Oncology nursing leadership around the world
There are nearly 10 million deaths from cancer across the world each year (1). The burden of cancer is continuing to grow globally, placing substantial pressures on individuals, health systems and the broader social and economic wellbeing in almost every nation. However, the burden of cancer is experienced differently across the world. Global cancer data indicate that many cancer patients across the world cannot access even basic cancer services, while in many developed countries survival rates of many types of cancers have significantly improved (1).
A strong cancer care system cannot be achieved without a strong nursing workforce. Achieving a strong cancer nursing workforce requires that nurses contribute as leaders across all aspects of cancer control. The purpose of this paper is to review the current development and status of oncology nursing leadership and to recommend priority actions to transform cancer control efforts across the world.
The critical role of nurses in cancer control
The State of the world’s nursing 2020 report made a compelling case that nurses play a critical role in achieving the Sustainable Development Goals (2). In particular, the World Health Organization (WHO) report highlighted nurses’ major contributions are in areas including achieving universal health coverage, management of mental health and noncommunicable diseases, emergency preparedness and response, ensuring patient safety, and the delivery of integrated, people-centered care (2).
As a non-communicable disease associated with significant morbidity and mortality, nurses play an especially important role in the control of cancer. Nurses play an important role across the full care pathway for people affected by cancer (3). Despite the critical role that nurses play in cancer control, the significance of nurses’ contribution has not been clearly articulated in major policy documents to date. For example, amongst its key recommendations, a recent WHO report (4) identified that optimizing the workforce and access to reliable, sustainable medicines are fundamental components of an effective cancer system. While the role of nurses as part of the multidisciplinary workforce is noted in the WHO report, the specific contributions that nurses make to improving survival and quality of life of people at risk or affected by cancer is not considered in sufficient detail to inform health system leaders and policy makers of specific steps they need to take.
The critical role of nursing leadership in cancer control
The landmark Future of Nursing Report (5) concluded that strong nursing leadership is critical to addressing the challenges associated with providing health care. The key message of the Future of Nursing Report is: “the nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.”
While the Future of Nursing Report was published in the US, the report’s central arguments are relevant to nurses across the world and apply to global cancer care systems. Additional efforts to support development of nursing leaders and systems which support nursing leaders will be required to enable this goal to be achieved in cancer control.
A number of studies have attempted to define the critical elements of nursing leadership. One recent review of leadership competencies in advanced nursing practice (6) identified key domains of nursing leadership include:
- Clinical leadership (e.g., of the health care team, for evidence-based practice, to address organizational systems);
- Professional leadership (e.g., professional organization involvement; activities which advance the profession);
- Health systems leadership (e.g., in setting and achieving standards, quality, policy);
- Health policy leadership (e.g., to influence practice, health services and public policy).
These broad leadership domains are reflected in position statements and competency standards developed by major oncology nursing organizations across the world. For example, the US Oncology Nursing Society (ONS) Leadership Competencies include five domains including: personal mastery, vision, knowledge, interpersonal effectiveness, and systems thinking (7).
The European Oncology Nursing Society (EONS) Nursing Education Framework draws out similar competencies that should be developed in nursing curricula for cancer nurses. These EONS competencies are presented in Table 1.
Table 1
| Use appropriate leadership and management strategies in practice and evaluate the impact of these strategies upon people affected by cancer, other members of the healthcare team and development of practice and/or services |
| Practice in accordance with legal, ethical and professional principles in order to provide safe, effective, timely, cost-effective cancer care to people affected by cancer |
| Practice in accordance with national and local policies and standards to provide safe, effective, timely, cost-effective cancer care to people affected by cancer |
| Provide leadership in the contribution to implementation, evaluation of policies, and standards relevant to cancer care |
| Assess risk and implement appropriate risk management strategies in order to promote patient well-being and safety in practice |
| Demonstrate evidence of continuing professional development |
| Actively promote the professional development of cancer nurses working in other areas of the organisation |
| Demonstrate the ability to plan, allocate, coordinate and evaluate the use of evidence-based resources in an appropriate manner when providing care to people affected by cancer |
Source: EONS Cancer Nursing Education Framework. 2018. © European Oncology Nursing Society (EONS) 2018.
The Canadian Association of Nurses in Oncology (CANO) similarly asserts that oncology nurses require leadership competencies to ensure high quality, equitable, safe and accessible cancer care. Importantly, the CANO position statement emphasizes that leadership development is the responsibility not just of the individual nurse, but requires attention by health care organizations, education providers as well as professional nursing associations (8).
The evidence to support leadership in cancer nursing
There is a growing body of evidence which demonstrates the crucial role that nurse-led interventions have in cancer control. At the clinical level, one recent scoping review of 214 studies concluded that nursing interventions were delivered across the cancer continuum from prevention and risk reduction to survivorship and that these interventions included case management, surveillance, teaching, counselling, and guidance, and a variety of treatments and procedures (9). A related evidence review which reported on pooled meta-analyses identified the benefit for nurse-led interventions on measures of constipation, nausea and vomiting, fatigue, and psychological morbidity (anxiety, depression, mood) (10).
Evidence to support the impact of nursing leadership at the health systems and health policy level is also available. The International Society of Nurses in Cancer Care (ISNCC) (11) argues that as the global burden of cancer continues to grow, the failure to use nurses to address the challenges associated with cancer means that patients and health care systems will be compromised. As such, ISNCC’s mission is to lead the global nursing community to reduce the cancer burden. The Society’s vision is that nurses worldwide are vital and central leaders in cancer care and control and has articulated four major strategic directions for the Society:
- Build and strengthen the cancer nursing workforce across the world;
- Influence global health policy;
- Advance and apply knowledge; and
- Leverage partnerships with members and global citizens (11).
Consistent with the Society’s mission, ISNCC has led a number of significant projects in recent years which have demonstrated the impact of nursing leadership in cancer control. To name a few, these projects include advancing nursing leadership through the establishment of a Center of Excellence in tobacco control in Eastern Europe, developing nurses’ capabilities in cancer screening in Central and South America, and building nurses’ competencies to develop patient self management capabilities in cancer. ISNCC in collaboration with International Council of Nurses (ICN) also held a global policy leadership workshop in 2019 involving 22 nurses from 21 countries to develop their policy leadership skills. ISNCC has also developed policy guidance and provides practical advice and mentorship to build national cancer nursing organizations, and has supported the establishment of national organizations in recent years in countries including the Emirates and Ethiopia. ISNCC also has a unique network of “Global Citizens”, a large network of cancer nursing leaders from across the world who commit to working towards the Society’s mission.
Additionally, it is promising to see that major strides have been made in some low- and middle-income countries in recent years. In Africa, one report notes that 16 countries in the region had some level of education for oncology nurses. The African Organization for Research and Training in Cancer (AORTIC) Nursing Special Interest Group is also currently developing competency standards for oncology nursing (12).
Barriers to nursing leadership in cancer control
The 2020 State of the World’s nursing report highlighted the wide variation in density of nursing personnel to population, especially in Africa, South-East Asia, Eastern Mediterranean regions and Latin America (2). This lack of an adequate nursing workforce means that nurses will be limited in their capacity to influence quality cancer care. The nursing leadership gap is further reinforced by data which indicate that just over 50% of respondents had advanced nursing practice roles, only 71% had a national nursing leadership position in health policy, and only 53% had a national nursing leadership development program (2).
The recent impacts of the pandemic have further exacerbated the challenges faced by nurses to optimizing their influence. A recent ICN led report highlighted the impact of the pandemic on nurses’ stress, workload and infection risks. The report noted that demands made on nurses to cope and be resilient and the moral injury they experienced were significant (13). In the context of cancer care, this has meant that nurses have been redeployed to areas outside of the cancer system, which likely has significantly impacted the quality of cancer care.
At the health system level, societal perceptions of the nursing role also create barriers to nursing leadership. The Future of Nursing Report (5) cited data from a survey which highlighted that opinion leaders perceive patients and nurses as having the least amount of influence on health care reform. Importantly, the report noted that top barriers to nurses’ influence is that nurses are not perceived as important decision makers, that they have a focus on acute rather than preventive care, and that they don’t have a single voice on national issues. Failure to address these barriers will mean that nurses’ leadership contributions will continue to be comprised.
In the context of cancer, some authors have argued that universal health coverage alone is not sufficient to achieve optimal cancer outcomes (14). That is, because cancer care requires highly specialized knowledge and skills, the nursing workforce needs to have an adequate level of education and appropriate professional acknowledgement within the cancer care system. Challinor et al. (14) note that education programs to develop the specialized oncology nurse workforce are not universal.
Advancing nursing leadership
The Future of Nursing Report (5) highlights key areas where opinion leaders noted nursing leadership can influence improvements in health care included reducing medical errors, increasing quality of care, and promoting wellness. These opinion leaders also noted that nurses need to be leaders, make their voices heard and have higher expectations (5). Such foci are core requirements for nurses to lead improvements in cancer control.
Despite the potential for nurses, much more needs to be done. To advance nursing leadership in cancer control, the position statement developed by peak oncology nursing organizations across the world, including ISNCC (3), calls for government and non-government organizations to optimize the nursing resources to reduce the global burden of cancer. The position statement notes that urgent action is required to ensure the following essential requirements are in place to enable nurses to be leaders in the cancer control:
- Adequate education for nurses.
- Removal of regulations which act as barriers to nurses’ practice.
- Safe staffing levels.
- Safe work environments.
- Investment in innovative nurse-led models and practices.
- Greater nursing leadership in cancer control.
- Stronger partnerships between all involved in cancer control.
- Research to advance the evidence base for cancer nursing.
There is also a need for more data about the nursing workforce in cancer care to enable better cancer control planning. Given the inequitable distribution of resources in cancer control and nursing across the world, global collaboration will be required which enables training opportunities and partnerships across various public and private sector organizations (4).
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the Guest Editors (Margaret Fitch and Annie Young) for the series “Oncology Nursing” published in Annals of Palliative Medicine. The article has undergone external peer review.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1145/coif). The series “Oncology Nursing” was commissioned by the editorial office without any funding or sponsorship. The author has no other conflicts of interest to declare.
Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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