INTRODUCTION—LINDA WATSON
Globally, cancer is increasingly affecting our societies, families and healthcare systems. It is estimated more than 14 million people are diagnosed annually, greater than 8 million people die of cancer each year, and there are more than 32 million people living with and beyond cancer around the world. Complicating these overwhelming statistics is the reality that many countries in the world do not have well developed cancer treatment programs; nor is it consistently recognized that specialized knowledge about cancer and caring for those with cancer is required by nurses.
CANO/ACIO has long held the vision of being a driving force nationally; but, importantly, we have also committed to being an influencing force internationally. To this end, a small working group of CANO/ACIO board members was created in 2014 to explore the potential role for the association within the international arena.
Our international interest led CANO/ACIO to host an International Symposium at the 2018 Annual Conference to highlight the work to date, discuss the guiding principles for our international work going forward, and explore how CANO/ACIO is currently engaging in the international arena. The symposium included two experiential cases that demonstrate how CANO/ACIO is actively influencing and advancing oncology nursing excellence internationally. In the first example, we heard from a CANO/ACIO member who, in collaboration with the Princess Margaret Hospital and the Aga Kahn University School of Nursing and Midwifery in Kenya, developed the first African-based oncology nursing diploma program. This program was built on the CANO/ACIO Standards for Oncology Nursing. The second case explored the mutually beneficial partnership between CANO/ACIO and the International Society for Geriatric Oncology (SIOG) to collaborate on filling the knowledge gap about how to best support older adults with cancer.
In this article, we will recap CANO/ACIO’s work to date on developing an international strategy, and explore how CANO/ACIO is actively influencing oncology nursing knowledge and expertise internationally. Although CANO/ACIO’s prime priority is still meeting the needs of its members in Canada, the organization believes it can improve the quality of cancer nursing at home and abroad by leveraging the existing CANO/ACIO work in a broader context.
DEVELOPING THE CANO/ACIO INTERNATIONAL STRATEGY—MARGARET FITCH
In 2014, CANO/ACIO established a work group to identify and define CANO/CIO’s role and framework for engaging in the international arena. This group developed a discussion paper, conducted an environmental scan of other international nursing organizations regarding their international strategies, and proceeded to draft an action-oriented framework. Two subsequent Roundtable Focus Group Discussions with CANO/ACIO members helped to shape and finalize the International Strategy and Framework, titled “Engagement, Exchange, Influence and Partnerships”.
In essence, CANO/ACIO sees that work is required both within and across borders in culturally sensitive ways to support the growth and development of oncology nursing. CANO/ACIO recognizes that nurses caring for cancer patients in many parts of the world do not have the benefit of access to specialized cancer nursing education nor specialty-related associations for support and, yet, they are facing an ever-growing population of cancer patients. In middle- and low-resource countries, almost three-quarters of the cancer population is diagnosed at an advanced stage and access to cancer treatment is very limited. In other words, the largest cancer burden is being felt by countries that are least prepared to respond to it effectively (Galassi, Challinor, et al., 2016a, 2016b).
Nurses have the potential to contribute in significant ways to cancer control. There are roles for nurses in prevention and public education, screening for disease, diagnosis, treatment and follow-up care. In particular, symptom management and patient/family education are roles nurses can undertake that will make a difference in the lives of cancer patients/survivors and their families around the world. However, to be effective, nurses need access to education and resources (So, Cummings, et al., 2016).
Not only are there important ways we can contribute beyond our borders, but there is also an opportunity for us to learn from those beyond our borders. Expertise in certain areas of cancer care has developed to a great extent in other nations. International collaborations provide the opportunity for us to incorporate that expertise into our work in Canada, and contribute to the further development of that expertise.
In thinking about CANO/ACIO’s international role, it is important to also think about the multicultural population within our Canadian borders. As a country, we have many ethnic and cultural communities, as well as populations facing disparities due to social determinants of health. Our efforts need to balance what is done beyond our borders with what is done within our borders.
The principles for engagement articulated within CANO/ACIO’s International Strategy include:
Mutually negotiated process of exchange
Social responsibility to articulate and build capacity
Actively understanding and identifying what other countries seek from CANO/ACIO
Forming partnerships
Building on opportunities that present themselves to strategically engage
Action-oriented framework applied in a phased-in approach.
The framework is depicted in Figure I and highlights the activities that are to be enacted with each phase of the work. The symposium at the 2018 conference was the first large-scale membership engagement in this work. Although the framework appears sequential and linear, the work outlined in the framework may not be, but will need to respond to the type/nature of opportunities that arise.
Figure 1.
CANO/ACIO Framework for a phased approach to international engagement, exchange, influence and partnerships
CANO/ACIO is most likely to be successful and effective within the international arena if it partners with other organizations such as the International Society of Nurses in Cancer Care, the Oncology Nursing Society, the European Oncology Nursing Society, and other national oncology nursing organizations (i.e., Australia) that are also actively engaged in international oncology nursing activities. Additionally, there may be opportunities to work collaboratively with organizations such as the Multinational Association of Supportive Care in Cancer (MASCC) and the International Psychosocial Oncology Society (through the Canadian Psychosocial Oncology Society) given we share similar goals for quality patient care. Such work can be synergistic and assist in initiatives within and beyond the borders of our country.
CASE STUDY: ONCOLOGY HIGHER DIPLOMA PROGRAM, KENYA—TAYREZ MUSHANI, PAMELA SAVAGE
Kenya, an East African country, is home to approximately 46.05 million people of which 45 percent are under the age of 15. Currently, the Kenyan health system is struggling to manage the rising burden of non-communicable diseases (African Health Observatory/World Health Organization, 2016) in the face of an underdeveloped healthcare system and a suboptimal health workforce. In 2013, Kenya reported two physicians and nine nurses per 10,000 individuals, far below the WHO recommendation of 44.5 physicians, nurses and midwives per 10,000 (2016). Additional challenges include the need to attract and retain nurses in specialized clinical areas, such as cancer care.
In response to this need, in 2013, Dr. Barry Rosen, a gynecologic oncologist, following a medical mission to Kenya, approached the nursing leadership at the Princess Margaret Cancer Centre (PM) to begin conversations on a philanthropic initiative to enhance oncology nursing capacity in Kenya through education. This conversation eventually led to a tri-institutional partnership between the PM, Moi Training and Referral Hospital (MTRH) and the Aga Khan University School of Nursing and Midwifery (AKUSONAM). MTRH, a public entity in Western Kenya which is funded by the Ministry of Health, runs a training school for various nursing specializations. AKUSONAM, a private entity, is part of the Aga Khan Development Network, a global non-governmental organization. The Aga Khan University has a School of Nursing and Midwifery in Nairobi. The PM and AKUSONAM jointly funded the partnership to collaboratively establish the oncology nursing diploma program.
The program mandate was based on the core principles of being standards based, meeting requirements set by the Nursing Council of Kenya, adapted to the East African context, and achievable within a realistic timeframe. Program outcomes had to be achievable, applicable with theoretical and clinical components, and sustainable in the long term.
Initial work on program development, framed on the medical model, commenced in 2013 under the MTRH oncology team. The tri-institutional partnership formulated in 2014 resulted in a program shift to a nursing model. In August 2014, development work on the Oncology Nursing Diploma progressed on the foundational components of the PM Nursing Orientation grounded in the CANO/ACIO Standards. A Canadian Oncology Nurse Educator based in Kenya was recruited to develop a joint curriculum for the two sites.
The final curriculum consisted of 16 modules, encompassing the cancer trajectory from diagnosis to rehabilitation. The module contents included, but were not limited to cancer biology, treatment, side effect management, adult and pediatric cancers, symptom management, community care, leadership, research, teaching and learning and palliative care. The program consisted of 50% theory and 50% clinical hours. Additionally, the curriculum covered all CANO/ACIO Standards, met the Nursing Council of Kenya requirements and identified specific graduate attributes aligned to those of AKUSONAM. Each site delivered the program over a period suited to local nursing population needs. The MTRH course, delivered over one year full-time, graduated seven students from the first class. The AKUSONAM course, a work-study program delivered over 18 months, two days per week, graduated 16 students from the first class.
The Canadian Oncology Nurse Educator divided her time between both sites. Content was developed, faculty were mentored in oncology practice, teaching and learning strategies, and exams were established. The Educator also worked with the Nursing Council of Kenya to develop an Oncology Syllabus, a template for other institutions aiming to develop an oncology nursing diploma program. The PM nursing leadership continually provided guidance and resource materials from abroad to support the Educator.
Key international partners further collectively supported the Diploma Program. The PM nursing leadership portfolio shared educational materials, and donated books and teaching mannequins. The Oncology Nursing Society donated books and the Oman Cancer Center sponsored faculty training in Muscat.
The CANO International Strategy identified roles in education, professional practice and research, and these were actualized through the development of the Kenya Oncology Nursing Diploma Program. The Program curriculum, founded on CANO/ACIO Standards, led to the recognition of oncology nursing as a specialization in Kenya. This work led to the development of an East African regional specific model of oncology nursing education for adaption in neighbouring countries. Finally, the Oncology Nurse Educator participated in grantfunded research to explore the beliefs of Kenyan women with particular cancers.
Reflecting on this experience, the authors shared prerequisites for international program development in oncology nursing education. Firstly, a standards-based customized nursing curriculum is crucial to ensure evidence-based nursing knowledge. The local presence of an oncology nurse expert or team of experts supported by an oncology centre such as PM ensures access to quality educational materials, updated relevant clinical content and peer support. Strong relationships with local and regional cancer care providers and nursing governing bodies ensures alignment of curriculum goals to the regional needs and context. Finally, mentorship of local and regional faculty for capacity building ensures long-term program sustainability.
CASE STUDY: STRENGTHENING THE NURSING CARE OF OLDER ADULTS WITH CANCER: AN INTERNATIONAL COLLABORATION—FAY J. STROHSCHEIN, MARTINE T.E. PUTS, CINDY KENIS, LORELEI NEWTON
In Canada, almost half of new cancer cases, and two-thirds of cancer deaths, occur among those aged 70 years and older (Canadian Cancer Society’s Advisory Committee on Cancer Statistics, 2017). Given that the number of older Canadians has doubled in the last 20 years, and is expected to double again within the next 20 (Statistics Canada, 2017), an increase of at least 40% in the number of new cancer cases over the next 15 years is expected (Canadian Partnership Against Cancer, 2017). Most of these will occur in older Canadians (Canadian Cancer Society’s Advisory Committee on Cancer Statistics, 2015).
Canada is not alone in these concerns. Population aging is mirrored in developed and developing nations worldwide (He, Goodkind, Kowal, & United States Census Bureau, 2016), with a corresponding impact on global patterns of cancer incidence (Global Burden of Disease Cancer, 2018). Internationally, researchers have identified important age-related disparities in survival (Coleman et al., 2011; Zeng et al., 2015) and treatment (Bojer & Roikjær, 2015; Fang et al., 2017; National Cancer Equality Initiative/Pharmaceutical Oncology Initiative, 2012). The Canadian Partnership Against Cancer is recognizing these concerns and has highlighted the importance of addressing the needs of older people with cancer in its strategy for Cancer Control for the next five years (Canadian Partnership Against Cancer, 2016).
Oncology nurses are uniquely positioned to identify and address the age-related concerns of older adults with cancer and their families. In 2015, a workshop was held at the Canadian Association of Nurses in Oncology/Association canadiennes des infirmières en oncologie (CANO/ACIO) Conference to explore the need and relevance of starting an Oncology and Aging Special Interest Group. Within this workshop, members discussed the age-related concerns that they saw in their practice, identifying issues related to ageism, suboptimal treatment outcomes, and ethical issues concerning treatment and care decisions (Strohschein & Newton, 2018). The concerns that participants expressed related to the age-related needs of their older patients, and the lack of resources to appropriately address these needs supported the development of this group.
Geriatric oncology is a small and growing, specialty in Canada, but is much further developed in Europe and the United States (Puts et al., 2017). The International Society of Geriatric Oncology (SIOG) is the foremost network of healthcare professionals and researchers striving to integrate understanding of geriatrics into oncology care. In 2017, Dr. Martine Puts, a member of the CANO/ACIO Oncology and Aging Special Interest Group and co-chair of the SIOG Nursing and Allied Health Interest Group, suggested collaboration between these two groups. There was an important fit between the mission and goals of the organizations, and of the special interest groups themselves). Both organizations focus on the development and advancement of healthcare professions and both interest groups strive to mobilize nurses to strengthening the care of older adults with cancer in clinical practice, research, education and policy. These shared objectives provided the opportunity to develop a partnership that assists each organization to meet its goals. In February 2018, a formal memorandum of understanding was signed.
The purpose of this international memorandum of understanding between CANO/ACIO and SIOG is to “increase collaboration, mutual recognition, and shared, culturally sensitive approaches to the work of both organizations” (CANO/ACIO & SIOG, 2018, p. 2). The partnership focuses on “educational, resource development, advocacy and research activities, as well as communication between the two organizations about strategies to develop and to promote optimal care of older people with cancer and those close to them” (CANO/ACIO & SIOG, 2018, p. 2). It also offers the opportunity for interdisciplinary and interprofessional collaboration and mentorship. To this end, CANO/ACIO and SIOG made the following commitments:
To work together to advocate for high quality care for older people at risk for/living with/or surviving cancer.
To work together to develop and promote geriatric oncology nursing as a sub-specialty.
To collaborate on the development of programs and/or resources for nurses, as well as for older people with cancer and those close to them. Programs/resources may include, for example, joint conference presentations or symposiums, joint position statements, clinical guidelines and practice tools, educational learning modules, or patient and caregiver information materials.
To exchange materials developed by both organizations. Materials may include, but are not limited to, position papers, educational resources, or other materials as agreed between the organizations. All publications and products developed as a result of this MoU [memorandum of understanding] will be co-branded and subject to relevant policies within CANO/ACIO and SIOG (e.g. Intellectual property policy). (CANO/ACIO & SIOG, 2018, p. 2)
This collaboration facilitated several joint projects in 2018, including a webinar, conference workshops and presentations, and a learning needs survey (Table 1). We are currently working to develop a joint international position statement concerning the role of nurses in optimizing the care of older adults with cancer and those close to them.
Table 1.
Overview of Organizations and Special Interest Groups
| Canadian Association of Nurses in Oncology/Association Canadienne des Infirmières en Oncologie (CANO/ACIO) (SIOG) Established in 1985 ~1100 members* “Mission to advance oncology nursing excellence through practice, education, research, and leadership for the benefit of all Canadians, and a vision of being an international nursing leader in cancer control.” (CANO/ACIO, 2017, ‘About Us’ section) Oncology and Aging Special Interest Group Established in 2015 ~100 members* Purpose is “to bring together nurses with a common interest in the care of older adults with cancer, engaging in activities to promote innovation in practice, research, education and policy development.” (CANO/ACIO & SIOG, 2018, p. 1) |
International Society of Geriatric Oncology Established in 2000 ~5000 members in 75 countries* Goal is to “foster the development of health professionals in the field of geriatric oncology, in order to optimize treatment of older adults with cancer.” (SIOG, 2015, ‘Mission & Vision’ section) Nursing and Allied Health Interest Group Established in 2014 ~50 members* Aims to promote “excellence in geriatric oncology nursing and allied health-related activities through the SIOG strategic directions: education and clinical practice, communication and advocacy, and research.” (CANO/ACIO & SIOG, 2018, p. 1) |
As of October 2018
In this collaboration, the mutual benefits have far outweighed any challenges (Table 2). Important facilitators of this collaboration have included common goals and objectives; ongoing support from the CANO/ACIO and SIOG boards, executives, and head offices; and members with joint involvement in both organizations. Collaboration at the level of special interest groups, a first for CANO/ACIO, has created a valuable synergy in the collaboration. Overall, this work has allowed us to draw on international resources to support CANO/ACIO members, while at the same time strengthening CANO/ACIO’s international voice.
Table 2.
Joint Projects
Webinar
|
Canadian Association of Nurses in Oncology/Association Canadienne des Infirmières en Oncologie (CANO/ACIO) Annual Conference 2018
|
International Society of Geriatric Oncology (SIOG) Annual Conference 2018
|
Online Learning Needs Survey
|
DISCUSSION/CONCLUDING REMARKS—MAURENE MCQUESTION
Following the two presentations that profiled different approaches to conducting international work, including 1) collaboration within a developing country using the CANO standards (i.e., Kenya), and 2) leveraging collaboration between CANO and an international association to develop resources that could be utilized both by CANO nurses and nurses working internationally (i.e., SIOG), input was sought from the symposium attendees. Feedback focused on the presentations and CANO’s current work related to improving the quality of cancer nursing at home and abroad through leveraging the existing CANO/ACIO work in a broader context. It was important to see if the work to date resonated with members and participants, and to garner input about the directions that CANO/ACIO should move within its involvement in international work. Questions to the audience included 1), what level of involvement should CANO/ACIO have regarding international activity (now, in future), and 2) what are the next steps for the organization regarding international efforts?
Participants supported that CANO/ACIO is moving in the right direction with the International strategy, but indicated there needs to be ongoing discussion. While there is a need to think within and beyond our borders, there is a different level of thoughtfulness and work required for these two diverse environments, as well as different levels of collaboration and sophistication. Different drivers and strategies would be required for each.
Ongoing work will focus on identifying the structures and supports that would enable CANO/ACIO to enact the international strategy. CANO/ACIO is committed to developing opportunities for members to be involved in international oncology nursing efforts, but further member input from those with an interest in this area is required. An important enabler to explore in this conversation is CANO/ACIO’s partnership with the International Society for Nurses in Cancer Care (ISNCC). This partnership may provide CANO/ACIO with direct opportunities to collaborate on international issues and to provide impactful solutions that do not duplicate the efforts of other oncology nursing associations.
ACKNOWLEDGEMENT
We would like to acknowledge the original group of CANO executives who led the development of the framework—Barb Fitzgerald, Tracy Truant, Shari Moura, and Margaret Fitch.
We would also like to acknowledge all the people involved in the collaborative work between Princess Margaret, Moi Training and Referral Hospital (MTRH) and the Aga Khan University School of Nursing and Midwifery (AKUSONAM) to develop an East African regional specific model of oncology nursing education based on CANO standards. In particular, the authors would like to acknowledge individuals who partnered with them to lay the foundation and vision for this program at its inception: Barbara Fitzgerald, former Director of Nursing at the Princess Margaret Cancer Centre, Dr. Doris Howell, RBC Oncology Nursing Chair, Dr. Yasmin Amarsi, former Dean of AKUSONAM, and Dr. Chite Asirwa, Moi University.
Finally, we would like to acknowledge the ongoing support offered by the board, executive, and administration of CANO/ACIO and SIOG in establishing a memorandum of understanding, and the CANO/ACIO Oncology and Aging Special Interest Group members and the SIOG Nursing and Allied Health Interest Group members whose hard work has made our joint initiatives possible.
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