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