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PAEDIATRIC CANCER

114 CANCER CONTROL 2015

to carry out physicians' orders without question, even when

the nurses believe there has been an error made. The critical

role of autonomous nurses who are able to fully participate

in patient care planning and monitoring is often highlighted

and should be role modelled by visiting teams from HICs. It is

our expectation that over time, the LMIC physicians treating

children with cancer who have received training in HICs will

also begin to integrate nurses into their daily rounds,

patient/parent conferences and treatment decisions.

Although better prevention and treatment of childhood

communicable diseases have led to better efforts in cancer

care and control in LMICs, there are still some LMICs where

communicable diseases remain the leading cause of

childhood death. One example is Pakistan, where the cause

of death in over 70% of children is communicable diseases

(38). Implementing the standards in these countries will be

very difficult and could potentially place hospital

management in the dilemma of choosing better care to a

limited number of children with cancer or providing

necessary treatment to a larger number of patients.

Nursing shortages and poor nurse retention rates are a

significant challenge in Pakistan, and other LMICs. The

nursing pay scales of local hospitals in LMICs compared to

HIC institutions are significantly lower and trained oncology

nurses are easily employed in HICs. Many nurses therefore,

move to other countries for better career opportunities. This

problem will continue as long as nurses in LMICs work

without adequate support and pay. The cost of adding

additional nursing positions and adequate resources will be

a challenge. However, this cost must be weighed against the

cost of high nurse turnover and an increase in patient

complications resulting in longer hospital admissions.

These baseline standards have been welcomed by the

international paediatric oncology community. The SIOP

PODC Nursing Working Group continues the work of

disseminating and advocating for their implementation.

Future work will be undertaken to review progress; to

understand and address barriers to implementation, and to

recognize and celebrate success. To date we are not aware of

an LMIC setting that has attempted to implement the

standards as a whole. There is interest in the SIOP PODC

Nursing Working Group members to bring the standards to

their local authorities to advocate for change. Progress

towards achieving the standards will be monitored at the

annual SIOP meetings.

There are challenges to implementing them, but the fact

remains that these basic standards are essential to providing

the minimum level of quality nursing care required to

improve the survival rate of children with cancer in LMICs. l

and isolation supplies. Nurses prepare chemotherapy

only if a pharmacist is not available, personal protective

equipment and a biosafety level two cabinet are

available, and periodic screenings for secondary cancers

(related to exposure to antineoplastic agents) are

provided.

‰ Standard 6: Evidence-based paediatric oncology nursing

policies and procedures are in place to guide the delivery

of quality nursing care. Because of the scarcity of nursing

research in LMICs, funding for locally directed research

is the next step to create relevant nursing policies and

procedures.

Discussion

To close the survival gap that exists between children with

cancer in HICs versus LMICs, institutions that develop

cancer services and those that participate in twinning

partnerships must invest in the nursing workforce. In HICs,

death due to toxicity is 0.2% to 7% and abandonment is rare

(36). In LMICs, toxicity and abandonment of treatment are

the leading causes of death (30). Both require quality nursing

care to improve and address the underlying issues. Providing

resources and support to improve medical care without

comparative interventions for nursing care will produce

results that fall short of what is possible and optimal. In some

cases, implementation of modern protocols without

adequate nursing care can actually cure fewer children due

to higher rates of toxic death (37).

While it may be premature to expect that all LMIC nurses

in the near future will enjoy the full spectrum of support

from improved staffing, educational programmes, essential

resources and a safe work environment, this does not mean

that achieving the SIOP Baseline Standards should not be

the goal. The standards are minimal or baseline and

implementation is possible, even in LMICs. For example,

implementation of a comprehensive nursing programme at

the Unidad Nacional de Oncología Pediátrica in Guatemala

City, Guatemala, resulted in improved quality of nursing

care as evidenced by a significant increase in the number of

quality standards met post-programme implementation

and a decrease in the rate of abandonment of treatment.

Key to the programme's success was the support of a fulltime

nurse educator, dedicated solely to staff education

and clinical training (28). This model could also be adapted

for the implementation of the proposed Baseline

Standards.

In many LMICs, nurses achieving the status of a respected

member of the interdisciplinary team will require a paradigm

shift in hospital culture where nurses are currently expected

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