Intrinsic Factors as to Why Advanced Practice Providers Stay in Oncology

Abstract

PURPOSE

To describe intrinsic factors influencing role retention of oncology advanced practice providers (APPs).

PARTICIPANTS AND SETTING

The current study examined 66 advanced practice RNs and three physician assistants completing a palliative care course for oncology providers offered by the End-of-Life Nursing Education Consortium through a grant from the National Cancer Institute.

METHODOLOGIC APPROACH

Participants were asked “Why do you stay?” on the final course evaluation. Deidentified qualitative responses were sorted using thematic content analysis to identify key themes affecting oncology APP retention.

FINDINGS

Five themes emerged from the analysis: calling/passion, personal or family history, people with cancer, challenging work/making a difference, and relationships with the oncology team.

IMPLICATIONS FOR PRACTICE

Despite the essential role of oncology APPs, little is known about what is important to them and what keeps them in the profession, particularly in the current healthcare environment. Stakeholders concerned about delivering quality cancer care must recognize the values and meaning that oncology APPs ascribe to their roles to support and retain this essential workforce. Understanding these factors will inform leaders of the issues that affect and cultivate the work of oncology APPs.

Advanced practice in oncology involves profoundly challenging work yet affords deep meaning and satisfaction. Advanced practice providers (APPs) are employed throughout the cancer continuum, from prevention to diagnosis, treatment, and end of life. Oncology APPs practice in all cancer care settings, including ambulatory clinics and inpatient settings. As the science of oncology has rapidly evolved, treatment options have multiplied, demanding the acquisition of strong scientific knowledge and sophisticated clinical skills (Lubejko & Wilson, 2019). Despite the essential role of oncology APPs, little is known about what is important to these providers, what meaning they find in their roles, and what keeps them in the profession.

Since its inception in 1975, the Oncology Nursing Society (ONS) has supported oncology nurses through education and advocacy to advance cancer care. More than 30 years ago, ONS commissioned the Life Cycle Task Force to better characterize the career trajectory of oncology nurses (McDonnell & Ferrell, 1992). The task force described how critical incidents influenced oncology nurses’ ability to thrive in their roles. It highlighted the joy and sorrow found in this work, celebrating clinical victories while witnessing deep sorrow associated with suffering and loss. The task force reasoned that understanding the experiences of oncology nurses would reveal opportunities for recruiting new members into the specialty and into ONS, as well as build commitment in those who had already chosen the field (McDonnell & Ferrell, 1992). The 10 essential concepts identified are outlined in Figure 1. An essential concept described by the Life Cycle Task Force was the essence of oncology nursing, which Cohen and Sarter (1992) revealed in a qualitative study as follows:

FIGURE 1.

Essential Concepts in the Life Cycle of an Oncology Nurse

Note. From “Oncology Nursing Society Life Cycle Task Force Report: The Life Cycle of the Oncology Nurse,” by K.K. McDonnell and B.R. Ferrell, 1992, Oncology Nursing Forum, 19(10), p. 1,548 (https://pubmed.ncbi.nlm.nih.gov/1461769). Copyright 1992 by Oncology Nursing Society. Adapted with permission.

Nurses described . . . being on the front lines of a war against death, disfigurement, and intense human suffering. It requires the performance, prioritization, and coordination of multiple complex tasks. It involves handling frequent, unexpected crises, both physiologic and psychological. It carries the rewards of reversing a fatal illness, balanced by the ever-present reality of death. (p. 1,485)

The rewards described by these participants were human interactions that are inherent in cancer care. Many oncology nurses in the current study and other studies have described their personal growth that evolved as a result of these human relationships (Carr, 2023; Cohen et al., 1994; Davis et al., 2017). The theme of rewards in oncology nursing was prominent when nurses were asked about the meaning of their profession. Raingruber and Wolf (2015) explored the uniqueness of oncology nursing and what sustains these nurses in daily practice. The gratitude and vulnerability of patients were cited as motivating factors, along with the ability to make a difference in the lives of patients. Intrinsic factors including experiencing a sense of grace, practicing compassion, and being present sustained these nurses as they provided care to people with cancer. A qualitative study by Loft and Jensen (2020) examined 28 experienced nurses in Denmark and revealed several key themes related to why they stay in their profession, including the importance of the specialty, management, professional challenges, good colleagues, and the ability to balance family, work, and life. These themes have also been reflected in additional studies of nurses in oncology and other clinical areas (Gaillard Ulysse & Cytall, 2022; Reinhardt et al., 2020).

The factors affecting job satisfaction and their impact on nurse practitioners’ intent to leave have been studied for more than 20 years. Extrinsic factors such as better benefits and compensation or career advancement are often cited as the primary reasons nurse practitioners change jobs (Hnath et al., 2023). Studies have demonstrated that mixed levels of job satisfaction are influenced by extrinsic factors including levels of autonomy in practice, interprofessional relationships with supervising colleagues, panel size, and the perceived ability to deliver quality care (Kim et al., 2024). In a study using a convenience sample of 193 oncology nurse practitioner members of ONS, Bourdeanu et al. (2020) reported that higher levels of job satisfaction and lower stress levels predict a lower level of intent to leave, with more than 50% of participants indicating that they are likely to stay.

The Advanced Practitioner Society for Hematology and Oncology conducted an online member survey to measure burnout and resilience among hematology and oncology APPs. Although respondents (N = 366) reported being overextended (37.4%) and 17.8% met the criteria for burnout, the group noted high levels of the intrinsic factor of personal accomplishment (4.9, where 4 = once a week and 5 = a few times a week) (Kurtin et al., 2023). A prospective, comparative, descriptive study noted that although resiliency was positively linked to personal accomplishment, it was not necessarily protective against burnout among oncology APPs (Baugh et al., 2024).

Because APPs play an increasingly prominent role within oncology teams, there is a compelling need to understand the motivation of these providers to remain in the field (Bruinooge et al., 2018). However, numerous challenges facing health care and the field of oncology seriously affect the role of oncology APPs and their ability to provide quality cancer care. Extrinsic factors such as workforce shortages, health disparities, shortages of critical cancer drugs, workload, electronic health records, cost of care, and regulatory burden are just a few current challenges affecting oncology teams (Pickard et al., 2023). A better understanding of intrinsic reasons why these vital members of the oncology care team stay in the profession will have widespread consequences for the quality of cancer care.

Purpose

This qualitative study sought to better understand what drives APPs to stay in the field despite the challenges in today’s healthcare settings. Understanding these factors will inform leaders of the issues that support and cultivate the work of oncology APPs.

Participants and Setting

Participants included a convenience sample of advanced practice RNs ([APRNs], n = 66) and physician assistants (n = 3) who attended the National Cancer Institute (NCI)–funded End-of-Life Nursing Education Consortium (ELNEC) Oncology APRN (EOA) course in Long Beach, California, in January 2024. Participants included a broad representation of APPs across the United States (27 states). ELNEC is a national and international educational initiative to improve palliative care and is a collaboration between the City of Hope in Duarte, California, and the American Association of Colleges of Nursing. The EOA course is a 2.5-day in-person training program to prepare APRNs in oncology settings to integrate palliative care within their current role in improving the quality of care of people with cancer. The course is intended for APRNs only; however, three physician assistants applied to attend and were accepted. The course is organized into eight palliative care domains, as defined by the National Consensus Project for Quality Palliative Care. The learning objectives of the EOA course are to (a) identify the eight domains of quality palliative care applied to oncology practice, (b) demonstrate skills for oncology APRNs in the domains of palliative care, and (c) develop goals for implementing skills training in practice through process improvement, staff education, and clinical care.

Methodologic Approach

A descriptive approach through thematic content analysis was used to understand the experience of oncology APPs and the meaning that they ascribed to multiple factors affecting their decisions to stay in their current roles. This methodology is useful in understanding the experiences of others and gaining insight through content-related categories (Braun & Clarke, 2006). Participants were invited to complete a course evaluation that included demographic information immediately following the EOA course. Study recruitment and procedures were deemed exempt by the City of Hope Institutional Review Board because all data were collected from course participants only.

Course participants completed the course evaluation on the final day of the course and responded to the following prompt:

We know that these are really challenging times in health care. There are many challenges with the workforce post-COVID, especially related to retaining nurses in the profession. Please share with us why you stay. Help us understand what keeps you in oncology nursing.

Evaluation responses were gathered into a Microsoft Excel document and reviewed multiple times by faculty members who coded the key phrases within each response. Five faculty members held several conference calls to discuss coding and achieve a consensus regarding the nine key themes that initially emerged from this review. The faculty team reviewed and further condensed these themes into five themes, illustrated in Figure 2.

FIGURE 2.

Key Themes: Why Do Oncology Advanced Practice Providers Stay?

Findings

Most participants were female (n = 62) and described their race as White (n = 56), followed by Black or African American (n = 7), Asian (n = 3), or more than one race (n = 3). Most participants described their ethnicity as non-Hispanic (n = 64). The participants had nearly two decades of experience in nursing or health care (X̄ = 18.6 years), with an average of 14.1 years of experience in oncology. The average time since completion of their highest degree was 8.6 years. Most course participants worked in adult (n = 62) and outpatient settings (n = 50), including ambulatory or outpatient/community cancer centers. Nineteen participants worked on inpatient oncology units, and 26 participants worked at an NCI-designated cancer center. Of participants, 56 were nurse practitioners, 7 were clinical nurse specialists, 3 were physician assistants, and 3 served in some other role (i.e., educator or staff nurse) (see Table 1). Five key themes emerged from a review of the participants’ responses to the question “Why do you stay?”

TABLE 1.

EOA Course Participant Demographics (N = 69)

Characteristic	X̄
Experience (years)
In nursing or health care	18.6
Since completion of highest degree	8.6
In oncology	14.1
Characteristic	n
Gender
Female	62
Male	7
Race
Asian	3
Black or African American	7
White	56
More than 1 race	3
Ethnicity
Hispanic	5
Non-Hispanic	64
Patient population
Adult only	62
Pediatric only	7
Title/position
Nurse practitioner	56
Clinical nurse specialist	7
Physician assistant	3
Other (i.e., educator or staff nurse)	3
Type of cancer center
Community oncology program	43
NCI-designated cancer center	26
Care status
Outpatient	50
Inpatient	19

EOA—End-of-Life Nursing Education Consortium Oncology Advanced Practice RN; NCI—National Cancer Institute

Calling/Passion

Participants expressed their passion for oncology and oncology nursing. Many described this as an existential calling to the profession and to caring for patients with serious illness. One participant noted, “It’s always been my calling/ministry. Overall, it’s a privilege to care for this vulnerable population.” Adult and pediatric APPs described experiences in which they found their work to be awe-inspiring and satisfying. They derived meaning from feeling dependable and needed by their patients by partnering with them as advocates. They explained how they felt good about helping others and finding fulfillment in their work, and how interactions, compliments, and comments from patients fueled them to keep going. They described how their work made them feel complete and gave them purpose. The following quotes reflect the deep meaning that participants ascribed to their work:

• ■ “Oncology care has always been my passion, and I believe I was initially drawn to it due to my aunt’s 28-year battle with breast cancer. I am now our primary breast cancer APP, as well as the supervisor for all medical oncology APPs. I take pride in developing a team that is passionate about oncology care and is willing to ignite practice changes and improvements to provide the highest quality care to every patient every time. It is a privilege to take care of patients and their families during some of the most vulnerable times of their lives, as well as an honor to lead a fantastic group of APPs who are providing quality care and driving practice changes within medical oncology. All of this is something I do not take lightly, and this is what drives me professionally.”

• ■ “I have always known that this was what I was meant to do. I don’t consider this a job, but a calling.”

• ■ “I stay because I want to do what is right for the patients. I went into oncology nursing because I am passionate about end-of-life care, and it seemed like a logical choice. I continue to advocate for palliative care and dignity when dying.”

APPs reported that they stay in their work because they feel privileged and lucky to care for their patients, particularly when they share their hopes and aspirations with them. This singular focus on calling and purpose was described by one participant quite succinctly with the question “What else would I be doing?” Another participant noted the following:

I feel privileged to be a part of each patient’s battle with cancer. They let me in their lives and share their most intimate fears, hopes, and aspirations. This is so precious. I have not experienced this in other specialties where I worked.

Personal or Family History

Participants described a personal or family history of cancer as a critical factor in why they chose oncology as their area of specialization as well as why they continued to stay in their present roles. Several participants described losing a parent, sibling, or aunt from colon, breast, pancreatic, or prostate cancer, or from glioblastoma or sarcoma. One participant stated, “Nurses helped me and my family navigate this ordeal, and I was compelled to pay it forward.” Additional feedback included the following:

I first decided to be an oncology nurse when my mother was diagnosed with colon cancer. A short time later, my mother-in-law was diagnosed with recurrent breast cancer. I vividly remember the conflict between what her family wanted her to do and what she wanted to do. I know firsthand you can’t always “fix someone,” but you can do your part to make things a little easier on their journey. I have had the profound joy and pleasure of caring for some of the most amazing individuals at one of the most difficult times in their lives. What better way to honor those who have gone before them than to walk beside those struggling on their journey?

People With Cancer

Many course participants described their “love for the patients or population of people with cancer,” identifying this population as “a unique group with unique needs” and “complex patients who face many challenges as they progress through treatment.” In addition, one participant stated, “I love my patient population—they are challenging, but they do very well after treatment, and we follow them for many years!” Additional comments included the following:

• ■ “I took a break (almost three years) to stay at home with my young children during the pandemic and have just returned to work within the last year. I was inspired to return to oncology nursing because working with these patients has given me perspective and helped me find meaning in life in a way that is hard to replace with anything else. The resilience of many of the patients I have cared for is especially inspiring, and supporting these patients is a very rewarding and satisfying role.”

• ■ “I love teaching and helping patients navigate their cancer journey. I have had many patients say, ‘I always feel better after our visits.’ That’s what it is all about.”

• ■ “I love this patient population. I never expected to care for this population or considered that I would be good with them. However, through some unforeseen circumstances, I ended up doing my new nurse training on an oncology floor. Most people have done nothing to warrant dealing with cancer. I love that they want to do the right things and assist you in caring for them in the best possible manner. I really enjoy being able to inject humor, where appropriate, to lighten the mood in the room. I also feel like they need people who tell them the truth about what is happening and how difficult things might be without diminishing hope.”

• ■ “I love what I do. Patients with cancer are very dear to my heart because my father died from cancer. I always want to be that person they can depend on and reach out to when, and if, they have a need. I stay because I am needed.”

Challenging Work/Making a Difference

Nurses and APPs often describe having chosen a caring profession as a career to “make a difference” in the lives of the people they serve. Oncology professionals appear to thrive on the multiple challenges that caring for people with cancer may present, including the evolving nature of cancer treatment. Adult and pediatric oncology APPs shared that they know their work makes a difference and they sometimes underestimate the impact they have on many people’s lives. Their stories revealed ways in which they helped people live better, brightened people’s days, and cared for people during their most difficult and trying times. A few specific comments about this factor include the following:

• ■ “I have a passion for oncology nursing. I love that it is constantly evolving and changing. There is always something new to learn. This is not a stagnant field in medicine. Cancer also impacts every single one of us; therefore, it becomes personal in one way or another. Patients with cancer are special in their own unique ways. They are tenacious and grateful for the care you provide. I can’t imagine doing anything else.”

• ■ “It really is not easy. But I know that the difference I’m making is profound in others’ lives. For palliative care, I always say to my patients that it is never easy to have to make any of these decisions, but it is an incredible blessing to be given the opportunity to make them. We need to keep fighting and keep advocating!”

Relationships With the Oncology Team

Multiple participants described their relationships with patients, families, and other members of the oncology healthcare team as a critical factor in their choice to remain in their roles.

• ■ “I know of no other specialty that allows for such deep involvement in the lives of patients and their families at a paramount and perhaps most important time in their lives. I believe this allows for relationship building in a professional setting that is unparalleled and deeply rewarding and everything that I had hoped medicine would be for me. It is a deeply satisfying profession that I am so happy and privileged to be part of.”

• ■ “I stay to be able to work with inspiring oncology nurses and APRNs whom I admire and respect, and from whom I can learn so much. I stay to be able to be present with patients, their families, and coworkers at sacred/messy and impactful moments. I have the opportunity to form therapeutic relationships with oncology patients and their families, knowing that by doing so I am hopefully decreasing to some extent the different types of suffering that patients and their families might be experiencing.”

• ■ “My patients and my oncology team are the two reasons I stay. I cannot imagine doing anything else and feel eternally grateful for the support I receive from my team.”

Other

Although most of the oncology APPs offered positive comments about their commitment to remaining in their current roles, some participants described the consequences of this choice on their physical, emotional, and spiritual well-being, such as the following quote:

Even when it seems to drain me, I come back time and again to these connections. It’s so hard because we build lasting and meaningful connections with these individuals. That being said, there have been multiple times that I have come very close to not only leaving oncology but also health care altogether. I still have doubts about longevity in practice. I have almost 30 working years left and given the current healthcare climate and the coming challenges, including shortages across the majority of specialties, I am concerned about how to maintain my physical, mental, emotional, and spiritual health in a system that often demands the utmost of all of these.

Discussion

In 2025, ONS and ELNEC celebrated significant milestones in their history and initiatives. ONS celebrated 50 years as the professional home for oncology nurses, with a mission to advance excellence in oncology nursing and quality cancer care and serve as the standard bearer of advanced cancer care (ONS, 2024). In addition, ELNEC celebrated 25 years, with more than 1.5 million nurses and other healthcare providers educated in palliative and end-of-life care (American Association of Colleges of Nursing, n.d.). ELNEC and ONS have a long history of collaboration related to palliative care education through joint sessions at ONS Congress^®, as well as NCI-funded grants to prepare ONS chapter leaders as ELNEC trainers and cancer-specific ELNEC programs to equip oncology nurses with knowledge, skills, and tools in palliative care.

Understanding why APPs remain in their roles can assist with recruitment and retention strategies for developing and sustaining the oncology workforce. The average orientation time for a new nurse practitioner or physician assistant is estimated to be three to six months, with longer periods required for specialty care (DirectShifts, 2022). Commitment to retaining this valuable workforce has implications related to maintaining the delivery of quality cancer care with retention of these highly skilled practitioners and avoidance of significant replacement costs related to nurse practitioner turnover (Kelly et al., 2024).

The current study examined the reasons why oncology APPs remain in the field despite the complexities in health care and healthcare systems. In this qualitative study, oncology APPs’ reasons were focused on five themes: calling/passion, personal or family history, people with cancer, the opportunity to do challenging work/making a difference, and relationships with the oncology team. The findings are consistent with those of other studies regarding the importance of the meaning and significance of oncology nursing and advanced oncology nursing practice (Bourdeneau et al., 2020; Cohen et al., 2010; Raingruber & Wolf, 2015). Critical concepts or themes that overlap with the findings of the ONS Life Cycle Task Force in McDonnell and Ferrell (1992) include “essence of oncology nursing,” “patient and family outcomes,” “nature of the work,” and “environment/culture” (pp. 1,547; 1,549).

Cancer care and treatments have significantly changed since 1992; however, the essential concepts remain similar in 2025. The importance of relationships with other members of the healthcare team cannot be overemphasized because the cultivation of a social network of colleagues contributes to the understanding of the definitions offered related to meaningful work (Robertson et al., 2020). Unlike other studies that described nurse practitioner job satisfaction related to extrinsic factors such as pay and benefits (Bourdeneau et al., 2020; Hnath et al., 2023; Kim et al., 2024), participants in the current study exclusively cited intrinsic factors related to purpose (passion/calling, personal or family history), professional experiences with people with cancer, opportunities for challenging work, and relationships with members of the oncology healthcare team as reasons why they remain in their current role. Participants’ interest in attending a course about palliative and end-of-life care may have affected their responses about why they stay. This is challenging work that often involves emotional and spiritual exploration of the meaning that it offers for individuals. Participant responses focused more on why they stay in oncology rather than why they stay in advanced practice.

Limitations

The current study had a few limitations. First, the sample was drawn from one NCI training course of APRNs and physician assistants who self-selected their participation. Second, the participants were primarily White and female, limiting perspectives that may not be fully represented. Last, although gathering responses on a postcourse evaluation was a convenient way to collect these data, the use of an open-ended evaluation question did not allow for follow-up.

Implications for Practice

Oncology APPs describe passion and purpose as primary drivers of what keeps them in their roles despite the complexities of cancer care. Organizations seeking to retain this valuable workforce should encourage reflection on these intrinsic factors and motivations. Additional qualitative research using focused interviews and a phenomenologic approach would be useful to explore intrinsic factors affecting APP retention. More evidence is needed to determine strategies for recruitment, retention, and job satisfaction in the workforce.

Conclusion

Oncology APPs are essential to the delivery of high-quality palliative care. Understanding provider motivations to continue in this often emotionally draining and challenging work is critical to recruitment and retention efforts for this important workforce. Self-reflection about why palliative care practitioners stay may be a useful tool to guide these conversations.

KNOWLEDGE TRANSLATION.

• ■ Advanced practice providers are a valuable mainstay of the oncology workforce and contribute to quality cancer care, including primary palliative and end-of-life care.

• ■ Reasons offered by oncology advanced practice providers as to why they stay in their roles are primarily related to intrinsic factors such as their purpose, passion, and commitment to caring for patients with cancer.

• ■ Encouraging all clinicians to reflect on the meaning that their work brings to their lives may serve as a valuable retention strategy.

Funding Statement

This research was funded, in part, by a National Cancer Institute grant (NCI R25CA217270).