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Oncology Nursing Society
Environmental Scan 2004
Cynthia Miller Murphy, RN, MSN, CAE, Layla G. Ballon,
Bridget Culhane, RN, MN, MS, CAE, Leonard Mafrica, MBA, CAE,
Michele McCorkle, RN, MSN, and Linda Worrall, RN, MSN, OCN
nvironmental scanning is a systematic effort to obtain
(Snyder, 2004). Despite the efforts of traditional cultures and
information about the world that will affect an orga-
some governments throughout the world, cultural, social,
nization. Scanning is important in managing change
and political isolation has become almost impossible. For
and avoiding costly mistakes. The Oncology Nursing Society
example, the number of Iranians with Internet access grew
(ONS) conducts an environmental scan at three-year intervals,
from 500,000 in 2000 to 1.75 million in 2002 and is expected
consistent with its strategic planning cycle.
to increase to five million within the next few years (Cetron
This environmental scan builds on previous work by incor-
& Davies, 2003a). More people around the world are gaining
porating a variety of methods, including
education and exposure to modern ideology and lifestyles.
A 2004 survey of ONS members
Many are interested in Western culture and desire American
A review of current business, healthcare, government, and
products, thus causing a backlash among some religious fun-
association management literature
damentalists who strive to preserve their traditional lifestyle,
Information provided one-on-one by nursing organization
especially in societies where xenophobia is common (Cetron
& Davies, 2003a). As cultural modernization continues to
A review of the ONS membership database
assault the world's traditional cultures, widespread political
ONS financial reports.
unrest and social tension are likely to elevate. Terrorist activ-
ity throughout the world is likely to continue through the next
The intention of environmental scanning is to understand
decade (Cetron & Davies, 2003b).
external trends affecting all organizations, those trends that af-
More businesses are going global. Despite the need for
fect our members' operating environment, business trends that
heightened security, multinational corporations prevail. Ameri-
influence the ways in which associations like ONS operate,
can, Japanese, and European companies are expanding to build
and internal facts and statistics about ONS itself. Environmen-
tal scanning is the first step in a strategic planning process in
consumer markets and also outsource work to developing
which trends are analyzed for the purpose of identifying the
countries where the desire for American products is high and
major implications for ONS.
labor costs are low. At least 220 Fortune 1000 companies have
ONS leaders will use the implications that arise from this
outsourced work to India, where technology developers cost
process to help them determine the major strategic directions
30% 60% less than their U.S. counterparts and call center
for ONS to pursue from 20062009.
workers earn just $1$2 per hour (Dalton, Jarratt, & Mahaffie,
External Trends
Cynthia Miller Murphy, RN, MSN, CAE, is the executive director
of the Oncology Nursing Certification Corporation in Pittsburgh,
PA. Layla G. Ballon, is the chief operating officer, Bridget Culhane,
The Internet has connected, but not necessarily united,
RN, MN, MS, CAE, is the executive director, and Leonard Mafrica,
the world. In 2003, 500 million people used the Internet
MBA, CAE, is the executive director of business development and
publisher, all at the Oncology Nursing Society in Pittsburgh. Michele
worldwide, and because of the rapid expansion of connectivity
McCorkle, RN, MSN, is the executive director of Oncology Education
in developing nations, the number of Internet users is expected
Services, Inc., in Pittsburgh. Linda Worrall, RN, MSN, OCN  , is the
to increase to approximately 900 million by 2005 (Cetron &
executive director of the ONS Foundation in Pittsburgh.
Davies, 2003b). In less than a decade, one-third of the world's
population (two billion people) will have access to the Internet
Digital Object Identifier: 10.1188/05.ONF.E76-E97
2003). The Internet enables even the smallest American
in the United States (National Council of State Boards of
business to market and sell its products to a wide array of
Nursing, 2004). As general immigration to the United States
international consumers.
rises, as does the immigration of international nurses to solve
the nursing shortage, nursing associations will be required to
meet the needs of an increasingly diverse constituency in the
very near future. The ONS membership has become slightly
merican associations must be prepared to
more diverse during the past decade, with the percentage of
provide their products and services to an inter-
Caucasian members declining from 91% in 1994 to 88% in
national constituency that includes the developing
nations of the world.
The populations of most developed nations will steadily
decline and age over the next 50 years. This is caused pri-
American associations must be prepared to provide their
products and services to an international constituency that
marily by birth rates falling below replacement levels. The
U.S. population is aging, although more gradually than the
includes the developing nations of the world. For example, in
recent years, the Oncology Nursing Certification Corporation
populations of Europe and Japan (Dalton et al., 2003). As
(ONCC), as well as other specialty nursing certifying organi-
the large baby-boom generation, which accounts for 38% of
zations in the United States, has experienced a strong interest
the adult U.S. population, continues to age and live longer
in and demand for certification in South Korea. ONCC has
than any generation before it, the median age in the United
administered certification examinations to 314 candidates in
States will climb (Mitchell, 2000). In 1990, the median age
South Korea during the past four years. Although the examina-
in the United States was 32.9 years. By 2010, the median age
tions currently are offered in English only, translation should
will be 37.2 years and the median age of the workforce will
be considered if this international market continues to grow.
be 40.6 years (Dalton et al.). In the next 20 years, the older
Associations have the opportunity to expand their organi-
adult population in the United States will nearly double from
zations through international membership or alliances and
40 million today to 77 million (Pinsonault, 2003). By 2010,
affiliations with organizations in other countries. This will
life expectancy will reach 76 years for men and 86 years for
involve adapting to the needs of potential members in these
women (Sussman, 2000).
As people live longer, the incidence of chronic illnesses,
countries. The translation of educational materials or the
including cancer, will rise dramatically. By 2010, an esti-
production of very basic educational materials for develop-
ing countries may be needed. Currently, fewer than 600 ONS
mated 40% of Americans will suffer from some type of chron-
ic disease, and another 40% will have more than one condition
members reside outside of the United States. ONS is in the
(Sussman, 2000). Because 76% of all cancers are diagnosed
process of developing an international marketing plan and
at age 55 or older (American Cancer Society [ACS], 2004),
examining the feasibility of international chapters and in-
ternational virtual membership subscriptions to attract more
the incidence of cancer in the United States will rise steadily
international members.
with increasing life expectancy. Healthcare professionals who
Populations around the world are increasingly mobile as
specialize in gerontology and conditions associated with ag-
people migrate to countries where opportunities for work and
ing, including cancer, will continue to be in demand. However,
improved quality of life are available. At an average of two
a shortage of such workers is on the horizon.
children per woman, the birth rate in the United States is at
The aging of the baby boomers is expected to place a large
replacement level. However, because of increases in the rate
burden on current social institutions, such as social security
of immigration, the U.S. population will grow steadily over
and, in particular, the healthcare system. The evolving nursing
the next 50 years. In 2005, the U.S. population will grow by
shortage is one of the first indications of this strain, as nurses
70 million people, an increase of 25% (Population Reference
age along with the rest of the population and younger workers
Bureau, 2004). Eight hundred thousand to one million people
are not available to replace those who retire. Trends in ONS
immigrate legally to the United States each year. One-third of
demographics clearly illustrate this problem. For example,
all immigrants to the United States come from Latin America,
10 years ago, 53% of ONS members were younger than 40
the Caribbean, and Mexico, and another one-third come from
years of age and only 15% were older than 50. Today, only
Asia. Within the next 25 years, the Asian and Hispanic popu-
30% of ONS members are younger than age 40 and 32% are
older than age 50.
lations in the United States are predicted to double, reaching
Baby boomers are redefining old age. The baby-boom
24 million and 68 million, respectively (Wellner, 2003), and
generation has transformed American culture in multiple ways
many regions of the United States will be primarily Spanish
speaking (Dalton et al., 2003).
and continues this transformation by redefining "old age" and
As the current nursing shortage worsens, a strategy already
all that has traditionally been associated with it. Industries
in place to help solve it is the immigration of foreign nurses.
and companies that traditionally have focused on youth have
International administration of the NCLEX-RN and NCLEX-
begun to seek customers outside the usual market of those
PN examinations was scheduled to begin in January 2005 in
aged 1834 (Wellner, 2003). Companies and organizations,
Hong Kong, South Korea, and England. These examinations
including associations, will have to establish brands that at-
tract older consumers without alienating younger ones and
will be identical to those offered for the licensure of nurses
market across generations. Smart marketers will create an
in the United States. The purpose of the international ad-
ministration is to provide convenience to candidates without
image of an ageless society where people define themselves
sacrificing standards while significantly minimizing the time
more by the activities in which they are involved rather than
their age.
required and overall cost to candidates to become licensed
Second, third, and even fourth careers within a lifetime
erogeneous than the generations whose members are older
could become the norm (Cetron & Davies, 2003b). People
than 40 (Dalton et al., 2003). By 2025, the term minority
as it is currently used will be virtually obsolete. The current
will cycle in and out of activities based on their interests, not
Caucasian, non-Hispanic segment of the population (73%)
their age (Wellner, 2003). This will apply to careers as well as
will fall to 60%. The Asian and Hispanic segments of the U.S.
other interests. Midlife changes in occupations will become
population will double because of immigration and higher
common. Baby boomers always have been committed to self-
birth rates (Wellner, 2003).
improvement and learning. Many even will enter new careers
Striking differences exist in the rate at which various
when they are past the traditional retirement age. ONS must
regions of the United States are becoming diverse. Re-
continue to focus on the "over 35" demographic, because
gions that currently are diverse will continue to become more
nursing is often a second career that is entered in the third
and fourth decades of life.
diverse, and those that currently lack diversity are expected
Baby boomers will redefine traditional retirement. Ac-
to remain unchanged over the next decade. For example, the
cording to a survey conducted by AARP, 7 out of 10 workers
non-Hispanic Caucasian population of California declined
aged 45 and older expect to work beyond their retirement
from 57% in 1990 to 48% in 2000 and will continue to de-
cline annually by about 1.2%. Conversely, Maine's Caucasian
years (Dalton et al., 2003). Some people may postpone true
population that was 98% of the total in 1990 is projected to be
retirement until very late in life (Cetron & Davies, 2003b),
97% of the total in 2005. The same disparity in age diversity
and some will be motivated to remain in the workforce for
also exists, with regional populations having the greatest ra-
financial reasons, fearing that social security will not be able
cial diversity also being younger on average than the regional
to support them. This fear may be realistic because genera-
tion X, which succeeded the baby boomers, is 35% smaller,
populations with greater Caucasian representation. Religious
and generation Y, which is almost as large as the baby-boom
diversity, also on the rise, is greatest in areas where there is
generation, will not be in its peak earning years when most
other diversity (Orndoff, 2003).
baby boomers need support. Other baby boomers may
fear that they will outlive their personal retirement funds.
However, many baby boomers will remain in the workforce
ike the for-profit sector of the country, ONS
because of a desire to stay active and connected to their
and its affiliates must learn to market to a con-
professions. A new state of "revolving retirement" may be
sumer base that will include a patchwork of racial,
created as people drop in and out of the workforce (Cetron
ethnic, and generational identities.
& Davies, 2003b). Associations are in a prime position to
provide the "connection" that these older professionals will
seek, even when they are not actively engaged in the work-
force (Dalton et al.).
Like the for-profit sector of the country, ONS and its affili-
Generations X and Y are independent, entrepreneurial,
ates must learn to market to a consumer base that will include
and likely to be self-employed. Generation X, the small gen-
a patchwork of racial, ethnic, and generational identities.
eration that followed the baby-boom generation, is composed
While focusing on recruiting younger members, ONS also
of individuals born from 19651976 and currently are entering
must keep in mind the importance that lifelong learning and
their peak earning years. This generation is well educated,
maintaining professional connections hold for older members.
media savvy, comfortable with technology, and self-reliant.
Strategies to recruit increasingly diverse younger members
Motivated by financial rewards, with little loyalty to institu-
also will need to be developed. Understanding the differences
tions, this generation is entrepreneurial and even more likely
in consumers' cultural identities will make the difference
to have multiple careers in a lifetime than the baby boom-
between failure and success (Wellner, 2003).
ers (Cetron & Davies, 2003a; Dalton et al., 2003; Mitchell,
2000). Many will prefer self-employment to working for
Advances in technology continue to dominate society,
others, especially when traditional institutions are involved.
and both technologic competence and dependence on tech-
Generation X currently accounts for 22% of the U.S. adult
population (Mitchell).
nology are increasing. Computers have become part of our
The baby-boom echo, or generation Y, born from 1977
environment rather than just tools we use for specific tasks.
1994, is almost as large as the baby-boom generation and
For a good career in almost any field, computer competence
comprises 26% of the current U.S. population (Mitchell,
has become mandatory. In 2005, computer competence will
2000). As children of the baby boomers, members of gen-
approach 100% in U.S. urban areas (Cetron & Davies, 2003a).
eration Y tend to hold similar values. They are socially con-
The rate at which transactions can be completed and data are
scious, civic minded, and altruistic. They are the first truly
available has led to rising consumer expectations for speed,
"high-tech" generation and are comfortable getting, using,
quality, and service (Dalton et al., 2003).
Cultural clashes, accelerated by globalization, threaten
and sharing information that is visual, fast paced, and con-
our security. Universal connectivity through technology has
ceptual (Dalton et al., 2003). Members of generation Y, like
their baby-boomer parents, are likely to seek involvement in
accelerated globalization, which continues to create cultural
professional associations. However, they may prefer more
clashes that governments must learn to solve (Coles, 2003).
high-tech and multimedia methods of engagement.
The forces of cultural modernization, accelerated by economic
A hallmark of generations X and Y is diversity of all
globalization and the rapidly spreading wireless telecommu-
types. The United States will experience a long-term shift
nications infrastructure, are likely to marginalize the world's
traditional cultures before the century is over. Because these
in the ethnic makeup of the population over the next several
forces are so powerful, the defenders of traditional culture
decades. Currently, younger generations are much more het-
have resorted to terrorism to preserve their way of life (Sny-
segment of the membership on a long-term basis. ONCC has
der, 2004).
begun to explore the development of psychometrically sound
This ongoing cultural conflict is likely to continue. How-
and cost-effective methods of awarding subspecialty creden-
tials to oncology nurses.
ever, the possibility of future terrorist assaults is not likely
The health and wellness movement, initiated by baby
to alter the way that Americans live or make daily decisions.
boomers in the United States, will continue to grow.
Studies reveal that Israeli citizens have not altered their daily
Lifelong learning is just one aspect of "remaining young"
routines of life as the result of terrorist acts because they
that the baby boomers have embraced. The health and well-
view these acts as random events for which no precautions
ness movement in the United States continues to flourish.
can prepare them (Snyder, 2004). The same may be said
Insurance companies that reduce premiums for policyholders
for ONS members. Although the Institutes of Learning that
with healthy lifestyles have fueled emphasis on preventive
immediately followed September 11, 2001, was poorly at-
tended, the spring 2002 ONS Congress was the best attended
medicine. Smoking and the consumption of distilled liquor
in the Society's history. The venue of Washington, DC, in a
are declining in the United States, and the companies that sell
year when patriotism was at its peak in America, may have
these products will increasingly target markets in developing
provided an additional draw to the conference. Since that
countries. As the health of America improves, healthcare costs
time, thousands of conference attendees and hundreds of
should decline. Diet, fitness, stress-control, and cosmetic-en-
hancement industries will prosper (Cetron & Davies, 2003a).
ONS and affiliated corporations' volunteers have traveled
ONS promotes healthy lifestyles among its employees through
to numerous meetings, undaunted by the inconvenience of
several policies and activities, such as the availability of on-
enhanced security measures.
The growth of the information industry has created a
site massages and annual influenza vaccinations.
The value of personal time is increasing. Workers in the
knowledge-dependent global society (Cetron & Davies,
Unites States spend about 10% more time on the job than
2003a). The development of new knowledge has become
they did a decade ago (Cetron & Davies, 2003b). American
exponential. All of the technical knowledge with which we
families collectively also are spending more time at work.
work today will represent only 1% of the knowledge that will
With mothers working in approximately 61% of families,
be available in 2050. Medical knowledge is doubling every
parents together work about 81 hours per week in the United
eight years. Half of what students learn in their freshman year
States (Dalton et al., 2003). This leaves little time for other
about the cutting edge of science and technology is obsolete,
activities, and the need for balance between work and leisure
revised, or taken for granted by their senior year (Cetron &
is greater than ever before. Leisure time has become a valued
Davies, 2003b). In this knowledge age, lifelong learning is
commodity, and consumers believe that they deserve whatever
paramount to success, and Americans are spending more
time savers and luxuries they can afford. More consumers are
time in school than ever before. Today, approximately 26%
shopping virtually and making purchases online to allow more
of adults have a college degree, compared with about 3% in
time for themselves and family. In a recent survey of the ONS
1900 (Dalton et al., 2003). The rapid development of new
membership, lack of time is cited as the primary reason for
knowledge requires not only increased academic education
not joining a local chapter or SIG and not volunteering on the
but also ongoing education for workers to maintain com-
petence. Workers and management must embrace the trend
national level. As volunteer organizations, ONS and its affili-
ates need to continue to offer members ways to be involved
toward lifelong learning because it will become a significant
and engaged that do not unduly interfere with personal and
part of work at all levels (Snyder, 2004).
family time. Alternative ways of offering CE and other prod-
ucts, as well as virtual meetings using Web and conference
call technology, should be implemented. The ONS e-Source
he role of professional associations is vital in
should continue to expand, providing online registration and
providing cutting-edge, specialized continu-
purchasing for all products and activities.
The public is beginning to demand greater accountabil-
ing education as well as support for the various
ity and transparency in both the private and public sec-
specialty and subspecialty areas of practice in a
tors. The recent wave of exposures of corporate malfeasance
at Enron, Tyco, WorldCom, and others has accelerated the
global movement toward greater transparency. These recent
exposures, along with the controversy of child abuse in the
For many professions, the size of the body of knowledge
Catholic church, have caused society to assign less weight
precludes expertise across all specialty and subspecialty areas,
to the guidance of their institutions and leaders and become
causing professionals to select very specific areas in which to
more self-regulating (Snyder, 2004). Inspiring trust through
work. The role of professional associations is vital in provid-
transparency in all operations and accountability by all lead-
ing cutting-edge, specialized continuing education (CE) as
ers must become priorities for all associations and related
well as support for the various specialty and subspecialty
organizations. ONS and its affiliates must remain diligent in
areas of practice in a profession. Although general medical
providing information to members and other stakeholders that
oncology continues to be the specialty practiced by the major-
will help them understand organizational processes as well as
the rationale for decisions that are made. ONCC recently was
ity (70%) of ONS members, about a quarter of the member-
ship belongs to at least one special interest group (SIG) and
in a position of explaining the rationale for discontinuing the
AOCN examination, which had been administered for almost
another 1,000 members participate in focus groups. Support
a decade, and replacing it with two new role-specific advanced
for nurses in these well-defined subspecialty areas of practice
practice certification examinations. Patience, diligence, and
and focused education may be vital to ONS maintaining this
consistency of communication are required. More about this
10% currently are trying to start their own businesses, which
trend is discussed in the Business Trends and Government and
is three times as many as in previous generations. Estimates
Regulation Trends sections of this report.
from the Bureau of Labor Statistics and Forecasting Interna-
tional indicate that 10.212 million people will be self-em-
ployed by 2006 (Cetron & Davies, 2003b). Since the 1970s,
small businesses have accounted for nearly all new jobs
NS and its affiliates must remain diligent in
created, and by 2005, 80% of the labor force will be working
providing information to members and other
for companies that employ fewer than 200 people (Cetron
& Davies, 2003b). To benefit from the expertise of talented
stakeholders that will help them understand or-
members of generation X, associations soon may need to
ganizational processes as well as the rationale for
consider contracting with these small entrepreneurial firms for
decisions that are made.
some services currently provided by traditional employees.
Gender diversity also continues to grow in the workplace, as
women become more educated and move into industries and
Cheating among students is on the rise. The erosion of
roles previously dominated by men. At the same time, men
ethical behavior also has filtered to the individual youth of
are moving into occupations that traditionally have been filled
our country as cheating in academic institutions is on the
by women, such as nursing. From 19791999, the number of
rise. Fifty years ago, 25% of high school students admitted
women earning four-year college degrees increased by 44%,
to cheating; today, 75%98% of students admit to cheating
whereas the number of men receiving four-year degrees declined
in some form. More than 50% admit to plagiarism (Kleiner &
(Cetron & Davies, 2003b; Cole et al., 2003). Of current col-
lege students, 57% are women. This percentage is even higher
Lord, 1999). Cheating on standardized tests is also on the rise,
among minority groups, with 60% of Hispanic and two-thirds
aided by today's technology. Testing companies have begun
of African American college students being women (Cetron &
to develop high-tech countermeasures for cheating, such as
Davies, 2003a). Although women's salaries are currently only
biometric scans (Kleiner & Lord). The required implementa-
tion of these measures has serious financial implications for
78% of men's, in 30.7% of households where both the husband
professional certification organizations.
and wife work, the wife's earnings exceeded the husband's (Tyre
& McGinn, 2003).
Work and Workforce
Two-income families have become the norm. With more
Like the consumer market, the workforce has become
and more women entering the workforce, the percentage of
multigenerational and increasingly diverse in every way.
two-income couples has increased dramatically. By 2005, both
With the baby boomers remaining in the workforce beyond
partners will work full-time in 75% of households, up from
the traditional retirement age, generation X entering its peak
63% in 1992 (Cetron & Davies, 2003b). Dual-income families
earning years, and generation Y entering the workforce in
enable the two partners to cycle in and out of the workforce and
large numbers, employers must understand the values and mo-
take sabbaticals to train for career changes. This trend toward
tivations of each age group to attract and retain experienced
two working partners will increase the demand for flexible
and younger workers. Baby boomers are known to have the
scheduling, on-site child care, extended parental leave, and
greatest institutional loyalty, though to a lesser degree than
other family-oriented benefits (Cetron & Davies, 2003a).
their parents of the World War II generation. However, as
Telework, made possible as a productive alternative to on-
baby boomers approach and surpass the traditional retirement
site work by Internet technology, has dramatically improved
age, their commitment to learning and self-actualization will
scheduling flexibility for American workers as well as de-
creased costs for employers. Currently, 28 million workers
cause them to seek new opportunities and perhaps begin new
telework under formal company policies, an increase from
careers that are less stressful and more fulfilling. They may
four million in 1990. By 2010, more than half of American
leave and reenter the workplace several times during their
"periretirement" years.
workers will spend more than two days a week working
Generations X and Y are spending more time in school and
outside of the office (Cole et al., 2003). The results of a
entering the workforce in later years than did the baby boom-
survey conducted by the International Telework Association
ers. For them, work is a means to the lifestyle they desire.
and Council indicated that most telecommuters work longer
They are not motivated by job security but rather seek social
hours than they would in the office and do not think that their
mobility and job fulfillment. Members of generations X and
work interferes with their home lives (Dalton et al., 2003).
Y thrive on challenge, opportunity, and training. Lifelong
The option of telework has enabled ONS and its affiliates to
learning is a way of life (Cetron & Davies, 2003b; Dalton
hire employees who are unable or do not wish to relocate to
et al., 2003). Employers who want to attract and retain the
the Pittsburgh area. It also has offered a flexible alternative to
best of these generations must provide ongoing cutting-edge
local employees on both a part-time and full-time basis. ONS
training as a benefit. Because of the accelerating turnover in
should continue to enhance and expand this option, requiring
knowledge, employers will be best served in the near future
those who telework more than one day a week to share office
by hiring employees with superior problem-solving and criti-
space with other teleworkers.
cal-thinking skills as well as a commitment to learning rather
Flexible in-office work schedules also are becoming a ne-
cessity to accommodate working parents. However, relatively
than seeking employees for the specific skills they possess,
because these skills may rapidly become obsolete.
few American workers currently control their work hours. The
With little loyalty to institutions, generation Xers are self-
percentage of full-time workers with flexible schedules has
reliant and entrepreneurial. Many would rather start their own
increased only slightly in recent years, from 27.7% in 1997 to
business than advance in the corporate ranks. Approximately
28.8% in 2001. Flexibility also is unevenly distributed, with
fewer lower-paid workers being able to set their work hours
of nanotechnology. The use of this technology shows promise
(Dalton et al., 2003). Associations may be able to offer flex-
in the prevention and control of cancer, early detection, imaging
ible work hours as a benefit and recruiting tool, enabling them
diagnostics, and therapeutics (i.e., "smart" drugs).
to compete with the for-profit sector, which may not be able
to offer the same flexibility. ONS currently offers some flex-
ibility in work hours, within specific parameters, and should
enetic mapping, coupled with technology,
consider ways that this may be expanded.
will pave new roads in science, including
A labor shortage will occur within the next decade.
nanotechnology, genetically altered animals, more
Although the current unemployment rate in the United States
is near 6%, the convergence of several demographic factors
advanced digital imaging devices, the use of bio-
soon will cause a dramatic labor shortage. In less than seven
materials, and tissue regeneration.
years, nearly 168 million jobs will exist in the U.S. economy
but only about 158 million people in the labor market to fill
them--a shortfall of 10 million workers, the U.S. Bureau
of Labor Statistics estimated (Challenger, 2003). Many in-
The biotech industry is booming, generating revenues of
dustries, such as nursing, manufacturing, technology, and
$33.6 billion in 2002 (McGarvey, 2004). The marketplace
construction, already are affected. Shortages in these areas
is embracing biotechnology, as evidenced by venture capital
exist because of an aging workforce and a lack of workers
ONS supports the specialty of genetics through its position
in the younger generations to replace those who are retiring.
statement and educates through the use of workshops and pub-
The baby boomers that remain in the workforce beyond the
lications. Biotech companies and molecular device companies
traditional retirement age are unlikely to continue to work in
are increasingly supportive of the organization as they develop
some of these physically demanding professions and, instead,
new products in the area of oncology and begin to recognize
will seek new career opportunities (Challenger).
the value of oncology nurses. The biotech industry will drive
Another factor contributing to the labor shortage is a cur-
rent skills gap among younger workers that is predicted to
the need for newer educational and business development
worsen. As technology development grows, so does society's
strategies. Would the start of a biotherapy professional nursing
dependence on technology and the number of jobs in these
society draw members away from ONS? The answer to this
areas. However, the number of students majoring in the fields
question remains unknown.
The average citizen has increased access to information.
of science, math, and computer applications has decreased
Currently, 73% of adults in the United States (156 million)
in the United States. Consequently, the lack of skilled work-
ers in the United States has led companies to outsource to
are online, up from 63% in late 2003 (Harris Interactive Inc.,
other countries. To prepare for this impending labor crisis,
2004). Younger and affluent individuals tend to use the Internet
employers should begin to determine where they are most
more than individuals who are older and have lower incomes.
vulnerable; find ways to keep older, experienced workers;
Seven percent of individuals online are older than 65.
and invest in school-to-work mentoring programs (Chal-
The Internet plays an important role in everyday life for
lenger, 2003).
the average American. Eighty-eight percent of Americans
online say that they use the Internet to conduct some por-
Science and Technology
tion of their daily activities, and 64% of online users' daily
We continue to gain knowledge of life at the molecular
activities would be affected if they could not use the Internet
level. The Human Genome Project, concluded in April 2003,
(Fallows, 2004).
represented a great breakthrough in providing a foundation
Of current Internet users, 44% have broadband access as
for making genetic discoveries. Researchers at the National
compared to 22% in 2002 (Harris Interactive Inc., 2004). In
Human Genome Research Institute (NHGRI) are working on
the future, households will have six different options of broad-
projects that will chart genetic variations within the human
band service from which to chose: cable, digital subscriber
genome and develop efficient ways of identifying and locating
line, satellite, fiber, power line, and wireless. Approximately
all genes within the human DNA sequence (NHGRI, 2004).
28% of American adults already use wireless connections
According to a report developed by PriceWaterhouseCoopers
(Horrigan, 2004).
(1999), 2030 revolutionary treatments and drugs will emerge
Instant messaging also has changed access to information.
from genomics. Individuals will know more about their ge-
Approximately 53 million American adults use instant mes-
netic profiles, allowing better prescriptive decisions tailored
saging. Of those, 11 million use it at work (Shiu & Lenhart,
to the individual patient. Ethical and moral issues surrounding
Optimists predict that, in the future, wireless Internet will
genetic mapping will continue to plague society.
become as common as a cellular phone connection. Street
Genetic mapping, coupled with technology, will pave new
access to the Internet already is available on New York City
roads in science, including nanotechnology, genetically altered
sidewalks via Web phones offering Internet connections.
animals, more advanced digital imaging devices, the use of
Consumers are using the Internet to access a wide variety of
biomaterials, and tissue regeneration (i.e., tissue implants).
information, including healthcare information. More than five
Nanotechnology, which involves the creation of materials and
million seniors (aged 65 and older) currently use the Internet
devices through the manipulation of matter on a miniscule
to access health information ("Seniors Turning," 2004). The
scale, is believed to play a pivotal role in the development of
use of personal digital assistants (PDAs) in the nursing envi-
new diagnostics and therapeutics (National Cancer Institute
ronment has increased greatly, especially among advanced
[NCI], 2004). Through its Cancer Nanotechnology Plan, NCI
practice nurses (Rempher, Lasome, & Lasome, 2003).
ultimately will create a laboratory to facilitate the development
between work and home. E-mail, cellular phones, and laptop
he use of personal digital assistant technology
computers enable people to work virtually anywhere, anytime.
Cellular phones have TV broadcast technology built into the
could boom in the nursing market, particularly
device. This constant accessibility means that it is more dif-
among advanced practice nurses.
ficult for most people to distinguish when they are off or on
the clock (Jackson, 2002).
The convenience of always being connected brings a
ONS members aged 2534 are most aware of the ONS Web
loss of privacy and a new wave of crime. The new face of
site as compared to any other age group, yet ONS journals are
cyber crime has moved from hacker vandals to professional
the most valued ONS benefit within all age groups. Overall,
hackers who aim for profit (Hallam-Baker, 2004). Because
the ONS Web site is the sixth most valued ONS activity or
of newer technology that keeps employees connected to
service. ONS Web site usage has increased consistently, aver-
the ONS network, ONS is able to offer full- and part-time
aging more than 2.4 million hits and 150,000 user sessions per
telecommuting opportunities to its employees. E-commerce
month. ONS also has responded to the need for members to
connects members to the organization 24 hours a day, allow-
remain connected to their home and work e-mail by offering
ing them to order products essential to their practice at their
free e-mail kiosks at national meetings.
convenience. ONS must continue to monitor privacy laws
ONS also is collaborating with a company to offer access
regarding Internet use and update policies as appropriate.
to oncology-specific content through PDA technology. The
Nondues revenue projects such as e-mail protection services
use of PDA technology could boom in the nursing market,
should be considered.
particularly among advanced practice nurses. ONS has not
conducted thorough needs assessments to determine unique
ways to support this member need.
Uncertain economic conditions continue to be of con-
Sensor and network technologies are expanding moni-
cern. Uncertain economic conditions continue to plague
toring and data collection throughout society. Collecting
the United States and the global market, despite economic
and monitoring data are much easier with the use of embedded
forecasters' predictions of economic rebound over the next
technology, such as sensors contained within various devices.
year (Miller, 2004). The dramatic increase in energy prices
These data may be used to provide more personalized and
has affected inflation rates and spending habits (Global Prov-
individualized services to customers. However, the ethics
ince, 2004; Miller). Inflation has risen sharply to an average
of what data are collected and how they will be used need
annual rate of 5.5%, and interest rates began to rise for the
to be examined. Limits need to be set regarding what data
first time in four years (Miller). The stock market continues to
are shared. For example, in 1999, Amazon.com employed
slump because of high oil prices and concerns about terrorism
an online marketing tool that revealed what customers from
(Despeignes, 2004). Consumer spending on "real consumer
well-known corporations were buying and reading (Roth-
purchases" slowed as more out-of-pocket money goes to
feder, 2004). This information was shared with the public
higher gas prices (Cooper & Madigan, 2004).
through book reviews. Those who read a review would see
The Consumer Price Index increased 4.1% during the first
that employees from Microsoft, for example, were reading a
seven months of 2004 as compared to a 1.9% increase in
particular book. It is important that businesses and organiza-
2003. Petroleum costs increased at a rate of 44.5% annually
tions use customer data in an ethical and legal way to maintain
(U.S. Department of Labor, Bureau of Labor Statistics, 2004a)
customer trust and loyalty.
and can be expected to top at a record high of $50 per barrel
With privacy being a concern to the general public, ONS
(Reed, 2004).
currently is developing confidentiality policies regarding the
The housing market accelerated because of low interest
ONS database. Careful consideration must be given to deci-
rates and increased home values. New home production
sions regarding the appropriate collection and monitoring
reached levels not met in decades (U.S. Department of Hous-
of data, especially when using customer preferences to sell
ing and Urban Development, 2004). Sales prices for existing
additional products and services.
homes increased 7.3% in 2004. Economists predict that the
Technology is creating new ways for people to commu-
Federal Reserve will raise interest rates to prevent a sharp
nicate and associate. With 65% of the U.S. adult population
decline in prices, causing further threat to economic recovery
having access to the Internet at home, millions of Americans
(Miller, 2004).
are engaging in unique ways of communicating with ease.
ONS and its affiliate corporations are not immune to the
For example, chat rooms, blogs, discussion forums, and
stock market slump. Investment losses over the past few
e-mail listservs are ways that bring new meaning to interper-
years are not uncommon as boards determine ways to protect
sonal communication. As of September 11, 2004, L-Soft, a
future interests. Although the housing market has been seeing
company operating a large listserv database, has cataloged
positive results, ONS continues to search for a tenant to rent
71,634 public lists, representing only 19% of all listserv lists
vacant space within its own building.
(305,253) (L-Soft International, Inc., 2004).
Rising costs, particularly energy costs, will affect the or-
Nearly 600 people remain connected professionally through
ganization if ONS members choose not to travel to meetings
20 different discussion forums available on the ONS Web site.
because of higher airfares and gas prices. Despite economic
ONS should continue to monitor ONS member needs regard-
conditions, ONS should continue to develop strategies that
ing new technologies and Web site trends.
move the organization forward. Such strategies, however,
People are beginning to question the value and utility of
should be examined carefully for long-term benefit versus
always being connected. Technology and the new connectiv-
risk. Savvy investment strategies must be employed, and al-
ity it affords have begun to blur the conventional boundaries
ternate methods of educating and bringing members together
Rising healthcare costs are challenging all employers,
using technology such as Web conferences should be used to
including local, state, and federal governments. Healthcare
a greater degree.
More than 8.2 million Americans were unemployed as of
costs and the number of people without insurance continue
July 2004, and the unemployment rate remains relatively
to rise. Businesses are paying more for health care than ever
unchanged at 5.5% (U.S. Department of Labor, Bureau of
before, at an average annual cost of more than $6,200 per
Labor Statistics, 2004b). Another 1.1 million people are not
employee in 2003 (Porter & Teisberg, 2004). Double-digit
working because of school or family responsibilities. Unem-
increases are expected to continue. Towers Perrin Publications
ployment is not a problem in the nursing market because the
(2004) predicted that employers will notice an 8% increase in
nursing shortage is expected to continue. However, workforce
healthcare costs in 2005, with an average monthly cost repre-
senting an average annual increase of $582 per employee.
issues that have resulted from the shortage, such as mandatory
According to the U.S. Census Bureau (2004b), an estimated
overtime and unsafe conditions for patients, continue to be of
15.6% of the population (45 million people) was without
great concern to nurses. According to the 2004 ONS Member
health insurance coverage in 2003, up from 15.2% (43.6
Survey, workforce issues are the second-most important issue
million people) in 2002. The percentage of people covered
facing cancer care today.
by employment-based health insurance fell from 61.3% to
60.4% in 20022003.
In 2002, the Centers for Medicare and Medicaid Services
ccording to the 2004 ONS Member Survey,
(CMS) projected that national health spending will reach
workforce issues are the second-most impor-
$3.4 trillion, or 18.4% of the gross domestic product, in 2013.
tant issue facing cancer care today.
These figures represent an annual growth rate of 7.3% from
20022013. CMS reported that health spending would begin to
slow in 2003 because of decreases in public spending (Medicare
ONS has been active in legislative and educational strategies
and Medicaid) and private health insurance spending.
aimed at the nursing shortage and must continue to do so. While
Although prescription drug spending will decrease, CMS
associations have suffered layoffs and unemployment issues,
(2002) predicted that it will continue to be the fastest grow-
ing healthcare sector, with growth rates at 13.4% in 2003.
ONS has been fortunate to remain stable in this area, maintain-
ing the ability to retain employees and hire new staff as needed.
Key drivers that will affect prescription drug spending from
In looking to the future, ONS needs to carefully consider inter-
20032013 include patent expirations, slower growth in drug
nal processes and procedures to ensure that they are the most
prices, and multitiered copayments. The use of tiered prescrip-
tion plans was mentioned in the 2002 ONS Environmental
efficient and cost conscious, and it must continue to examine
Scan (Mafrica et al., 2002) and was linked to a decrease in
and make decisions to proceed with projects that are fiscally
out-of-pocket costs (Heffler et al., 2001). However, out-of-
responsible while meeting the ONS mission and vision.
Income inequality continues to be an issue in the United
pocket spending is predicted to increase over the next decade
States. Income inequality has been a long-term trend since
because of increased employer and employee cost sharing.
The key driver in growth of healthcare spending is predicted
1969 and can be attributed to historic unequal wage gains for
to change from prescription drugs to hospital spending.
top-line workers and losses for bottom-line workers (U.S.
The cost of prescription drugs is a source of ongoing debate
Census Bureau, 2004a). Income inequality, most commonly
within the United States. In the public media, rising drug
measured by the Gini Index, did not change from 20022003.
costs are often blamed for rising healthcare costs. However,
According to the same report, the female-to-male earnings
according to the Pharmaceutical Research and Manufacturers
ratio for full-time, year-round workers declined for the first
of America (PhRMA, 2004b), every additional dollar spent
time since 19981999. Although the median income for men
on new drugs saves $4.44 on hospitalizations. The debate will
increased 0.8%, the median income for women decreased by
continue as all issues and options are explored. The Medicare
The official poverty rate, defined as annual earnings of
Prescription Drug, Improvement, and Modernization Act
$18,810 or less for a family of four and $14,680 or less for a
(MMA) affects future reimbursement of oncology-related
family of three, rose from 12.1% in 2002 to 12.5% in 2003.
benefits and services. More information about this law and
The number of people in poverty increased by 1.3 million, to
future implications can be found in the Government and
a total of 35.9 million in 2003. Poverty rates for people aged
Regulation section of this report.
1864 and those 65 and older remain unchanged. From 2002
ONS has firsthand experience with rising healthcare costs,
2003, Hispanics experienced a decrease in median income,
both to the organization and the employee. For 2004 2005,
Asians demonstrated increased poverty, and non-Hispanic
ONS is faced with a 21% premium increase to maintain the
Caucasians had declines in healthcare coverage.
current level of coverage for its employees. Health insurance
Average annual earnings for RNs, including clinical nurse
costs to employees and employers inevitably will continue to
specialists (CNSs) and nurse practitioners (NPs), demon-
increase. ONS needs to identify innovative budget strategies,
strated a steady increase from 19922000 (American Nurses
as well as include an inventory of all organizational benefits,
Association, 2003). More recent statistics were not available
to determine which should be continued and which should be
eliminated or decreased.
at the time that this report was written.
ONS has not experienced large membership declines be-
cause of income issues. The average ONS member salary is
Firms are rethinking their business models more fre-
$50,000 (ONS, 2004a). ONS should continue to offer mem-
quently as they strive to compete and grow. Business has
bership as an added value for the dollar and continue offering
an attractive membership benefits package.
undergone significant change during the past few years as a
result of tough economic times. Mergers and acquisitions are
reputation components ranging from being trustworthy to
commonplace as companies look for ways to cut costs while
treating employees fairly. On average, the industry functions
at a high- to medium-quality ethics reputation.
looking toward future growth. Mergers and acquisitions are
Healthcare professional CE is not immune to conflict of inter-
not uncommon to the pharmaceutical industry. As reported
est issues. In April 2003, the Accreditation Council for Con-
in the 2002 ONS Environmental Scan (Mafrica et al., 2002),
tinuing Medical Education (ACCME, 2004) adopted updated
heavy mergers and acquisitions will continue to occur in an
attempt to meet changing customer needs.
guidelines mandating providers to resolve conflicts of interest
Although ONS has no current plans to engage in mergers
to those in a position to control the content of the educational
and acquisitions, the organization and its affiliate corpora-
activity. The need for this change stems from an increased
tions closely monitor business models that, if implemented,
prevalence of financial relationships with commercial interests.
potentially could save the organization money. ONS regu-
A small task force currently is convening to investigate recent
larly examines its internal processes as a way of improving
ACCME changes and possible implications for ONS.
productivity, efficiency, and quality. An organization such
Dealing with ethical issues and conflict of interest was a
as ONS, with its rich history and staff loyalty, may overlook
key initiative for ONS and its affiliate corporations during
more efficient and cost-saving ways to conduct day-to-day
20032004. The ONS President's Council convened to discuss
tasks and functions. ONS also has experienced the positive
the global issue of ethics and conflict of interest under the
and negative aspects of pharmaceutical company mergers
facilitation of an ethics expert. The need for the President's
because approximately 25% of the ONS revenue stream is
Council Conflict of Interest Task Force unfolded as the ONS
from corporate support, mainly pharmaceutical companies.
Board and the boards of its affiliate corporations began to
Changes in the funding procurement process, such as the way
engage in discussions related to complex conflicts of inter-
est, such as the issue of having representatives of corporate
in which requests are processed, increased length of time for
funders (member and nonmember) sit on boards. Outcomes
approval, and increased staff time in securing funding, have
from this task force include revisions to the conflict of inter-
affected ONS.
est policies and education among the leadership. The ethics
expert who provided consultation is now a member of the
ONS Board of Directors.
o remain viable, ONS must continue to rethink
ONS will need to continue exploring and discussing conflict
the way it conducts business. Ways to cut
of interest and governance policies, being flexible to necessary
costs, while delivering valuable services to mem-
revisions and the resulting implications. ONS also needs to
bers, must be established.
fully investigate and set policies in a proactive manner regard-
ing recent ACCME changes.
Business is changing to be part of the solution, not part of
the problem. Recent business scandals mentioned previously
To remain viable, ONS must continue to rethink the way it
prompted corporate reform and the passing of the Sarbanes-
conducts business. Ways to cut costs, while delivering valu-
able services to members, must be established. ONS must
Oxley Act. Businesses and healthcare institutions now are hir-
ing corporate compliance officers (CCOs) to oversee corporate
continue to support the business development process, explor-
ing ways to meet the ever-changing and complex requirements
compliance programs. According to a survey, CCO positions
of corporate supporters.
were one of the 10 "hot jobs" of 2004 (Christian & Timbers'
Businesses are pressured for greater transparency. As
Hot Jobs for 2004, 2004).
noted previously in the Societal Trends section, the fall of
In addition to Sarbanes-Oxley, other regulatory agencies,
Enron and others turned the business world upside down and
including the Office of the Inspector General (OIG), have
set the stage for greater transparency, including the enactment
instituted laws surrounding compliance and privacy issues.
of the Sarbanes-Oxley Act of 2002. Details of the provisions
The Health Insurance Portability and Accountability Act of
of this act can be found in the Government and Regulation
1996 and the PhRMA Code on Interactions with Healthcare
section. Recent business scandals are placing emphasis on
Professionals (PhRMA, 2004a) have set the stage for organi-
zational changes in business practice.
executive conduct and organizational standards and practices.
The pharmaceutical industry has undergone significant
According to the 2003 National Business Ethics Survey (Eth-
ics Resource Center, 2003), employees viewed ethics in their
change with the adoption of OIG's (2003) Compliance Pro-
gram Guidance for Pharmaceutical Manufacturers. The new
organizations more positively in 2003 as compared to 2000
guidelines require a separation between promotional and con-
and indicated that honesty and respect are practiced more
tinuing medical education (CME) activities. This has caused
frequently in their organizations. The survey also reported
quite a stir in the industry because of the various interpreta-
that ethics programs make a difference and are associated
tions of the guidelines. The industry began to shift money
with higher levels of perception that employees are held ac-
countable for ethics violations. Of note was the finding that
from promotional activities to educational activities. In turn,
smaller organizations (i.e., less than 500 employees) were less
ACCME, the governing body providing voluntary accredita-
tion to CME providers, updated standards to ensure that CME
likely to have key elements of an ethics program in place than
activities remain independent and free of commercial bias.
larger organizations.
The new guidelines have affected ONS directly and in-
Research regarding pharmaceutical companies' ethics
directly. ONS (2003b) revised its policies and position on
reputations (RRC Rating Research LLC, 2003) revealed that
corporate support based on its interpretation of the ACCME
ethical behavior was the second-most important factor govern-
ing how companies are perceived (Gasorek, 2003). Industry
and PhRMA guidelines. These safeguards allow ONS to
executives participating in the survey identified 12 ethical
continue to provide high-quality educational opportunities
that are underwritten through corporate support yet free of
acquisitions), tracking and sharing sponsorship activity,
promotional influence. Interestingly, the American Nurses
staying aware of new product developments that affect ONS
Credentialing Centers (ANCC) Commission on Accreditation,
members, and being prepared for potential turnover in key
the governing body that accredits ONS as both an approver
ONS staff. In addition, greater emphasis has been placed on
and provider of CE in nursing, has not changed its standards
business development efforts by dedicating significant senior
in tandem with ACCME.
management time in ONS; Oncology Education Services,
Inc.; ONCC; and the ONS Foundation. Furthermore, ONS
has enhanced the annual corporate support meeting as a way
of leveraging not only information given but also informa-
NS has experienced changes in securing grant
tion received about corporate supporters' own priorities and
funding from the pharmaceutical industry.
E-commerce continues to grow. According to the U.S.
Census Bureau (2004c), retail e-commerce sales for the
second quarter of 2004 were $15.7 billion, a 23.1% in-
ONS has experienced changes in securing grant funding
from the pharmaceutical industry. These changes include
crease from the second quarter of 2003, whereas retail sales
increased and detailed industry paperwork regarding the na-
increased only 7.8%. Online retail sales are expected to
ture of the funding request, delayed grant funding approvals
grow 27% to $144 billion in 2004, with health and beauty
because of internal routing procedures, and increased staff
predicted to show the largest increases (Shop.org, 2004).
time required to secure funding. Many times, funding requests
The ability to purchase products and services via the Inter-
net provides convenience to a fast-paced culture that places
undergo multiple changes before the approval is granted. In
value on leisure time.
addition, pharmaceutical companies want to ensure that they
In 2002, ONS launched e-commerce capabilities within its
fund programs that attract the right target audience that meets
Web site, providing members with the opportunity not only
their overall needs. They no longer are looking for company
to order ONS publications online but also renew member-
exposure but rather to interact with key constituents who can
ships, register for educational meetings, apply for certification
either recommend or administer their products. ONS and its
examinations, submit documentation for recertification, and
affiliates are being asked, with much greater frequency, to
purchase ONS Foundation products. Since 2002, more than
include detailed needs assessment information about reach-
ing a particular group of nurses, such as oncology nurses who
11,500 orders have been placed online, with total sales reach-
ing nearly $1.65 million. Sales in 2004 alone reached more
administer targeted therapies in the outpatient setting. With
than $945,000 as compared to $29,403 in 2002. Membership
the current demographic database, it is difficult to provide
renewals via e-commerce (in effect in 2003) jumped from 106
companies with this information that, in turn, is necessary in
securing educational program funding.
in 2003 to 3,145 in 2004. Online certification and recertifica-
Although ONS and its affiliates do not target the physician
tion applications account for 37% of all such transactions.
audience when providing CE, the industry will continue to
Of certification candidates, 80% opt to make their testing
appointments online rather than by phone.
hold them to PhRMA and ACCME guidelines. Thus, ONS
It is apparent that oncology nurses are increasing their use
must maintain current knowledge regarding the guidelines
of and comfort with e-commerce. ONS needs to continue
and make necessary strategic changes even if these changes
monitoring e-commerce activity within the Web site and de-
are not mandated by ANCC. ONS also needs to be aware of
velop innovative online initiatives that meet members' needs
the impact that NPs or CNSs may have on industry funding
and attract new members.
procedures because of prescriptive authority. ONS should
Involve customers in innovation. Innovation will continue
look at current member demographics to determine whether
to be a priority for companies through 2006 (Conference
they are specific enough or useful in gleaning the information
needed in future grant funding requests.
Board, 2004). Of 100 companies surveyed, 90% said that in-
Organizations are struggling to share what they know
novation already is integrated into their businesses' strategic
internally and acquire what they do not know. In 2002,
goals, whereas 60% reported that it is part of their mission or
U.S. companies spent $4.5 billion on software and technolo-
vision statements. The challenge is making innovation part
gies to help employees share what they know (Gilmour, 2003).
of daily practice. Businesses and nonprofit organizations
Because of the large financial commitment, some companies
should develop partnerships with customers by establishing an
are forced to move the knowledge-sharing initiative to the
emotional relationship that results in effective brainstorming
lower priority list or even cut the initiative altogether as a
(Schweitzer, 2004). Creative thinking leads to innovation, and
cost-saving measure, and employees believe that knowledge
organizations can begin the cultural shift by conducting an
sharing is deficient (Gilmour). Using organizational knowl-
organizational innovation audit. Innovation is not just about
edge for strategic advantage can prove to be an invaluable
ideas--it includes an ebb and flow of knowledge.
resource. According to De Cagna (2004), forward-thinking
As an organization, ONS has implemented a variety of
associations create, share, and leverage knowledge. Knowl-
innovative strategies to maintain organizational vitality. Op-
edge becomes a strategic resource when association staff,
portunities do exist to "think outside the box" in all areas to
members, and stakeholders leverage knowledge in day-to-day
develop creative solutions that meet the ONS mission. Cre-
ative solutions are dependent on relationships with individuals
work rather than maintain databases that are not linked in a
such as members, with corporate funders, and with companies
strategic manner. Organizations should create an environment
providing services to ONS. The ability to remain innovative
where all stakeholders can collaborate openly.
with these groups continues to be of utmost importance to
ONS developed a knowledge management initiative as a
the organization.
way of regularly tracking corporate activity (e.g., mergers,
People expect organizations to provide individualized
proposed 2005 budget reflects a deficit of $364 billion (U.S.
services. Technology has revolutionized every aspect of
Department of State, 2004).
American society, from grocery shopping to education. As a
When deficits began to grow 20 years ago, the retirement
result, businesses and marketers are increasingly challenged
of the baby-boom generation was a distant worry. Now, as
to find the right way to send the right message to the right
the nation faces years of red ink, the graying population is a
person at the right time (Bianco, 2004). Mass marketing is
fast-approaching reality that will put unprecedented strains
a thing of the past and is being replaced by micromarketing
on Medicare, social security, and the economy beginning in
as America becomes a more commercially indulgent society.
2010. At the same time, by committing to years of deficit
Technology provides businesses and associations with the
spending, the government is reducing national savings and
ability to collect and track customer- and member-specific
putting upward pressure on interest rates, which will limit
information, thus creating various market segments used
the ability of Congress to increase taxes, issue bonds, or
for customized products and services. Examples include
take other steps to reform massive healthcare and retire-
ment programs, forcing even deeper benefit cuts. Today,
grocery store frequent shopper cards and targeted Web site
social security and Medicare payroll taxes are generating
promotional e-mails.
a surplus. By 2008, however, the government will have to
ONS has been using an allegiance program that segments
start pumping money into Medicare. Even without the new
members based on individual preferences. ONS began to
Medicare prescription drug benefit, the Medicare program
investigate a customized dues menu in 2002 as a way of
alone is expected to consume 20% of all revenue by 2026
providing individualized services. ONS needs to explore in-
novative ways to meet members' needs in a more customized
(Kirchhoff, 2003).
Currently, Medicare and social security are generating
surplus trust funds, yet the government is targeting these
Government and Regulation
programs for cuts just when the majority of baby boomers
The costs of government grow with every passing year.
will be retiring in the next five years. In actuality, no money
However, the government's financial "pie" is limited, and
exists in the trust funds. The Treasury Department has been
resources continue to shrink in the face of growing demands.
using that money to pay for other government services and
The competition for federal funding is extremely stiff, re-
issues special government bonds to cover what is taken. In
quiring associations and nonprofit organizations to put more
other words, the trillions of dollars that are supposed to be
resources into advocating for their specific federal priority
accumulating in the trust funds are, in essence, IOUs, and
issues. Many trends are influencing the effects of government
now the bill is coming due. This problem has been exacer-
bated by the large tax cuts enacted during the current Bush
and regulation on associations, particularly associations deal-
ing with healthcare issues.
administration. In the next 25 years, the number of people
Greater demands are met with limited resources. Gov-
in retirement programs will increase from 48 million to 84
ernment is experiencing pressure to do more with shrinking
million people. Without drastic changes, the costs of social
discretionary funds. With a finite pool of funds, more funding
security and Medicare will rise substantially (McBride,
allocated to issues such as homeland security and the war in
2004). ONS must continue its efforts to advocate before
Iraq translates into less funding to support budget appropria-
Congress for Medicare reform that will neither underpay nor
tions for the NCI, Centers for Disease Control and Prevention
overpay for Medicare services and to prevent proposed cuts
(CDC), and the Nurse Reinvestment Act (NRA). Increasing
in Medicare services from adversely affecting the quality of
appropriations in these areas are crucial to quality cancer care
cancer care to Medicare beneficiaries.
MMA may affect the timeliness of oncology treat-
and the profession of nursing.
ment. Sorting through the massive provisions and writing
the implementation regulations that go with it will absorb a
s appropriations to the National Cancer Institute
large part of CMS's agenda over the next several years. The
central oncology-related policy change contained in the new
decrease, ONS will be forced to rely even more
Medicare law moves the current system of outpatient drug
heavily on corporate funding sources and fees for
reimbursement from average wholesale price- (AWP-) based
services to offset the decrease in federal grants.
reimbursement (until now, Medicare reimbursed outpatient
chemotherapy at 95% of AWP) to a system that uses a cal-
culation of average sales price (ASP). In 2004, Medicare
ONS has a track record of securing educational grants
reimbursed for covered drugs at a rate of 85% of AWP. In
from NCI to conduct educational programs for members. As
2005, Medicare moved to ASP plus 6%. In an effort to more
appropriations to NCI decrease, the amount of grant funding
appropriately reimburse for currently underpaid practice
available will shrink considerably. ONS will be forced to rely
expenses and oncology nursing services, the bill includes
even more heavily on corporate funding sources and fees for
approximately $500 million for practice expenses. Although
services to offset the decrease in federal grants.
this increase in practice expense payments is a step in the
Government costs continue to rise. President Bush's
right direction, the amount falls short of the funds necessary
budget proposal for fiscal year 2005 restrains spending on
to ensure access to quality community-based care. Further-
more, the reimbursement for practice expenses decreases to
most domestic programs while increasing funding for national
$460 million starting in 2005, further reducing the resources
defense and international aid. The $2.4 trillion budget focuses
available to community-based oncology practices.
on three overriding goals: advancing the war against terror-
ism, enhancing U.S. security, and strengthening the economy.
Of additional concern is that the legislation includes a pro-
vision giving physicians the option of obtaining covered drugs
The 2004 budget deficit is projected to be $521 billion. The
Demands for transparency are rising. In the face of
through a third-party vendor. This represents a significant
change in the current practice of oncology. ONS has serious
recent corporate scandals in the public and private sectors,
concerns that under this new system, timely and convenient
demands for greater public scrutiny are increasing. As a
administration of treatment to Medicare beneficiaries will be
result of corporate scandals, government is stepping in to
virtually impossible because patients will likely not be able
place greater controls on the governance structures and
to receive treatment the day it is prescribed, resulting in delay
financial accountability of organizations and their boards
of treatment and patients having to travel multiple times to
via the Sarbanes-Oxley Act, which was passed in 2002.
receive care.
Although most of the Sarbanes-Oxley provisions apply
The Medicare bill also addressed reimbursement for cancer
only to publicly traded corporations, the new law is likely
care provided in hospital outpatient departments. Among
to raise the bar for nonprofit groups as well, especially in
other improvements to the hospital outpatient prospective
the wake of several well-publicized lapses in charity gov-
ernance. The major provisions of the act are intended to
payment system, sole-source drugs cannot be paid less than
ensure that people with financial expertise, including board
88% in 2004 and no less than 83% in 2005. Comparatively,
members, have both the access and the independence needed
payments for some single-source cancer drugs were as low
to audit an organization's financial records and evaluate
as 50%60% of AWP in 2003 (ONS, 2003a). ONS opposed
the manager's performance. Two provisions of the act cur-
this cost-cutting legislation because of its detrimental effects
rently apply specifically to nonprofit groups: those protecting
on quality cancer care and is working with Congress to try to
reopen the bill for technical amendments in 2005.
whistleblowers and those making it a crime to alter, falsify,
or destroy records (Board Source and Independent Sector,
2003; Green, 2003).
It is in the best interest of nonprofit organizations to begin
nother ONS priority that is adversely affected
implementing the provisions in Sarbanes-Oxley because all
by these budget woes is the Nurse Reinvest-
predictions are that these same provisions will be brought
to bear on nonprofit groups in the near future. ONS and its
ment Act (NRA). ONS worked with other nursing
affiliates recently have taken steps to form an audit com-
groups in coalition to get the NRA signed into law.
mittee that will oversee all of the organizations' annual
financial audits.
States are likely to seek new ways of raising revenue.
Another ONS priority that is adversely affected by these
Many U.S. states are facing huge budget deficits, and their
budget woes is the NRA. ONS worked with other nursing
search for new revenues is intensifying. More than 30 states
groups in coalition to get the NRA signed into law. Because
have approved the Streamlined Sales Tax Project, aimed at
the NRA is an authorization bill, it gives the government the
collecting state and local taxes on items sold online. Local
authority to set up programs to deal with the nursing short-
governments soon may have a new weapon in the fight against
age but it does not provide funding. The funding needs to be
budget woes. Federal legislation has been introduced that
sought on an annual basis in the federal budget process. Be-
would allow states to require remote, or out-of-state, retailers
cause of the shrinking federal resources, securing full funding
to remit state and local sales and use taxes for online, cata-
logue, and over-the-phone purchases (Ursery, 2003).
for the NRA has been difficult.
The original Internet Tax Freedom Act of 1998 created
ONS also strongly supports budget increases to support
a moratorium on the creation of any new taxes on Internet
research at the National Institutes of Health (NIH), NCI, and
commerce. State governments have seen this as a threat to
CDC. The increases have been disappearing in recent years
their sales tax collection ever since. The original moratorium
because of other federal priorities. NIH, NCI, and CDC have
and its extensions expired in the fall of 2003, so the debate on
been asked to accept level funding, which, in essence, is not
Internet taxation is heating up again (Oliva, 2003).
a budget freeze but rather a budget cut because it does away
with any adjustments for inflation.
New legislation regarding Internet sales taxes could have
Government is losing the public's trust and confidence
significant impact on associations that conduct sales and busi-
in its ability to solve complex problems. As one possible
ness transaction via e-commerce on the Internet. ONS needs
to monitor this type of legislation closely.
result of this loss of trust is that the public's apathy toward
Women are becoming more influential in government
voting has been increasing. Voter apathy resulted in only 36%
positions. When women first entered the congressional
of the electorate voting in the 2002 mid-term elections, one
political arena in the middle of the past century, they faced
of the lowest turnouts in half a century. Even in presidential
the assumption that they could not win and hold onto
election years, voter turnout has decreased by 12% in the
statewide offices in their own right, that is, without hav-
past 40 years (Pearson Education, Inc., 2004). That is until
ing first succeeded a husband who died or resigned from
the recent 2004 presidential election, which resulted in the
office. Currently, women hold 73 of the 535 seats in Con-
highest voter turnout in 36 years. An estimated 120.2 mil-
lion people cast ballots in 2004, a figure that translates into a
gress (13.6%): 14 of the 100 seats in the Senate (14%) and
59.6% turnout rate. That is five percentage points higher and
59 of the 435 seats in the House (13.6%). A total of 215
15 million more voters than in 2000 and the largest turnout
women have served in the U.S. Congress, to date, since the
since Richard M. Nixon faced Hubert H. Humphrey in the
first woman was elected to the House in 1917 (Center for
1968 election (Faler, 2004). ONS needs to encourage its
American Women and Politics, 2004b). In addition, eight
members to take a more active role in voting and government
women currently are state governors and 17 are lieutenant
affairs to raise awareness of their priority issues and have their
governors. Women serving in state legislatures numbered
members' voices heard.
1,680 in 2002, or 22.6% of all state legislators. That is more
than five times greater than in 1969, when only 4% of all
Agency overstepping their bounds with the legal rights of
state legislators were women (Center for American Women
citizens. The act includes provisions to allow the government
and Politics, 2004a, 2004b).
to access the records of libraries and bookstores to see what
people are reading and monitor Internet usage at libraries.
Bookstores and libraries are prohibited from notifying their
customers that they are being investigated in this way. The
ssociations need to acknowledge the growing
law also deals with the seizing of assets, which could lead
influence of women through advocacy efforts,
to unconstitutional seizures in the future (USA Patriot Act,
policy agendas, networking, and recruitment and
The provisions of the Patriot Act could have implications
training for leadership positions.
for associations. Associations may be required to share certain
information about their members, libraries, and book sales
without being able to notify their members of these investi-
gations. Foreign students are being tracked more closely, and
Associations need to acknowledge the growing influence of
associations may be expected to account for their international
women through advocacy efforts, policy agendas, networking,
members. Many associations are becoming concerned about
and recruitment and training for leadership positions. This
the implications for individual privacy with more intensive
is especially true for nursing associations like ONS, whose
government information gathering. For now, the future of
members are predominately women.
Interest groups are organizing into electronic networks
the Patriot Act is uncertain, but with terrorism being a con-
and coalitions. Many like-minded organizations and groups
stant threat, observers say that the government is unlikely to
relinquish many of the new powers it received under the act
are combining their strategies to share and extend their po-
litical clout and their roles in government, federal regulatory
and opposition to government surveillance has not gathered
much momentum.
processes, and national and state policies. These groups are
Wider Internet access is influencing governance. As-
forming networks and coalitions with mutual interests and
sociations are increasingly using Internet tools to broaden
priorities. These coalitions allow groups to work together
the reach and scope of their members' responses to public
to deliver the same message to legislators and regulators
policy and legislative issues. Government agencies also are
and increase the number of interested parties delivering the
becoming more efficient in moving and handling information
ONS is already a member of several coalitions that advocate
needed by the public via the Internet. Geography and loca-
tion are becoming less relevant to political action. People can
for issues related to quality cancer care and the profession
organize around a global issue as easily as a local one. The
of nursing, such as One Voice Against Cancer, the National
pace of political action is becoming faster, and people who are
Coalition for Cancer Research, Americans for Nursing Short-
age Relief, and the Campaign for Tobacco-Free Kids. ONS
interested in an issue can become involved with it and track
its progress online with increasing ease.
needs to continue to look for opportunities to partner with
ONS has responded to this trend by developing an active
other organizations in the cancer and nursing communities
Legislative Action Center (LAC) on its Web site. The LAC
to extend its message and reach concerning government and
provides general resources to help educate members about the
regulation issues.
Government is becoming more involved in surveil-
political process and grassroots advocacy as well as legislative
lance. With increasing concerns about domestic security and
action alerts that allow members to contact their members
crime prevention, the government is becoming increasingly
of Congress about an issue via e-mail with a few clicks of a
involved in surveillance of its citizens. New technologies
mouse. The LAC, coupled with the ability to send out links
are making surveillance techniques not only possible but
to alerts via bulk e-mail to members, has been invaluable in
also cheaper.
getting timely information out to members regarding health
The series of terrorist attacks in September 2001 led to the
policy issues.
passage of the Uniting and Strengthening America by Pro-
The 2004 survey of ONS members asked participants to
viding Appropriate Tools Required to Intercept and Obstruct
identify the top three legislative priorities for ONS. The issues
Terrorism Act, otherwise known as the USA Patriot Act. This
consistently among the top five identified were
1. Reforming the healthcare system to overcome barriers to
legislation touches on some of the most fundamental rights
quality care for all (53%)
that U.S. citizens hold dear, such as issues of privacy, free
2. Ensuring access to pain control and symptom management
speech, and the right of citizens to know when they are being
from diagnosis through end of life (40%)
investigated by the government. The act was passed during
3. Ensuring private insurance coverage for cancer screening
a period of unprecedented national unity. Although critics
and early detection (36%)
argued at the time that the law would be harmful to the rights
4. Increasing Medicare reimbursement for oncology nursing
of Americans, the act was passed very quickly and without
and practice expenses (35%)
much debate. President Bush signed it into law less than two
5. Increasing federal funding for research, early detection,
months after the attacks. By the following year, the mood
prevention, and risk reduction (34%).
of the country had shifted and the effects of the Patriot Act
When survey respondents were compared for educational
began to be debated seriously for a number of reasons (USA
level, years in nursing, years in oncology, certification, and
Patriot Act, 2002).
age, very little deviation existed from these top five issues,
The Patriot Act destroyed the wall between the intelligence
particularly for the number one issue regarding the need for
and criminal branches of the Justice Department and may lead
reforming the healthcare system.
to the Federal Bureau of Investigation and Central Intelligence
Services [HHS], Health Resources and Service Administra-
NS needs to continue to educate members re-
tion, Bureau of Health Professions, National Center for Health
Workforce Analysis, 2002).
garding health policy advocacy and recruit more
HHS (2002) identified numerous factors contributing to
members into the grassroots response network.
the nursing shortage. Factors affecting the supply of RNs
include the aging of the RN workforce because of a decreased
number of nursing school graduates and a higher average age
ONS needs to continue to educate members regarding
of recent graduates, alternative job opportunities available
health policy advocacy and recruit more members into the
for RNs, and, although actual earnings for nurses increased
grassroots response network. Further ongoing development
over the past 20 years, relatively flat earnings for the past
and expansion of the LAC are also important for the contin-
10 years when adjusted for inflation. Factors that affect the
ued development of a politically active membership that will
demand for RNs include population growth, aging of the
help shape future health policy.
current population, increased per capita demand for health
care, medical advances that heighten the need for nurses, and
Members' Operating Environment
trends in healthcare financing. In addition, fewer individuals
are entering the nursing profession because of the numerous
Health Care
professional opportunities that exist today (DeYoung, Bliss,
The American consumer expects high-quality health
& Tracy, 2002).
care to be provided at minimal out-of-pocket expense
Nurses are predominately female, Caucasian, and aging.
(Kirkman-Liff, 2002; Reece, 2003). Reece identified eight
A look at the current supply of nurses shows nursing as a pre-
trends that are leading health care, with cost being a factor
dominately Caucasian, female profession. In 2000, fewer than
in almost all eight directions. Direct costs related to pre-
5.5% of nurses were male and 12% were non-Caucasian. Of
scription drugs or health insurance coverage shifting from
the 12% non-Caucasian nursing population, black or African
employers to employees play a major role in the future of
American and Asian nurses constitute the largest segment,
health care.
with 5% and 3.5%, respectively (Spratley, Johnson, Sochalski,
As the population ages and individuals live longer, health-
Fritz, & Spencer, 2000).
care issues will revolve around meeting the needs of these
In 2000, a majority (61%) of nurses were between the ages
individuals. Prescription drugs will play a major role in
of 3559 and 49% of those were between the ages of 4559.
the management of chronic diseases, and the costs associ-
Seventy-five percent of employed nurses younger than the age
ated with these drugs will continue to affect health care. In
of 30 and less than half of the nurses 50 and older worked in
addition to disease management, healthcare programs will
hospital settings (Spratley et al., 2000).
The majority of nurses works in the hospital setting. Of
need to focus on disease prevention and early detection. The
uninsured will continue to have limited access to preventive
the 82% of the RN population employed in nursing in 2000,
care and rely on emergency departments for care (Kirkman-
a majority (59%) worked in hospital settings, 18% worked
Liff, 2002).
in public or community health settings, 9.5% worked in
In addition to the nursing shortage, a shortage of physicians
ambulatory care settings, and 7% worked in nursing homes
is beginning to affect healthcare costs and quality. Decreasing
and extended care facilities (Spratley et al., 2000). Nurses
reimbursement for physician care and increased malpractice
employed in nonnursing occupations accounted for ap-
premiums have resulted in physicians leaving practice, no
proximately 5% of the total RN population. The demand for
longer performing high-risk procedures, or not entering into
nurses in the hospital setting will continue to be the major
practice at all.
requirement, but it will remain rather stable in comparison
Health care continues to move from inpatient to outpatient
to the increased need for nurses in settings focused on care
services, with Internet technology playing a key role. Im-
for older people (e.g., nursing homes, home care) (HHS,
proved quality of care, consistency, and outcomes are mea-
Overall, 70% of nurses report being satisfied in their
sures of performance that Americans are expecting from their
current positions. The least satisfied nurses were staff nurses
healthcare providers. Putting systems in place to measure
quality, consistency, and outcomes requires time and resources
working in nursing homes followed by those working in hos-
(Kirkman-Liff, 2002). Trends in health care directly affect
pitals, both areas of future demand. Nurses in positions other
nursing and the care delivered.
than staff nurse reported the highest levels of satisfaction in
ambulatory care settings followed by those working in hos-
pital settings (Spratley et al., 2000). In a survey of RNs who
The nursing shortage is expected to continue throughout
voluntarily terminated their employment or changed their em-
the next 15 years. In March 2000, an estimated 2.7 million
ployment status to as needed in three separate hospitals, 50%
individuals were licensed to practice nursing in the United
cited work hours, working every other weekend or holidays,
States. Of those licensed nurses living in the United States,
and shifts as the reason for their departure or change, and 31%
81.7% were employed in nursing. Despite these numbers,
cited opportunities for more money and better hours as the
nursing, a vital component to health care, is facing a shortage.
reasons for their change or departure (Strachota, Normandin,
The supply and demand for full-time equivalent nurses in the
O'Brien, Clary, & Krukow, 2003).
Baccalaureate preparation for nurses is on the rise. Three
United States in 2000 were estimated at a shortage of 6%.
This shortage is anticipated to continue at a slow pace until
educational paths can lead to registered nursing: a bachelor of
2015 when the shortage will begin to accelerate to a projected
science degree in nursing (BSN), an associate degree in nursing
29% by the year 2020 (U.S. Department of Health and Human
(ADN), and a diploma. BSN programs, offered by colleges and
universities, are four-year programs. ADN programs, offered by
ONS members who identify themselves as CNSs or NPs are
community and junior colleges, take about two to three years
prepared at the master's level.
to complete. Diploma programs, administered in hospitals, also
are two- to three-year programs. In 2002, 678 nursing programs
offered degrees at the bachelor's level and 700 offered ADN-
he shortage of nursing faculty has a major im-
level education. A small number of diploma programs exist, and
pact on the overall nursing shortage.
that number is declining. Generally, licensed graduates of any
of these educational programs qualify for entry-level positions
as staff nurses (U.S. Department of Labor, Bureau of Labor
Statistics, 2004c).
The shortage of nursing faculty has a major impact on the
Because of hospital-based diploma programs closing and
overall nursing shortage. The faculty shortage is the result of
a decline in enrollments into degree programs, the number of
faculty age and retirement time lines. The mean age for nurs-
ing faculty in 2002 was 48.8 years for master's-prepared fac-
RN graduates decreased from 19952000. From 20002001,
ulty and 53.3 years for doctoral-prepared faculty. On average,
baccalaureate enrollment increased 4%. Because the length
nursing faculty retire at age 62.5, with only 3% being older
of educational preparation for baccalaureate nurses versus
than age 65 (AACN, 2003). Of the individuals who received
associate degree nurses, it will be longer before we see these
nursing doctoral degrees in 1999, only 6.8% were younger
nurses in the workforce. Associate degree programs, the
than age 35 (Berlin & Sechrist, 2002). These numbers indi-
largest sources of new nurses, also have seen a decrease in
cate that a high number of vacancies will exist in the nursing
graduates. With the decline in both diploma and ADN gradu-
ates and an increase in baccalaureate enrollment, the future
faculty profession within the next few years. DeYoung et al.
workforce will see a greater percentage of baccalaureate
(2002) suggested providing incentives to nursing faculty to
nurses (HHS, 2002).
delay retirement as a strategy to help ease the shortage until
A large number of individuals choose nursing as a second
the supply can meet the demand. The use of part-time faculty
career. Thirty-seven percent of RNs worked in a healthcare
has helped somewhat; however, the extra burden of adminis-
trative duties and carrying out the mission of the institution
occupation immediately prior to attending a basic nursing
still falls on the full-time faculty.
education program, and a majority of these individuals (56%)
enrolled in associate degree programs. Eighty-two percent
Although public campaigns to entice individuals into the
of RNs who were employed as licensed practical nurses and
nursing profession may work, the ability of schools of nurs-
ing to accept all interested and qualified individuals into
licensed vocational nurses prior to becoming RNs selected
existing programs is not possible in part because of the lack
associate degree programs (Spratley et al., 2000).
of qualified faculty members available to educate new nurses
In 2004, the American Association of Colleges of Nursing
(DeYoung et al., 2002). A recent survey revealed that 16,000
(AACN) published results of a 20032004 survey that looked
qualified applications were not accepted in baccalaureate
at 682 institutions with baccalaureate and higher degree
programs because of seat limitations and limited faculty
programs in nursing. The overall response rate was 82.7%.
(AACN, 2004).
In comparing data from 2002 and 2003, AACN showed that
Unfortunately, salaries in academia do not compare to
baccalaureate enrollment and graduations increased by 16.6%
those of nurses with similar education working in clinical
and 4.3%, respectively. Master's- and doctoral-level students
roles. Low salary often is cited as a reason for leaving aca-
increased by 10.2% and 5.6%, respectively, but graduations
decreased by 2.5% and 9.9%.
demia and deters other nurses from entering (DeYoung et
Five-year trends (19992003) from the AACN survey
al., 2002). This does not bode well for increasing the nurs-
ing academia population. A change in the salary structure
revealed that baccalaureate students and graduates declined
may be required to increase the current number of nursing
from 19992000 and then increased from 20012003. Al-
though this increase is encouraging, it is not enough to meet
the healthcare needs of the future. Master's enrollment de-
Faculty in schools of nursing are required to have a mini-
clined from 19992001 and then increased from 20022003,
mum of a master's degree, and most are required to have a
but the number of graduates steadily declined over the five
doctorate. In nursing, most individuals do not reach this
years. Doctoral-level enrollments increased, but the number
level until they are in their 40s or older. This is much later
of graduations showed little change (AACN, 2004).
than in other professions because, in nursing, those pursuing
The academic preparation of the RN population in 2000
higher education are expected to have a fair amount of clini-
cal practice experience. With most faculty members retiring
was 22% diploma, 34% associate degree, 33% baccalaureate
in their early 60s, the careers of nursing academicians may be
degree, an estimated 9.6% master's degree (21% of those in
relatively short. To bring new faculty into the profession at an
a nursing-related field), and 0.6% doctoral degree (51% of
earlier age, DeYoung et al. (2002) suggested creating a fast
those in a nursing-related field). A little more than 7% of the
track from baccalaureate to doctorate and decreasing clinical
RN population is prepared in an advanced practice role (e.g.,
experiences before graduate work.
CNS, NP, nurse anesthetist, nurse midwife). CNSs and NPs
The number of master's degree programs with education as
make up 80% of the advanced practice population, with 7.5%
a major area of study has declined. Although there has been
having both CNS and NP education. In 1996, only about 46%
an increase in these programs in the past few years, they must
of NPs were prepared at the master's level compared with
continue regardless of low enrollment. Schools recently have
62% in 2000 (Spratley et al., 2000). As of March 2005, 14%
begun to offer post-master's certificate programs in nursing
of ONS membership was prepared at the diploma level, 27%
education, including some that are Web based (DeYoung et
associate degree, 40% baccalaureate degree, 18% master's
al., 2002).
degree, and 1% doctoral degree. Eighty-two percent of the
The aging population will increase the demand for
porate cost-effective management models into their plans of
oncology nurses. The demand for more nurses in the future
care (Wakefield, 2003). Today's healthcare models do not
is based on many factors. HHS (2002) anticipates that the
require patients to stay in the hospital for long periods for
population will grow 18% from 2000 2020, with a higher
service. Unfortunately, learned nursing practices do not fit
proportion of people older than age 65. According to ACS
into the short stays of today's healthcare environment (Porter-
(2004), 76% of all cancers are diagnosed at age 55 and older.
O'Grady, 2003).
Nurses must acquire technologic competence. Healthcare
As the 65 and older population increases, so will the number
of cancer diagnoses being made. Oncology nurses will be in
systems are increasingly becoming more technologically
great demand to care for this population.
advanced, with computerized systems in almost every area
Patient safety is in jeopardy. Patient safety always has
of health care. Nurses will need to become proficient in a
been an integral part of nursing care, but a main focus on
variety of technologic systems to perform their daily work
safety has been a trend since 1999, when it was estimated
routines (Stokowski, 2004). Nursing care must incorporate the
that 44,000 98,000 patients die yearly as a result of medi-
latest technologies and pharmaceuticals, which are changing
cal errors. Unfortunately, with the current and worsening
constantly, into education, practice, and research to provide
nursing shortage, patient safety can be jeopardized (Sto-
competent care (Wakefield, 2003). The addition of new tech-
kowski, 2004). Recent studies by the Agency for Healthcare
nologies and the need to be proficient in these technologies
Research and Quality (2004) indicate that there is "at least
add another level of stress in the work environment (Porter-
some association between low nurse staffing levels and
O'Grady, 2003).
one or more types of adverse reactions" (p. 3). Adverse
Association Industry Trends
reactions include pneumonia, pressure ulcers, urinary tract
infections, wound infections, injuries from falls, and sepsis.
Professional membership societies, like ONS, operate in an
As of March 2002, 24% of the 1,609 sentinel events that
environment known as the association industry. Trends in how
have been reported cite staffing levels as a contributing
associations themselves manage their operations and deal with
factor (Joint Commission on Accreditation of Healthcare
the trends affecting their members' professional environments
Organizations, 2002).
The public is making more informed decisions about
also have implications for ONS.
health care today. A public survey in 2002 revealed that
According to the American Society of Association Execu-
tives (ASAE, 2003), more than 147,000 associations exist in
96% of Americans believe that nurses play a major role in
the United States, employing 295,000 people. Associations
a patient's welfare and recovery, and 73% are much more
pay $6 billion in annual health insurance premiums, as the
likely to select a hospital that employs a high percentage of
source of health insurance for more than eight million people.
nurses with additional specialty certification (Harris Interac-
tive Inc., 2002). With access to vast amounts of healthcare
Associations, often using members' skills for the greater com-
mon good, document more than 173 million volunteer hours
information, consumers are becoming more informed than
in community service annually.
ever before. They are making informed decisions about their
Most professional societies do essentially the same kind of
care, the clinicians who provide their care, and selecting the
work, regardless of the professions they serve. Associations
setting in which they obtain such care (Wakefield, 2003).
publish periodicals and books and offer educational program-
Trends in health care also affect the demand for nurses.
ming to their members. They hold annual conventions with
The number of individuals utilizing complementary and
commercial exhibitions, produce public information services,
alternative therapies has increased. Nurses need to be knowl-
edgeable about such therapies to discuss them intelligently,
conduct industry research, and are typically the definitive
answer questions, and explain them to patients (Stokowski,
sources for professional codes of ethics and practice standards
and guidelines.
2004). In addition, the future holds an even more diverse
To fully understand the environments in which ONS oper-
population within the United States that will require nurses
ates, it is important to examine the broad trends affecting the
to understand and incorporate cultural differences into the
association community as well as those affecting the more
care they provide to each individual (Stokowski; Wakefield).
specialized community of nursing specialty organizations.
The number of uninsured and the high cost of new life-sav-
ing technologies and medicines also will affect nursing care
This section of the Environmental Scan places ONS within
in the future (Wakefield).
the context of each of these communities.
A 2003 manual published by ASAE (Dalton et al., 2003)
identified new trends representing recent changes in the inter-
nal environment for associations. These trends, summarized in
o stay current and work within the constraints
the following paragraphs, show where ONS currently is with
of cost-effective care, nurses will be required to
respect to the trend as well as the future implications for the
alter the way they practice.
Society. Other specialty nursing organizations' experiences
with each trend, determined through an informal survey of
their executives in September 2004, also are included.
Nurses must adapt to new ways to manage patients. To
Microspecialties will expand. As indicated previously in
stay current and work within the constraints of cost-effective
the Societal Trends section, the size of the body of knowledge
care, nurses will be required to alter the way they practice.
in many professions precludes expertise across all special-
ties and subspecialty areas. Although oncology nursing is
In addition to caring for individuals diagnosed with cancer,
a well-defined specialty, many oncology nurses focus on a
nurses will manage chronic diseases that affect individuals
subspecialty area of practice. As more and more members
for years or even decades. They will be required to incor-
demand services and knowledge that is specific to their in-
members, responses from the executives surveyed centered
dividual professional needs, professional societies are faced
on those things that make professional societies unique. For
with creating services that are less directed at the whole
example, leadership development opportunities, practice
guidelines, information that is specialized to the field, and
population and more tailored to individuals. Determining
quality of services were cited as important differentiators.
how to balance between specialized and general needs is a
In expressing the desire to stand out, one executive direc-
growing challenge.
tor said, "We don't want anyone to think, `what have they
ONS began to address this issue with the "customized dues
done for us lately?' . . . Our large, quality presence (in their
menu" project in 2001, which resulted in the inclusion of one
mailbox, on their computer, in their workplace, and at their
free SIG membership to members. The team examined several
annual meeting) is intended to make the competition pale in
ways to individualize member services but stopped short of
recommending any individualized services. Recommenda-
Aging membership may limit growth. According to
tions have been made for test marketing and potential changes
to the ONS Periodicals Publishing program based on a 2004
ASAE (2003), "Aging will affect some associations profound-
ly. Those with large aging populations and leadership could
member segmentation study (ONS, 2004b). ONCC currently
spend a lot of time thinking about how to attract younger
is exploring ways to recognize competence in various subspe-
cialty areas within oncology.
members without actually recruiting them." Associations are
ONS will need to closely monitor the needs and wants of
likely to begin placing younger people in leadership roles
earlier than in the past.
members and potential members to continue to be relevant to
ONS has paid a great deal of attention in the past few years
newer and younger oncology nurses, more experienced oncol-
ogy nurses whose needs are changing, and other nurses who
to the aging of the nursing population and its own member-
ship. Specialized programming for students and younger
care for people with cancer but do not necessarily consider
nurses, mentoring programs to develop new leaders, and
themselves oncology nurses.
marketing programs designed to appeal to younger people
Most of the specialty nursing organizations surveyed indi-
cated that they were providing some level of customization
have been developed. All of this has been done with an eye
of member services. However, none is customizing to the
toward maintaining its traditionally loyal membership base
individual level. For example, one organization provides
and tapping into the experience it represents.
Web resources customized to practice settings, and another
offers selection of bundles of services that are customized
to a predetermined list of specialty interests. The "Amazon.
nstead of being one thing for many different peo-
com" level of individualized marketing is not a reality for
ple, ONS will need to be many different things
most organizations, and none of the organizations responding
for many different people.
indicated that this was in their plans.
Associations will differentiate themselves. Associa-
tions offer information, education, and community to the
people who join them. People have more choices than ever
ONS will need to continue to expand efforts to address
before to satisfy needs traditionally fulfilled by belonging
the needs of newer and younger nurses without alienating
to formal member groups like associations. People recog-
its traditional membership base. As implied previously, this
nize that information, even very specialized information, is
means instead of being one thing for many different people,
easily accessible today. CE also is widely available, from
ONS will need to be many different things for many different
commercial sources, traditional educational institutions,
All of the nursing organizations responding to the survey
and other associations. Community--often referred to as
indicated that they are watchful about aging membership, yet
professional networking--becomes less defined by the or-
ganizational entity and more by individuals seeking other
most have experienced overall growth nonetheless. Demo-
graphics and average ages cited were similar to those found
individuals in the fluid and ever-changing domain of the
within ONS. There were some indications that, although aging
Internet. A professional association that emerges as a leader
membership is a concern, the population of potential members
will be the one that is able to adapt so it remains a choice
is large enough that membership declines are not a real threat
that its members will continue to make. This means that the
in the long run.
association will need to be different from other information
Relevance will be a growing challenge. An ongoing and
and education sources and different from other communities
much-noted challenge for working people is the pursuit of
available to its members. ONS's diverse educational offer-
ings, expansive range of publications, and extensive Web
work-life balance. As noted previously in the Societal Trends
site have helped to position it as the best resource available
section, the value of personal time has increased. The pres-
sures of working families and busier lives and the desire to
for its members.
maintain a healthy balance among multiple priorities some-
ONS will need to abandon some of its assumptions about
times push associations down the list.
member needs that are based on the traditional array of mem-
ber benefits and services. ONS must closely and regularly
We know that nurses' lives have become busier as a result
monitor member segments, needs and wants, and behaviors
of sweeping changes in health care, the nursing shortage, and
and attitudes. Current and potential members--both tradi-
the aging patient population. Lack of time often is cited as the
tional and nontraditional--will need compelling reasons to
reason for nonparticipation by members and attrition among
keep ONS among their choices.
members. ONS is continually challenged to convince oncol-
ogy nurses to renew their memberships, read the literature,
When asked what their organizations are doing to differenti-
and participate in education programs.
ate themselves from others that are providing services to their
ONS will need to position membership as a way to face the
Similarly to ONS, the nursing organizations responding to
challenge of work-life balance as opposed to being an extra
our survey have not seen significant effects on conference at-
tendance or other forms of participation that they can attribute
thing to take care of. The challenge is to convince current and
to perceptions of risk among members.
potential members that involvement is a way to improve their
Traditional association structure and operations are shift-
career potential, enhance their ability to care for patients, and
ing. In many associations, more attention is being paid to the
keep them motivated to advance in their profession. Members
business of the organization. Management accountability and
should be provided with engaging ways to become involved
business success are seen as more critical to an association's
in ONS that do not unduly detract from personal and family
ability to fulfill its mission. Many associations are placing
time, such as meeting via conference calls or Web confer-
growing emphasis on nondues revenue. Issues of leadership
Specialty nursing organization executives were asked what
transparency are becoming more important as well.
they were doing to overcome the fact that their members have
ONS has dedicated a great deal of board and management
less time to dedicate to association activities. Short-term, big-
time and attention over the past few years to issues such as
impact commitments; small, focused project teams; and more
organizational ethics and conflict of interest. In addition, ONS
staff time dedicated to coordinating volunteer work were cited
has carefully monitored the outcomes of measurable goals that
as ways to overcome time constraints. Organizations also are
have been set in support of its strategic priorities. ONS has
increasing their use of communications and Internet technolo-
been careful to maintain a stable balance between volunteer
gies and conference calls. In contrast to the decreasing time
leadership and professional staff and has structured itself in
commitment required of most volunteers, some organizations
ways that capitalize on this balance.
are seeing greater dedication and time commitment on the
The association executives surveyed were asked what was
part of a core leadership group. One executive director said,
the most significant change in organizational structure that
"The time demands on our board of directors have increased
they have experienced in the last two years (e.g., larger or
significantly, yet our board members continue to meet that
smaller boards, committee structure, staff structure). The re-
sponses indicated a trend toward governance boards focused
Perception of risk will remain high. The general percep-
on policy issues, a movement to advisory councils and project
tions of risk and concerns for personal security have been
teams versus standing committees, and more reliance on pro-
fessional staff for operational issues.
major factors in Americans' decision making since 2001.
ONS must continue to regard business success as a critical
Many people consider the terrorist attacks of September 11