The Nurse’s Role in Oncology: An Essential Element of Cancer Control in Low and Middle-Income Countries

Blanca Nieves Maradiaga preparing chemotherapy at Hospital Escuela in Honduras.

Can we hope to improve cancer care in developing countries without paying attention to the training and continuing education of health care teams (doctors, nurses, pharmacists, technicians and many others)? Clearly not! And although each team member has an important role, that of the nurse is often not given the emphasis it deserves. Nurses tend to have much more limited responsibilities in low-income countries compared to high-income countries – to a considerable degree a consequence of male-dominated societies.

Yet nurses, who are in much closer contact with patients than are doctors, are responsible for the delivery of many of the medical interventions necessary for effective treatment; their day-to-day observations are critical to the identification of potential problems, including treatment toxicities, and their role as communicator and intermediary between doctors and patients has an important impact on the effective delivery of care and measurement of its outcome. For nurses to be maximally effective team members in the care of the cancer patient, they should, like doctors, receive oncology specialty training.Unfortunately, there is limited available information on the number of oncology nurses and the quality of oncology nursing in developing countries and few formal training programs in such countries. Given the demonstrable shortage of general nurses in developing countries (who are sometimes outnumbered by doctors) it is clear that few are available to work in cancer units. Among other factors identified as impeding nurses’ involvement in cancer care are: the lack of specialist doctors in charge of training and support, the traditional exclusion of nurses from decision making at most of levels in the health system, the undervaluing of the nursing role and the lack of continuing educational opportunities. Changing the present situation will be difficult, but not impossible. The development of oncology-specific education for nurses, as long as it is associated with appropriate recognition, including higher income, is the primary requirement. The enhanced role of nurses should lead to improved communication between doctors and nurses, a greater role in decision making and at the same time, a reduction of the work load of doctors. Appropriately trained nurses can perform many routine procedures, have a larger role in ensuring that necessary investigations are performed, provide necessary information to patients (and to doctors) and even, in some circumstances, prescribe particular medications.

INCTR recognizes the importance of the patient perspective in the fight against cancer and believes that beneficial actions are possible even when human and material resources are severely restricted. Education is central to this goal and nursing education, given their closer relationship to patients and pivotal role in the oncology team, has a high priority. While each country may be different in its oncology nursing needs and its willingness to accept an enhanced role for nurses, a core curriculum based on essential knowledge for all oncology nurses should not be difficult to develop. In order to move forward, however, it is essential to know where one presently stands. The present article is the first of two parts. The present article is the first of two parts. We begin with a review of current oncology nursing programs in Latin America, with a special emphasis on pediatric oncology. Part Two, focusing on INCTR initiatives in cancer nursing in Morocco and Niger, will appear in the next edition of Network.

Part ONE.
Pediatric Oncology Nursing In Latin America (Julia Challinor, RN, PhD¹)

“More than 85% of pediatric cancer cases occur in developing countries that command less than 5% of the world’s resources” (Yaris, Mandiracioglu, & Buyukpamukcu, 2004, p. 240). Yet in some of the poorest developing countries there is only one trained pediatric oncologist, in others, none. In such situations, nurses, who provide coverage 24 hours a day and seven days a week, have a critical role in enabling the complex treatment for children with cancer to be delivered in a timely manner. Although the number of physicians required to care for children with cancer is much smaller than the number of nurses, the current global flight of trained nurses to more developed countries leaves understaffed units with overworked nurses (WHO, 2006). For example, in the Dominican Republic with a population of nine million, five professional oncology nurses and eight nursing assistants work in the sole pediatric cancer unit, comprised of 16 inpatient beds and an outpatient unit.

Most developing countries lack supportive care and multidisciplinary teams that include nutritionists, pediatric oncology pharmacists, intravenous teams, nurse educators, palliative care teams, social workers, etc. Therefore, these responsibilities are devolved to the pediatric oncology nurses who are already struggling with high patient-to-nurse staffing ratios. Needless to say, many aspects of total care are, of necessity, neglected. As an example, in El Salvador, there is one nutritionist for 300 children hospitalized in the one pediatric hospital, Hospital Benjamin Bloom, in the capital, San Salvador. This is the only referral center for children with cancer (30 beds) in a country with a population of 6.9 million and chronic malnutrition rates of 19.5% for first graders and 18.5% for children less than five years of age (World Food Program, 2007).

Other aspects of the limited resources of developing countries also increase the workload of oncology nurses. In Bolivia, for example, and several Central American countries, nurses are expected to prepare as well as administer chemotherapy. This is a consequence of the shortage of pharmacists in the country and the lack of funds to hire a pharmacist specifically for pediatric oncology. In Nicaragua, one nurse mixes all inpatient chemotherapies four hours a day, Monday through Friday for up to 30 hospitalized patients while the outpatient nurse mixes and administers chemotherapy for approximately 40 patients a day during the week. In some countries, such as the Dominican Republic, pharmacists earn less than a professional nurse so that the lack of a pharmacist adds to the cost of the chemotherapy preparation and reduces the time available for direct nursing care. Another example arises from the limited use of central venous access catheters in developing countries, largely because attempts to do so have resulted in unacceptably high infection rates and correspondingly higher mortality rates. This means that a great deal of time is spent in establishing intravenous access – which becomes more difficult as time goes by and veins are damaged by the administered drugs.

The level of parental education is often low in developing countries, due to poverty. In Nicaragua, 82% of people live on 1 dollar a day or less and 36% of the population cannot read or write. The literacy rate in Guatemala is 70.6% overall and 63.3% among women who bring their children to the public hospitals for treatment. In addition, 40% of the population does not speak Spanish, or speaks Spanish as a second language, their first being one of the 23 officially recognized Amerindian languages (CIA Factbook, 2007). This greatly complicates the task of the pediatric oncology nurse in teaching parents how to care for their child during treatment for cancer. However, severe understaffing leaves little time for nurses to listen to and address the specific needs and anxieties of the family while trying to ensure that the child will be in a safe home environment when discharged during treatment.

Palliative care is a constant concern for nurses caring for children with cancer in developing countries. Unfortunately, a significant number of children in most developing countries are diagnosed in the late stages of their disease and there is no hope for cure. As stated by the International Atomic Energy Agency, “For most of the developing world, the reality is overstretched health systems, where few cancer patients are screened, diagnosis comes too late or treatment is just not available” (International Atomic Energy Agency, 2003, p.13). However, limited access to morphine as well as inappropriate medical or cultural concerns about addiction can be obstacles to appropriate pain control. The low consumption of opioid analgesics for the treatment of moderate to severe pain, especially in developing countries, which account for only some 6% of global morphine consumption, continues to be a matter of great concern to the International Narcotics Control Board (International Narcotics Control Board, 2005, p. 25). There are few home palliative care programs in developing countries and therefore no support for the family when the terminally ill child is discharged from hospital.

The inclusion of nurses in the multidisciplinary team, which is generally the case in the more developed countries, is still rare in the less developed countries. This has a negative impact both on the nurses and the entire care team; without an equal opportunity for continuing education nurses will remain as undervalued and constrained partners in the fight against childhood cancer, while their omission from the multidisciplinary team can result in overlooking information important to the patient’s welfare. Nurses are more likely to be from similar socio-economic groups as the patients and often privy to personal family information that is not shared with the physician. Those countries where they have been identified as an important partner in care and given the opportunity to excel as a result of continuing education programs and international twinning (partnership) and networking programs have demonstrated a decrease in the abandonment of therapy before its completion and higher cure rates, e.g., in El Salvador, Honduras, Guatemala, and Nicaragua. Strong international partnerships that include pediatric oncology nurses will ensure a stable nucleus of these dedicated, essential health professionals which can be expanded to serve both present and future needs. Providing continuing education for oncology nurses while training more, and simultaneously improving their local professional opportunities in order to reduce their desire to emigrate once trained are important, but frequently overlooked, aspects of cancer control.

¹ Member of INCTR and ICEDOC, specialist in Pediatrics

Julia Challinor, University of California San Francisco, San Francisco, USA
and Sabine Perrier-Bonnet,
AMCC, Montpellier, France


References
CIA Factbook (2007). Guatemala. https://www.cia.gov/cia/publications/factbook/print/gt.html retrieved 5.3.07.

International Atomic Energy Agency, (2003). A silent crisis: Cancer in developing countries. Austria: IAEA. http://www.iaea.org/Publications/Booklets/TreatingCancer/treatingcancer. pdf retrieved 4.21.07.

International Narcotics Control Board (2005). Report of the International Narcotics Control Board for 2004. New York, NY: United Nations. http://www.incb.org/en/annual_report_2004.html retrieved 4/21/07.

WHO (2006). WHO’s “World Health Report” warns that workforce crisis is endangering the fight against disease. Retrieved 1/31/07 http://www.wpro.who.int/media_centre/press_releases/pr_20060407.htm

World Food Program (2007). “Where we work – El Salvador”. http://www.wfp.org/country_brief/indexcountry.asp?country=222 retrieved 4/20/07.

Yaris, N., Mandiracioglu, A., & Büyükpamukcu, M. (2004). Childhood cancer in developing countries. Pediatric Hematology and Oncology 21, 237-253.