The following is a
knowledge management "system" that staff can use regularly
summary of the issues with implications for ONS.
to track corporate activity (e.g., mergers, acquisitions), track
1. Meaning: Competition for members' time and involve-
and share sponsorship activity, stay aware of new product
ment is increasing as delivery channels broaden and more
developments that affect ONS members, and be prepared for
providers develop the capabilities to provide traditional
potential turnover in key ONS staff.
association services. ONS's ability to create meaning in
In addition, knowledge that staff obtains on a day-to-day
the form of relationships, a sense of belonging, purpose,
basis can be shared effectively with other staff. ONS has cre-
and contribution will differentiate ONS from providers of
ated a knowledge management resource center on its office
similar services, such as commercial Web sites, education
intranet. This resource center is one of several tools that staff
companies, and publishers.
can use to manage this knowledge.
Table 2. Five-Year Revenue Trends as of Year-End 2001, Oncology Nursing Society and Subsidiaries, Shown
as a Percentage of Gross Revenue
Revenue Source
Member dues
Contributions, awards, and grants
Registration and exhibit fees
Advertising and publications
Management fees
Interest and dividends
Miscellaneous income
Gross revenue: Oncology Nursing Press, Inc.a
Gross revenue: Oncology Education Services, Inc.
With the dissolution of the Oncology Nursing Press at the end of 2000, revenue that previously came from the publishing subsid-
iary is distributed across several lines in 2001, including advertising and publications and portions of royalties and contributions,
awards, and grants.
Note. Because of rounding, not all percentages total 100.
MAFRICA VOL 29, NO 9, 2002
2. Global goals, local services: Organizations are expected
More reliance on staff
to achieve national and international goals while tailoring
More reliance on nondues revenue sources
products and services for local markets. Challenges for
Project teams replacing committees
ONS include maintaining a balance between support of
Continuous needs assessment
local chapter interests and national unity of purpose, mo-
Aging members
bilizing grass roots support for national initiatives, and
Anticipating decreases in conference revenue
Technology affecting all aspects of operations
providing top-level representation and individual cus-
Thinking more about partnering
tomer service simultaneously.
More globally focused
3. Inclusiveness: Associations will leverage multicultural,
More image conscious
multigenerational, and multi-interest diversity to expand
Concerned about the nursing shortage
opportunities, recognizing the value that differences bring
to decision making. ONS, as a reflection of the nursing pro-
Figure 1. Organizational Trends Common Among Specialty
fession in general, has much to do in this regard. The nursing
Nursing Organizations
shortage and aging of the nursing workforce make it even
more urgent that exclusivity be replaced by inclusiveness.
vices (2000a), nursing is by far the largest single healthcare
4. Generational synergy: All organizations are faced in the
profession, with approximately 2.7 million RNs licensed to
near-term with an unprecedented age mix as five distinct
practice in the United States. Although this was a 5.4% in-
generations share the same workplace and (one hopes) are
crease from 1996, it was the lowest increase reported in all
members of the same organizations. Associations will be
previous national surveys. Nursing's multiple entry points
challenged to accommodate these five generations in
are arguably one of its greatest problems. The growing de-
meaningful ways. ONS shares this challenge, as well as the
mand for RNs with more specialized skills will make it neces-
daunting challenge of recruiting nurses from several gen-
sary for the profession to distinguish between the various
erations into the oncology nursing specialty.
paths to nursing practice and articulate a clear continuum of
5. Learning culture: Educational programming will need to
education and practice in nursing.
adapt to advances in technology, generational and cultural
One of the most significant issues for the foreseeable future
differences, and the constant need for people to retrain for
is the aging of the nursing workforce (see Table 3). At a time in
new professions and, indeed, relearn their professions.
the not-too-distant future when aging baby boomers will need
ONS is in the education business, competing with an in-
more nursing services than ever, many RNs will need care
creasingly crowded field of providers. ONS carries the re-
themselves rather than be able to provide it for others. The
sponsibility of delivering the most reliable and credible
"graying" of American nurses and nurses worldwide also will
education, when it is needed and where it is needed.
require a reexamination of working hours, retirement benefits,
6. Transparency: Several factors are driving a trend toward
recruitment and retention packages, and pay schemes for
more openness and accessibility by associations. These in-
people who reach the top of their salary ranges.
clude greater public activism, a demand for accountability, a
Table 4 shows characteristics of the U.S. nursing work-
more litigious society, and communication technology. As
force compared with ONS members. One of the most pro-
ONS seeks and acquires a "seat at the table" among more
found changes in nursing care in the 21st century will be
well-known entities and as it gains more recognition in pub-
where care is provided. Outpatient services are growing at a
lic arenas, it increasingly will be expected to maintain trans-
rate 18 times greater than inpatient services (Luther, 2001).
parency in its policies, processes, and advocacy activities.
The data in Table 4 indicate this shift already is more pro-
7. Living organizations: Structured management styles are
nounced in oncology nursing than in nursing in general. The
giving way to more fluid, flexible, and adaptive approaches
lack of diversity in the workforce also is clear and fairly con-
such as those that foster self-organizing activity. The chief
sistent between ONS and the general RN population.
challenges for ONS in this regard are maintaining the mo-
mentum gained by recent organizational changes, keeping
The Nursing Shortage
new structures from becoming too rigid or institutional-
The national unemployment rate for nurses is at its lowest
ized, and holding to the ONS mission and goals in front of
level since the late 1980s. However, as opportunities for
chapters and special interest groups (SIGs) even as they
women have expanded, the number of young women enter-
are encouraged to become more independent.
ing the RN workforce has declined. Buerhaus, Staiger, and
To place association industry trends in the context of
nursing, executives at five specialty nursing organizations
were interviewed by telephone about the association trends
identified by ASAE (1999). Responses were consistent with
Table 3. Aging of the Nursing Workforce
general association industry trends. Recent organizational
ONS Members
changes experienced at other nursing associations were simi-
Age (years)
1980 (%)
2000 (%)
2002 (%)
lar to those experienced in ONS. Common trends are summa-
rized in Figure 1.
< 40
> 30
Members' Operating Environment
ONS--Oncology Nursing Society
The Profession of Nursing
Note. Based on information from the Oncology Nursing Soci-
According to a 2000 national sample survey of RNs con-
ety, 2002a; U.S. Department of Health and Human Services,
ducted by the U.S. Department of Health and Human Ser-
ONF VOL 29, NO 9, 2002
Table 4. Selected Characteristics of RNs in the United States
With respect to the oncology nursing workforce, anec-
Compared With Oncology Nursing Society Members
dotal reports suggest that the current nursing shortage is af-
fecting oncology as severely as other highly specialized nurs-
% of
% of ONS
ing areas. Satryan (2001) reported that the shift in cancer care
All RNsa
from dedicated oncology units to medical and surgical areas
of the hospital will result in patients with cancer no longer
having the benefit of specialized oncology nursing care.
These changes to mixed units could affect the safety of can-
cer care, psychosocial care, and patient and family teaching
Advanced practice
and counseling and may have a negative impact on the qual-
Work setting
ity of care received by patients and families.
Public or community health
The results of a recent workforce study by ONS (Buerhaus
Outpatient or ambulatory care
et al., 2001) coincide with commonly held views of the
changes occurring throughout the nursing workforce. Not
only do oncology nurses believe that overall and oncology-
specific nurse staffing currently is inadequate, these views
Associate degree
also are shared widely by oncologists and nurse executives.
Bachelor's degree
Nurse executives report great difficulty in retaining experi-
Master's or doctorate
enced oncology nurses and have a lack of qualified appli-
Age (years)
cants for open positions (Buerhaus et al., 2001).
> 40
Oncology nurses perceive the work environment as one
< 40
marked by increasing workloads, inadequate and decreasing
staffing levels, rising paperwork, and sicker patients. Results
of the ONS workforce study suggest that nurses in dedicated
oncology units perceive their workplace environments more
positively than their colleagues who work on mixed units
Percentages do not total 100 because some respondents
(Buerhaus et al., 2001; Lamkin, Rosiak, Buerhaus, Mallory,
did not answer all questions and because only selected cat-
& Williams, 2001).
egories are presented.
Evidence suggests that perceptions of staffing and charac-
ONS--Oncology Nursing Society
teristics of the workplace vary according to where oncology
Note. Based on information from Oncology Nursing Society,
nurses are employed. Oncology nurses working in freestand-
2000a; U.S. Department of Health and Human Services, 2000a.
ing ambulatory settings perceived their work environments
more positively than either their inpatient or hospital-based
Auerbach (2000) reported that women graduating from high
outpatient department counterparts. Oncology nurses in free-
school in the 1990s were 35% less likely to become RNs
standing ambulatory settings were significantly more likely
than those graduating in the 1970s. Reductions in nursing
to state that nurse staffing had increased, although they also
program enrollments through the 1990s attest to this narrow-
perceived increasing numbers of patients in their workloads
ing pipeline. According to a National League for Nursing
(Buerhaus et al., 2001).
Accrediting Commission, Nursing Executive Center (2000)
Regardless of their setting, oncology nurses' perceptions of
report, enrollment in diploma programs dropped 42% and
more difficult work and sicker patients has not dampened
enrollment in associate degree programs declined 11% from
their enthusiasm for their profession. They retain a strong
19931996. Furthermore, from 19951998, enrollment in
commitment to nursing and caring for patients with cancer.
bachelor of science in nursing programs declined 19% and
Two-thirds of oncology nurses would recommend the nurs-
graduate programs declined 4%. The number of individuals
ing profession as a career (Buerhaus et al., 2001).
passing national RN licensing examinations declined from
Nursing Education
97,679 in 1996 to 74,787 in 2000, a decrease of 23%.
Growing concerns about the nursing shortage and the abil-
Since 1980, basic nursing education has moved away from
ity to retain nurses are becoming more widespread. As of
diploma programs to associate degree or baccalaureate pro-
June 2001, legislation to address the nursing shortage had
grams. The portion of diploma graduates fell from 63% in
been introduced in 15 states. Additionally, legislation to re-
1980 to 29.6% in 2000. From 19802000, the number of as-
duce mandatory overtime for nurses had been introduced in
sociates degree and bachelor of science in nursing graduates
10 states and has been introduced at the federal level (U.S.
increased from 19% to 40.3% and 17.3% to 29.3%, respec-
General Accounting Office, 2001).
tively. The average age for RNs graduating from basic educa-
The nursing shortage, coupled with an aging and growing
tion programs from 19952000 was 30.5 years (U.S. Depart-
population, poses a particularly difficult problem for areas
ment of Health and Human Services, 2000a).
within nursing that serve older patients and require special-
The National League for Nursing Accrediting Commis-
ized skills and experience. Because cancer is the second lead-
sion, Nursing Executive Center (2000), reported 86 diploma,
ing cause of death and disproportionately affects older pa-
885 associate degree, 695 baccalaureate degree, 358 master's
tients, oncology nursing may be more vulnerable to these
degree, and 75 doctoral nursing programs in the United
professional and demographic trends than other areas of nurs-
States. Changes in the healthcare environment have affected
ing (Buerhaus, Donelan, DesRoches, Lamkin, & Mallory,
the basic knowledge and skills nurses must possess to pro-
vide adequate nursing care. Baccalaureate nursing programs
MAFRICA VOL 29, NO 9, 2002
courage nurses to pursue their academic education. Nursing
typically provide a broader, more scientific curriculum than
organizations can assist in the academic preparation of nurses
other basic nursing programs and enable a sound foundation
by providing resources to schools of nursing.
for nursing (National Advisory Council on Nurse Education
and Practice, 1996). A survey conducted by the American
Nursing Leadership
Association of Colleges of Nursing (2001) noted that after a
six-year decline, enrollment in baccalaureate nursing pro-
Regardless of their positions within organizations or com-
grams had increased in 2001. Although it is a positive sign,
munities, confident nurses who are willing to lead and not
this increase is not sufficient to meet the demand of a million
afraid of change have the potential to become future leaders
nurses by 2010. Enrollment in graduate and higher degree
of the profession. Nursing leaders develop strong communi-
programs showed little change in the same period (American
cation skills and are knowledgeable about the role of nursing
Association of Colleges of Nursing).
and the state of health care. As suggested by Grossman and
The nursing shortage has affected many areas of the profes-
Valiga (2000), nursing leaders are those who focus on the
sion, including the colleges and universities that educate new
opportunities of today and tomorrow.
nurses. Nursing faculty decline has been attributed to the ag-
Nursing associations with access to large numbers of
ing nursing population (mean age for nursing faculty from
nurses interested in advancing their profession are in a
19992000 was 50.2 years), the decline in nursing school en-
unique position to provide the guidance, direction, and sup-
rollment, and the variety of nursing positions available to
port for the future leaders of nursing. Nursing organizations
today's nurse (Hinshaw, 2001). With the decline of enrollment,
can provide a variety of opportunities for nurses within their
colleges and universities have decreased the number of faculty
communities to become leaders. Assisting nurses to practice
positions available, thus sending potential faculty members
leadership skills, create a vision, strategically plan to accom-
into other areas of nursing practice. The shortage and decreased
plish the vision, and implement change within their own en-
enrollment will leave many vacancies in faculty positions
vironments not only will strengthen individual nurses, but
when current faculty retires. In addition, nurses usually do not
also the nursing profession and healthcare environment as a
enter into academia until later in their careers, decreasing the
whole (Grossman & Valiga, 2000).
time they have to refine their skills as teachers (Hinshaw).
2001 Environmental Scan Sur v ey
The academic norm for educating at the baccalaureate and
graduate level is a doctorate degree. To date, only 50% of nurs-
In November 2001, an environmental scan survey was sent
ing faculty of degree programs are prepared at the doctoral
to approximately 3,300 ONS members (ONS, 2002b). Of
level. Although this number is significantly greater than 15%
these, 3,000 were randomly selected from among ONS indi-
in 1978, it had not changed significantly from 19952000
vidual RN members and approximately 300 were members
(Hinshaw, 2001). With the low numbers of nurses pursuing
holding leadership positions within ONS (e.g., boards of di-
advanced degrees and the anticipated retirement of many fac-
rectors, councils, SIG coordinators, chapter presidents). The
ulty through 2010, this number will not be increasing in the
overall response rate was 15% (472 responses), including
near future (Hinshaw). In an effort to effect change, specialty
329 members and 143 leaders.
nursing organizations joined together to endorse the Ameri-
The purpose of the survey was to measure members' and
cans for Nursing Shortage Relief and outlined numerous con-
ONS leaders' perceptions of the trends in their operating en-
sensus issues. Recognizing the decline in nursing faculty at
vironments and gauge their expectations of ONS with respect
schools and universities across the United States, funding in-
to these trends. Questions addressed the external operating
creases have been recommended for faculty development, as
environment and the internal ONS environment.
well as for creating a fast-track nursing faculty scholarship and
loan program (American College of Nurse Practitioners and the
Most Important Issues
Americans for Nursing Shortage Relief Coalition, 2001).
Four of the ONS survey questions asked respondents to se-
Competencies will change for 21st century nurses. Future
lect issues (from a list of 21) that are most important in cancer
RNs will need ever-increasing critical thinking skills, inde-
care, are most important in cancer nursing, most affect their
pendent clinical judgment, management and organization
practice, and are most important for ONS to address. Seven
skills, leadership abilities, and understanding of technologies
issues emerged as important with respect to all four questions
to practice in diverse settings. A broader educational founda-
(see Table 5).
tion will be needed to ensure that nursing professionals have
The nursing shortage was cited as the most important issue
the knowledge and skills needed to assume greater responsi-
facing cancer care today by 48% of respondents, the most
bility for the management and coordination of personnel,
important issue facing cancer nursing by 60%, the most im-
services, data, and resources, in addition to their roles as care
portant issue for ONS to address by 38%, and affecting prac-
providers (Pew Commission, 1999).
tice the most by 30%. Interestingly, those issues cited as
Every day, new therapies and treatments are being discov-
most important were not always the same issues affecting
ered that will save, enhance, or sustain lives. Education no
practice the most (e.g., care by nonspecialty providers) and
longer can end with a degree, but must continue throughout
those most important to nursing were not always the most
every nurse's career. Nurses graduating today will not have
important to cancer care (e.g., advanced practice role).
the skills to care for patients in 10 years without adding to
One important observation is that the top issues are di-
their basic nursing education. In addition to providing edu-
vided between those that have to do with advocacy and those
cation directly to practicing nurses, nursing organizations are
that have to do with services. Advocacy initiatives are broad
in a unique position to provide specialty education to nurses.
and outward-looking (e.g., nursing shortage, reimbursement,
Not only must nursing organizations provide continuing-
access to care). These issues are served by ONS's efforts to
education opportunities for nurses, but they also must en-
ONF VOL 29, NO 9, 2002
Table 5. Ranking of Seven Top Issues Identified in the 2001 Oncology Nursing Society Environmental Scan Survey
Need for
Care by
ment Issues
to Care
Survey Item
Most important issues fac-
ing cancer care today
Most important issues
facing cancer nursing
Issues currently affecting
your practice the most
Most important issues for
the Oncology Nursing
Society to address
that 79% of the respondents' employers support time off for
influence policymakers, legislators, and public opinion and,
thus, have to do with representing the members rather than
continuing-education programs, 68% will reimburse for for-
mal education programs, and 67% will pay registration for
providing something for the members. Other top issues, nota-
continuing-education programs. Forty-six percent of the re-
bly keeping abreast of new knowledge and the need for evi-
spondents' employers pay for certification examination fees
dence-based guidelines and standards, have to do with pro-
and travel expenses for continuing-education programs.
grams and products (i.e., services that ONS provides to
ONS members are more technology-literate than ever be-
members). The respondents to this survey called on ONS to
fore. Eighty-nine percent of respondents to this survey said
do both, which has implications for how ONS needs to allo-
that e-mail is the most effective way for ONS to communicate
cate its resources in the near-term.
with members. Finally, for ONS members who said they do
Support for ONS Advocacy Efforts
not participate in various programs, lack of time was the
chief reason, cited by 87%.
The ONS survey listed 15 health policy issues that the So-
Three trends that emerged from the survey responses in-
ciety currently is advocating on Capitol Hill. Respondents
clude less time, increasing support by employers for educa-
were asked to select the most important. The five top issues
tion, and increasing comfort with technology, which com-
selected were
bine to confirm that ONS may be at the right time and place
Private insurance coverage for clinical trials (38%)
in terms of development of technology alternatives for dis-
Medicare reimbursement for anticancer therapies (35%)
tance education programs.
Private insurance coverage for screening and early detec-
tion (31%)
Areas for Improvement
Patients' Bill of Rights for cancer care (31%)
Access to appropriate pain and symptom management
When asked what ONS needs to improve, 64% of respon-
therapies (27%).
dents said ONS should increase visibility and political influ-
All of these issues relate to access to care and reimbursement,
ence. Fifty-three percent said ONS should increase opportuni-
both of which were among the top-rated issues in terms of im-
ties for new nurses or staff nurses to be more involved, and
45% said ONS should increase opportunities for mentorship.
Thirty-eight percent said ONS should increase opportunities
M o s t Valued Services
for networking.
In response to a question about the most valued ONS ser-
Currently, two of the main ways that ONS facilitates all of
vices, the top four were
these is through its chapters and SIGs. Forty percent of the
Journals (76%)
respondents were members of SIGs, and 78% were members
National conferences (57%)
of chapters. In both cases, lack of time was selected as the
Practice standards (44%)
chief reason for not participating by 66% of the non-SIG
ONS Online (34%).
members and 53% of the nonchapter members.
All of these are tied closely to keeping abreast of new
Given the overwhelming reason for not participating (i.e.,
knowledge and the need for evidence-based guidelines and
lack of time), ONS clearly must find ways to increase oppor-
standards, which are two of the top-rated issues in terms of
tunities while simultaneously reducing the time commitment
importance. This list of most-valued services is almost iden-
required of volunteers. The opportunities for ONS to achieve
tical to the list obtained consistently from ONS's ongoing
both of these goals may reside, again, in the effective use of
satisfaction surveys.
technology to facilitate meaningful participation.
This survey revealed interesting trends with respect to
General Implications for the
employers' support of nursing professional development.
Sixty-three percent of the respondents indicated that profes-
O n c o l o g y Nursing Society
sional development is considered important or very impor-
tant in their healthcare settings, and only 8% said it was not
This report examined ONS's operating environment with
considered important. This is supported further by the fact
respect to the macro environment, internal ONS operating
MAFRICA VOL 29, NO 9, 2002
A variety of technologies is available to deliver distance learning in ways that and places where members need it.
Upcoming generations will expect educational opportunities in nontraditional formats.
The fields of expertise in nursing education are changing dramatically and rapidly.
The need for new knowledge affects Oncology Nursing Society (ONS) members' practice the most.
Members face increasing challenges in terms of discretionary time and money for continuing education.
Institutions that employ nurses are challenged by the nursing shortage to recruit and retain staff.
The events of September 11 have caused people to reexamine what is most important to them; their employers may become
more focused on training issues, such as emergency preparedness, rather than on continuing education in specialty areas.
Member needs identified through a variety of instruments are very consistent and well represented by the education blueprint
developed annually by the ONS Steering Council.
ONS exhibits and conference registrations continue to be highly profitable activities that members consider important ONS
More than ever before, ONS must lead the effort to demonstrate the impact of cancer nursing on patient outcomes.
ONS must continue to promote nursing practices that are evidence-based.
ONS must continue to seek and expand opportunities to fund its own initiatives by finding common ground with research-
funding sources.
Electronic publishing technologies continue to evolve faster than our members' adoption of them, yet members are more
technology-literate than ever before.
The next generation of workers will have highly refined technical skills, which will influence publishing and the delivery of edu-
cational content.
ONS publications consistently are cited among the most important benefits of membership.
Published standards and guidelines are becoming increasingly important.
Recruiting members to leadership roles continues to be a challenge.
Nurses may be the best recruiters and mentors of young people into nursing.
Leadership development content must be expanded to reach to a greater number of members.
Formal mentoring programs need to be developed and refined.
The wisdom of retiring members can be rechanneled to strengthen the specialty and the organization.
ONS must find ways to provide meaningful participation with less commitment of volunteer time.
Members with identified expertise are main avenues for the development of expert content.
Chapters play a vital role in recruiting and retaining members.
ONS must attract young people into oncology nursing.
ONS needs to reach beyond the traditional profile to find tomorrow's oncology nurses.
ONS's relationships with corporate funders will be strengthened by efforts to seek common ground.
Opportunities exist to shift ONS's relationships with its chapters from parent-child to partner-partner.
ONS must partner with other nursing organizations (e.g., shared benefits, services programs).
ONS must partner in ways that will attract students to oncology nursing.
ONS must partner with patient-advocacy groups and other cancer-related organizations on issues of common concern.
Public outreach
Public-education programs can contribute to the public's understanding of what constitutes quality cancer care.
Focus should increase on public awareness of the role of the nursing profession in the delivery of quality care.
Chapters must be supported for grass roots activities related to advocacy, nurse recruitment, financial sponsorship, healthcare
policy activism, and public education.
ONS has built considerable momentum in the legislative arena, and this momentum needs to continue at an increasing
ONS continually must increase efforts to get oncology nursing a seat at decision-making tables.
Members need to develop heightened awareness of the need for nurses to be healthcare policy advocates.
ONS needs to be proactive in influencing policy that affects the practice of oncology nursing and access to quality cancer
Managing the ONS business
Managing corporate knowledge at ONS is a critical element in maintaining revenue streams.
ONS operates in a business environment that is influenced greatly by changes in the pharmaceutical industry.
Nondues revenue is an increasingly larger portion of total revenue.
Business objectives need to continue to drive much of ONS's decision making.
Figure 2. Strategic Implications Identified in the Environmental Scanning Process
ONF VOL 29, NO 9, 2002
environment, trends in the association industry, and the
leaders that helped to guide the development of the 2003
members' operating environment. A general set of implica-
2006 Strategic Plan.
tions emerged for ONS, which were used as a starting point
for a discussion of broad strategic goals. These implications
are summarized in Figure 2. The implications identified in
Author Contact: Leonard Mafrica, MBA, CAE, can be reached at
the environmental scanning process provided a tool to ONS
len@ons.org, with copy to editor at rose_mary@earthlink.net.
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