Understanding the Challenges of Providing Holistic Oncology Nursing Care in Nigeria.

This article describes the current state of cancer nursing and the various challenges that hinder the provision of effective nursing care to cancer patients in Nigeria. The major issue identified was the lack of specialized oncology nursing education which should actually form a basis for nurses to practice in the oncology setting. Other issues include poor facilities for oncology nursing care, lack of specific cancer centers resulting in the management of cancer patients in non-specialist wards. It is therefore recommended that solidified structure be put in place in order to establish and strengthen the nursing curriculum which has a strong potential for improving the knowledge and skills of nurses to care for people living with cancer in Nigeria.

Introduction

Cancer has been described as a major source of morbidity and mortality globally. It has become a threat to public health, especially in sub-Sahara Africa. According to the International Agency for Research on Cancer, about 715,000 new cancer cases and 542,000 cancer deaths occurred in Africa in 2008.[1] Moreover, this number is expected to double by 2030 due to the aging and growth of the population.[1] The burden of cancer has the potential to become even greater because of behavioral and lifestyle adoption associated with economic development such as unhealthy diets, smoking, and reduced physical activities.[2] Despite these projections and the growing burden, cancer has continued to receive low priority with regards to public health in Africa principally due to inadequate resources and competition from other public health problems.[3] The burden of cancer in Africa has also been complicated by the low awareness about the magnitude of the current and future cancer burden among policymakers, the general public, and international private or public organization.[3] Nigeria has not done enough to fight cancer as evident by the lack of adoption of national strategies that focus on research, improved awareness and provision of treatment centers. This situation also exists in other African countries such as Ghana.[4]

Nursing is an integral part of the health-care system and encompasses the promotion of health, prevention of illness, care of physically and mentally ill as well as the disabled across all age groups. An oncology nurse is a professional who specializes in caring for cancer patients undergoing or recovering from cancer treatments as well as people at risk of the diseases. According to Jenerette and Leak, oncology nurses most often care for patients who are admitted for oncologic or malignant hematologic disorders.[5] The role of the oncology nurse is expanding, especially in the developed countries. Experienced, professional oncology nurses contribute significantly to patients’ well-being and clinical outcomes, in addition to advancing the art and science of oncology nursing. Historically, in the United States of America, oncology nurses worked as data managers for cancer research studies[6] but as the treatment in oncology became increasingly complex, there was a pressing need for a collaborative relationship between the nurse and physicians to provide unique and comprehensive patient care.

The dramatic rise in cancer incidence in Nigeria is stretching the already limited resources and equipment. Shortage of qualified staff and equipment are growing constraints in treating cancer efficiently in Nigeria. The picture is, however, similar across major developing countries where insufficient funding in the healthcare delivery system is the order of the day.[7]

The Role of the Nurse in Cancer Care

The oncology nurse assumes many roles throughout a patients’ cancer experience. Although cancer patients may look to all other caregivers to address issues related to their conditions, nurses are usually involved in the patients’ care over the entire course of their illness. In lower- and middle-income countries (LMICs), a patient’s first encounter with the health system often is with a community health worker (CHW) at the dispensary (community) level; however, CHW and nurses’ knowledge of cancer and cancer risk factors, signs, and symptoms in many LMICs is low.[891011] Oncology nurses placed throughout the country could dramatically increase the number of cases diagnosed in early stages. In addition, oncology nurses can educate CHWs about cancer to raise awareness and appropriately refer a patient for further evaluation.[812] Thus, nurses can act more efficiently as patient navigators through the continuum of care to link the patient to local health systems and decrease delay in care.[1314]

Currently, nurses in cancer care in Nigeria do not have an expanded role due to limitations arising from lack of specialized education and training for nurses in cancer care unlike what is obtainable in most developed countries.[15] In countries where there are established specialization training for oncology nurse, the oncology nurse focuses on patients assessment, education, symptom management, and supportive care. In medical oncology, they play an integral role in the administration of chemotherapeutic agents and are responsible for safe handling of drugs, evaluation of laboratory data, calculation of drug dosages based on patients’ body surface area, insertion of intravenous line as well as assessing central venous devices, monitoring of adverse reaction and drug interaction and also participate in cancer research.[16]

Nurses in cancer care in Nigeria are equally expected to accomplish these roles. The extent to which they could accomplish these tasks is questionable based on the fact that majority of the nurses in cancer care learn on the job through experience, intuition, and doctors instructions as well as ad hoc training and conferences. Based on the current burden of cancer in Africa and in Nigeria specifically, there is an urgent need for role expansion of the Nigerian oncology nurse.

Cancer will continue to rise in the developing countries. Unlike the high-income countries where the ratio of incidence to mortality is approximately one-third, 80% of cancer cases in LMICs will die of their diseases.[17] The aggressive development of guidelines and call to action for cancer research, prevention, and control in the developing countries is a strong indication of awareness of current needs and future demands.[1819]

While nurses are eager to engage in cancer care, the personnel do not have specific training in cancer care and chemotherapy. Therefore, Nigerian nurses in cancer care need to be trained specifically in the care of cancer patients, safe handling of drugs, administration of chemotherapeutics and supportive care.[20]

Oncology nursing in the western countries has been transformed to tumor specific cancer nursing. For example, in England, the best practice guideline in cancer recommends that all cancer patients have access to a specialist nurse such as the tumor specific clinical nurse specialists.[21] This role has become pivotal in providing diverse and holistic care, meeting information needs, holistic nurse-led follow the care, symptoms control, managing care, and providing psychological and social intervention including referral to other advanced specialists. Globally, the increased demand for oncology services consequently encouraged the development of specialty in this area.[22] This in turn, led to the emergence of oncology nursing organizations, the need for a graduate course to include oncology in the curricula and to offer specialization, refreshers, and extension courses among others.

From this perspective, it is essential to reflect on the nursing practice in terms of its requirements for broad knowledge from scientific, technological and humanistic perspectives with regards to different care demands that cancer patients and their families experience throughout the illness process.

Caring for Cancer Patients by Nonspecialist Nurses and in Nononcology Wards

Cancer care in nononcology units is the usual practice in Nigeria and is obtainable in most tertiary health institutions. This situation is compounded by the few established cancer hospitals as compared to the increasing number of old and new cancer cases that require treatment. Although certain situations may warrant this, such as cases of co-morbidity, they require other specialists; thus, the role of the specialists cannot be over emphasized.

Considering the shortage of trained oncology nurses in Nigeria, nonspecialist oncology nurses are often ill-prepared to nurse the cancer patients. Interestingly, the findings of Botti et al.[23] in their qualitative study showed that the nonspecialized and inexperienced oncology nurses were the most vulnerable and most likely to become emotionally affected.

The acknowledgment of the complexity of the needs of individuals diagnosed with cancer and their families has led to an increased awareness of the need for especially trained and educated nurses.[24] Notwithstanding, many cancer patients are cared for by nonspecialist oncology nurses at all level of healthcare delivery in Nigeria.

The nature of healthcare today with increases in cancer cases and hospital admissions implies that much of care required will be provided by nonspecialist staff.[25] In Nigeria, nonspecialist nurses are the first nurses that cancer patients come in contact with and they play an important role in supporting the patients and including the provision of vital information. However, nonspecialist nurses are likely to have little or no training in area of cancer care and thus, may not be able to attend to the immediate needs of cancer patients and relatives.

A lot of attention has been paid to cancer care in the literature; most of these studies have focused on the experiences of oncology trained nurses and those working in specialist cancer units. There exists paucity in literature with regards to the experiences on nonspecialist nurses caring for cancer patients on nonspecialist units. This, therefore, raises a lot of concern because in practice, these nonspecialist nurses are the ones that provide the large proportion of the care to cancer patients.[2526]

A diagnosis of cancer is a significant life event that causes disruption to the lives of patients and their families.[27] Therefore, meeting the emotional and psychological needs of these patients becomes a compelling challenge to health professionals and particularly to those who are not specialists in oncology.[2526] This can also possibly have an impact on noncancer patients who are being treated on same units with cancer patients.

Building Capacity through Specialized Oncology Education in Nigeria

Training and specialization continue to be inconsistent in relation to the specific content related to cancer during nursing diploma, undergraduate, and postgraduate training in Nigeria. There is a gap between the technical and scientific preparation as well as the practice of specialized care. The importance of extending the qualification of health professionals should be strengthened considering the figures which show that out of the many accredited Schools and Colleges of Nursing in Nigeria, none offers specialized oncology nursing program. Although recently, the Federal Government of Nigeria proposed to establish schools for oncology nursing training, the political environment may pose a huge hindrance.[28]

The current curriculum prescribed by the nursing and midwifery council of Nigeria for basic and undergraduate nursing education contains very minimal aspects of oncology nursing; the scenario is even more worrying with regards to contents specifically geared toward the pediatric population affected by cancer. Thus, the acquisition of skills to care for this population is achieved by individual attempts and learning on the job. However, as a leading cause of death in adults and a significant cause of disease and treatment-related morbidity, concerted efforts need to be employed to build capacity required to tackle the scourge. Cancer is a major global health problem. With the aging population, the prevalence is expected to increase. There is an urgent need to develop programs designed to assist nurses develop expertise and in-depth understanding of the field of oncology nursing. These programs should produce oncology nurse who have cancer – specific knowledge base and clinical expertise in cancer care beyond what is acquired in the basic nursing program. However, it is essential to note and understand that the preparation at the diploma and baccalaureate degree level is basic and general and thus, does not make a nurse an expert in cancer care.

In all aspects of the fight against cancer, nurses participate dynamically as part of an interdisciplinary team. A well-prepared oncology nursing workforce includes generalist nurses who are prepared at the basic level and provide health promotion, risk assessment, and care for people who receive cancer treatment in their general practice; specialized nurses whose primary focus is the delivery of cancer care and who care mostly for people with or at risk for cancer; and advanced practice oncology nurses who provide cancer care at the master's degree level of education or higher.[17] Oncology nurses with master's and doctoral education contribute through advanced practice, education, and scientist roles. Additional education and training must be provided to support nurses gain requisite knowledge and clinical expertise to render the specialized care required by cancer patients, survivors, and families.

Role-specific trainings have been adopted by some developed countries. For example, in the US, chemotherapy administration requires a nurse to update their knowledge for this role.

Ethical Issues in Oncology Nursing

The oncology nurses encounter increasingly complex ethical challenges in clinical practice. In an ethnographic study conducted by Pavlish et al.[29] to explore oncology nurses’ description of ethical situations and factors that influence the development of ethically difficult situations in oncology nursing practice, findings showed that the nurses described preventing patients suffering and injury, being honest with patients and contributing meaningfully to patients’ improvement and stated goals as important situations that generated ethical concern to them. In this study, the challenges experienced by nurses in meeting their goals included being the eyes and arms of the patient, experiencing the precariousness of competing obligations, navigating the intricacies of hope and honesty, managing the urgency caused by waiting, straining to find the time and weighing risks of speaking up in a hierarchical structure.

This clearly defines the role of the oncology nurse as one filled with ethical considerations. Even the best input of the nurse could generate ethical issues with associated conflicts. Unresolved conflicts can cause feelings of frustration and powerlessness which could lead to compromises in patient care, job dissatisfaction, disagreement among those in the health-care team and burnout.[30]

Because most Nigerian oncology nurses are not trained specialist in the field, they are usually not deemed significant in decision making. Expansion of biomedical technologies and cost containment policies have the ethical concern and problems of the oncology nurse, yet nurse often are not included as major contributors in deliberations about solutions to these ethical problems.[31]

The nurses in cancer care are expected to demonstrate conflict resolution skills by taking actions to resolve conflict and develop innovative solutions to practice issues in partnership with the oncologist and other members of the interprofessional health-care team.

Conclusion

The menace of cancer in Nigeria has continued to be of great concern due to its destructive tendencies in family life and colossal amount of funds required for diagnosis and treatment. The rise in number of new cancer cases poses a huge burden on the already deficient health-care system in Nigeria. When the escalating incidence of cancer cases require concurrent therapies, targeted therapies, and advanced treatment technology, it becomes extremely imperative to make provisions for capacity building for advanced practice oncology nurses in Nigeria. This could be feasible by enhancing the oncology nurses’ education which will allow nurses to have greater contribution to cancer care in Nigeria.

Nigerian Oncology nurses need to take an active, participative role in developing prevention programs for cancer. The expected contribution of the Nigerian oncology nurses requires that they be well educated to think critically, analyze, reflect, apply problem-solving skills, and apply high-level knowledge and understanding that is based on evidence.

There is an overwhelming need for stakeholders to embrace and resolve the needs of nurses working in cancer care to better further the course of oncology nursing care in Nigeria. The leadership of Nigerian health care administration should foster actions directed at promoting the development of work environment as moral context, through systematic attention to conceptual, structural, process, and leadership issues that support collaboration, open communication and person-centered oncology nursing care in Nigeria.

Then, establishment of oncology nursing society in Nigeria, as well as oncology nursing forum, will create avenues that will facilitate and develop the active roles of nurses in cancer care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.