A Sustainable Model for Pediatric Oncology Nursing Education and Capacity Building in Latin American Hospitals: The Evolution and Impact of a Nurse Educator Network

Abstract

Through an “educate-the-educator” twinning model, pediatric oncology nurse educator roles and programs have been established at hospitals in Latin America since 2008. However, with increasing demand for nurse educator programs in the region, a twinning approach was no longer sustainable. Thus, a “nurse educator network” approach was established to scale adaptable, standardized multisite education and quality initiatives. The development, expansion, and impact of a sustainable network approach for pediatric oncology nursing capacity-building in Latin America is described. The educator network approach serves as a potential model for other geographical regions. COVID-19 impact and adaptations are addressed.

Children receiving cancer-directed services in countries with strong healthcare systems have 80% or greater chance of survival. However, in countries with developing health systems, survival may be as low as 10%¹. In Latin America and the Caribbean survival rates range from 37% to 80% and account for roughly 11% of annual global childhood cancer cases (~17,000 children, 0–14 years)^2,3. Contributing to the disparity in under-resourced and fragile health systems, low-and-middle income countries (LMIC) offer few accredited and subspecialty health education programs. Moreover, many existing education programs have failed to keep pace with modern health care needs and challenges⁴, as new medical knowledge is estimated to double every 5–8 years⁵. Given that numerous childhood cancers are curable with access to quality treatment centers and trained health professionals, international collaborations have been established to help strengthen service delivery in Latin American hospitals through subspecialty education and quality programs^6,7.

In many Latin American hospitals, nurses caring for children/adolescents with cancer have limited subspecialty education and training.^8,9. Since the 1990’s, twinning models (i.e., one-on-one partnerships between hospitals in high income countries [HIC] and LMIC) have been employed to meet the need for pediatric oncology nursing education in Latin America^10,11. Education models have largely included workshops, online seminars, international observer programs and in-country training centers^10–13. More recently, a sustainable educate-the-educator twinning model was established through a training center for pediatric oncology nurse educators in Santiago, Chile¹³. This model was successful for nearly 10 years. However, due to increasing program demand, the one-on-one twinning approach became unsustainable. Thus, a nurse educator network approach was established to facilitate the scaling-up of capacity building initiatives within hospitals across Latin America. Herein, the development, expansion and impact of a sustainable network approach for pediatric oncology nursing education in Latin America is described.

The Latin American Center for Pediatric Oncology Nursing Education

In 2007, the Latin American Center for Pediatric Oncology Nursing Education (the Center) was established at Hospital Dr. Luis Calvo Mackenna in Santiago, Chile, funded through a St. Jude Children’s Research Hospital international initiative. The purpose of the Center is to equip experienced pediatric oncology nurses with the knowledge and skills to develop subspecialty educator roles and programs, a role pioneered in Latin American hospitals through this program¹³. Center staff presently includes a director, pediatric oncology education supervisor and palliative care education supervisor. The Center’s onsite curriculum consists of 4 weeks (176 hours) of didactic and skills training in pediatric oncology nursing and educator competencies. A “partnered educate-the-educator twinning approach” was utilized where the Center and St. Jude Global nursing collaborated to support educators with implementing their programs. This one-on-one approach to mentoring was manageable during the program’s initial years in operation. However, with the expansion of St. Jude’s International Outreach Program into the Department of Global Pediatric Medicine, in 2015, demand for nurse educator training began to increase exponentially.

The Latin American Nurse Educator Network Approach

As the program grew, St. Jude Global nursing and Center staff determined the need to adopt a new approach that would sustain future program growth and development, while strengthening existing collaborative efforts. Thus, a “nurse educator network approach” was developed. The St. Jude Latin American Nurse Educator Network (LANEN) was established in 2015 and is comprised of active Center graduates from Mexico, Central and South America and the Caribbean. LANEN provides Center graduates with an online peer community, multi-layered mentorship and support to implement standardized multisite education and quality projects adapted to educators’ respective practice settings.

While new educators continue to be trained at the Center, the network approach deviates from the former educate-the-educator twinning approach as graduates return to their home institutions. In the former model, Center and St. Jude Global nursing staff met each month one-on-one with each educator, providing direct mentorship and support with program/project implementation. Through the network approach: 1) an additional layer of middle management was added to the program operational structure; 2) in addition to one-on-one meetings with direct mentors, active LANEN members participate in two monthly online network meetings to discuss collaborative projects and hone their educator skills through presentations; and 3) multisite education and quality improvement projects were designed and implemented across LANEN, which serves as a dissemination platform for collaborative projects. This contrasts a more individualized approach in the former model focusing primarily on education. Thus, the nurse educator network offers an expanded operational structure and collaborative approach to support ongoing growth of the network, conduct multisite implementation and improvement projects, while facilitating a community for pediatric oncology nurse educators across Latin America.

Network Structure and Governance

To support the nurse educator network, two regional LANEN nursing education coordinators were hired for Mexico and Central America/Caribbean. LANEN coordinators are experienced graduates of the Center with leadership and management experience and serve as the primary mentors and support for Center graduates in their regions. Each coordinator dedicates 8 hours per week and oversees 8 sites. Responsibilities include helping to identify regional needs and facilitating the development of new collaborative educational and quality programs. Coordinators also schedule and hold one-on-one educator meetings, receive and review quarterly activity reports and provide status reports to the Center and ultimately to St. Jude Global Nursing. Regional coordinators directly report to the Center director and receive support and mentorship from Center staff (education and palliative care supervisors); Center staff report directly to the St. Jude Global nursing project coordinator.

Center staff function as regional coordinators for 9 hospitals in South America and oversee daily Center operations and onsite training, LANEN coordinators’ educator activities and the network (Fig.). Additional responsibilities include providing ongoing education, training and mentoring through LANEN; supporting St. Jude Global Nursing in the oversight of multisite programs/projects; and coordinating virtual and in-person conferences and workshops. Strategic directions of the Center and LANEN are spearheaded by St. Jude Global nursing and Center staff in alignment with St. Jude Global regional and nursing strategic priorities.

Figure.

Latin American Nurse Educator Network model and operational structure

Network Community Engagement

Monthly online professional development sessions were initiated to support educators’ continuing education in pediatric oncology and educator skill development. Professional development sessions provide a safe space for educators to practice presenting educational topics with feedback from other network members. Topics are selected by Center staff and include oncologic emergencies, chemotherapy toxicity, oncological pathologies, evidence-based nursing practices and nursing research, among others.

Monthly online group meetings continue to be held with Center graduates, providing opportunity within the LANEN network to share experiences and progress in implementing the educator role and programs within their respective hospitals. Network meetings highlight individual educator’s orientation and continuing education programs and quality improvement projects. Members share barriers and challenges to implementing projects and serve as support and encouragement for one another, as a community of like-minded professionals.

In addition to online meetings, an annual in-person meeting is held with LANEN members at the Asociación de Hemato-Oncología Pediátrica de Centro América (AHOPCA) meeting. The meeting provides educators the opportunity to network and strengthen collaborative efforts. LANEN members are financially supported to attend the congress by St. Jude Global, and are invited to prepare an oral presentation about research, practice or educational projects for the nursing track of the congress. Center staff review and critique educators’ presentations, promoting their ongoing professional development and dissemination of scholarly work. Center and St. Jude Global nursing staff also support the local organizing committee in coordinating the nursing session.

Key Outcomes: Center Graduates and Network Members

Since 2008, 49 nurses from 32 hospitals in 15 countries have been trained at the Center. Twenty-two of these nurses graduated between 2017 and 2019 (primarily from Mexico and South America) and comprise 45% of total Center graduates. Upon program completion, 43 nurses (88%) representing 31 hospitals in 15 countries assumed educator roles. Of those, 18 (42%) assumed full-time and 25 (58%) assumed part-time educator responsibilities. Over time, some educators were promoted to other leadership positions requiring new educators to be trained. Presently, there are 32 active LANEN members from 27 hospitals in 14 countries that oversee the education of 1500 or more nurses at any given time.

Nurse Educator Core Functions & LANEN Initiatives

Prior to acceptance for nurse educator training at the Center, hospital administrators agree to create and support a dedicated nurse educator role and protected time for educating nurse staff, as outlined in the LANEN pediatric oncology nurse educator job responsibilities. Upon graduation from the Center, educators return to their institutions to assume their new full- or part-time pediatric oncology nurse educator roles. Core educator functions include development and implementation of 1) a pediatric oncology nursing orientation program, 2) a continuing education program, and 3) quality improvement projects within their institutions. Educators also contribute to evidence-based nursing practice guideline development and dissemination. Each educator reports their productivity through a quarterly activity report to LANEN leadership, which may also serve as a report to their local supervisor.

Tiered Orientation Program Project

Graduates from the Center receive standardized curriculum materials to create their orientation programs. Yet, through a program review in 2014, it became clear that educators required additional guidance and support in implementing these programs within their respective hospitals. Therefore, a tiered orientation program model for newly hired pediatric oncology nurses was developed to tailor program content according to the amount of protected time hospital administrators allotted for subspecialty orientation. St Jude Global nursing, Center staff and nurse educators held an initial meeting with administrators from each hospital to identify which “tier” was feasible to implement.

In the tiered model the theoretical and skills component addressing core pediatric oncology nursing content ranges from one to two weeks. Four tiers were developed with Tier 4 meeting the International Society of Pediatric Oncology (SIOP) Pediatric Oncology in Developing Countries (PODC) Baseline Nursing Standards. The standards recommend two weeks of theoretical/skills training followed by ≥ 3–4 weeks of mentored clinical observation and practice prior to providing independent patient care⁸ (Table). Topics not addressed in orientation are taught as continuing education.

TABLE.

Tiered pediatric oncology nursing orientation program model

	Program tier
Program duration	Tier 121	Tier 2	Tier 3	Tier 4*
Total orientation program	1 week	2 weeks	4 weeks	5–6 weeks
Component duration
Theoretical/skills competency component	1 week	1 week	2 weeks	2 weeks
Supervised clinical observation/practice component	0 weeks	1 week	2 weeks	3–4 weeks
Content** Theoretical/skills competency component	Didactic: Pediatric oncology overview; pediatric cancers; chemotherapy administration and side effect management; management of venous access devices (central and peripheral); infection prevention and control; blood product administration; oncologic emergencies, part I Skills validation: Venous access; chemotherapy administration	Tier 1 plus: Pain assessment and management; nutritional support; patient and family education; palliative/end of life care; psychological and social support of patients/families.	Tier 2 plus: Oncologic emergencies, part II	Tier 3

^*SIOP PODC Baseline Nursing Standard.

^**Table reflects main program content and is not comprehensive.

Key Outcomes: Tiered Orientation Program Project

Presently, 20 sites have implemented an orientation program and seven sites are developing programs. Of those, none had pediatric oncology orientation programs prior to implementing the nurse educator role. Before implementing the tiered structure in 2017, only five of 10 sites (50%) had protected time for orientation (n=10; mean=1.6; range=0–4 weeks). After implementing the tiered model, by 2019 13 sites established Tier Three (4 weeks) programs, six established Tier Two (2 weeks) and one established a Tier One (1 week) program (n=20; mean=3.25 weeks; range=1–4 weeks). Of the twelve hospitals with full-time educators, 92% (n=11) have established orientation programs, in contrast to only 53% (n=9) of the 15 sites with part-time educators. Thus, a full-time educator position is essential to facilitating successful program implementation and ensuring new nurses receive foundational orientation prior to caring for patients independently. Furthermore, a tiered orientation program model provides hospital administrators and educators with a standardized and graduated approach to achieve the SIOP PODC Baseline Nursing Standard for orientation.

Positive Patient Identification (PPID) Quality Improvement Project

Patient misidentification is associated with errors related to medications, transfusions, laboratory testing, wrong person procedures and discharge of infants to the wrong families¹⁴. A multisite nurse educator-led quality improvement (QI) project was designed based on the Joint Commission International Patient Safety Goal: Identify Patients Correctly¹⁵. The project is implemented across active LANEN sites. Project objectives include 1) standardizing patient identification processes within pediatric oncology services/units at LANEN educator hospitals, and 2) enhancing nurses’ PPID verification practices prior to delivering care (i.e., medication administration, specimen collection, blood transfusions and procedures) in LANEN hospitals.

Key Outcomes: PPID Multisite Quality Improvement Project

Between December 2014 and 2019, 25 institutions in 14 countries participated in the PPID quality improvement project. By December 2019, eight institutions had participated for one or more years, ten were completing their first year and seven institutions were in the planning phase. Of the eight institutions engaged for one or more years, the mean proportion of patients wearing identification armbands increased from 81.0% (n=325/401 observations) at baseline to 94.7% (n=428/452 observations) by the fifth project quarter. Nurses’ overall mean PPID verification practices increased from 29.1% (n=148/508 observations) to 70.6% (n=867/1228 observations). In one Central American pediatric oncology hospital, PPID was adopted as a hospital-wide quality indicator for continuous monitoring. These preliminary findings demonstrate the need for, and effectiveness of quality improvement initiatives focused on patient identification practices within participating LANEN hospitals.

Summary

Through an educator network approach, the future growth and development of LANEN is well-positioned for success. The Latin American Center for Pediatric Oncology Nursing Education and nurse educator role continue to meet a significant need for subspecialized education in Latin American hospitals. Transformation from a partnered educate-the-educator twinning approach to a nurse educator network approach has provided an operational structure to sustain future network expansion, facilitate and standardize adaptive multisite capacity-strengthening initiatives and foster a community of Latin American pediatric oncology nurse educators. As the network continues to grow, additional operational support is planned to sustain regional programs and new initiatives.

Broader International Application

This model may be adapted to other regions in need of pediatric oncology nursing education and such approaches have been adopted internationally. For example, the Association of Pediatric Hematology/Oncology Nurses (APHON) and St. Jude Global recently partnered to bring APHON’s chemotherapy/biotherapy provider and instructor courses to Latin America, establishing an instructor network, which included LANEN educators¹⁶. Additionally, through a working group of nurse leaders from 11 Eurasian countries, a regional train-the-trainer pediatric hematology/oncology nursing course is being implemented¹⁷. A pediatric oncology nursing education center in Pakistan provides courses for nurses from across the geographical region and supported a network of hospitals in Pakistan with implementing the SIOP PODC Baseline Nursing Standards¹⁸. Finally, an institute for pediatric oncology nurses in Asia Pacific was recently established in Singapore (modeled after the Latin American Center), which consists of an onsite intensive followed by ongoing mentorship of graduates with education and quality project implementation within their respective hospitals¹⁹. Partnered mentorship is provided by Institute members representing KK Women and Children’s Hospital, National University Hospital, VIVA Foundation and St. Jude Global. Thus, international partnerships, regional training centers and collaborative networks are successful models for building sustainable and impactful pediatric oncology nursing educational capacity in LMIC.

COVID-19 Impact and Adaptation

Latin America Center for Pediatric Oncology Nursing Education

Due to the COVID-19 pandemic, the education of new nurse educators at the Center was temporarily placed on hold. We have since adapted the program to a virtual format consisting of 100.5 hours of didactic/skills intensive over four weeks. Subsequent quarterly professional development sessions and progress report meetings with hospital leaders occur over one year. Professional development sessions are open to all LANEN members and focus on evidence-based practice, infection prevention and quality improvement, and self-care and burnout. In the future, an onsite intensive with virtual program graduates is planned.

Latin American Nurse Educator Network

COVID-19’s impact on LANEN members’ educator roles and responsibilities has varied. Some educators were asked by hospital administrators to temporarily assume frontline nursing responsibilities due to acute staffing shortages. Others remained dedicated to education and largely shifted their focus to COVID-19 preparation and precautions. Despite the pandemic, most LANEN members continued to participate in the monthly network, professional development and one-on-one meetings. Patient identification monitoring was interrupted at many sites due to the shift in hospital priorities to the pandemic. However, several months into COVID-19, educators began to re-engage in the quality improvement project. Lastly, the annual LANEN meeting at AHOPCA will be held virtually, attesting to community, comradery and resilience throughout these unprecedented times.

Abbreviations Full term

LMIC

Low-and-middle income countries

HIC

High-income countries

the Center

Latin American Center for Pediatric Oncology Nursing Education

LANEN

Latin American Nurse Educator Network

AHOPCA

Asociación de Hemato-Oncología Pediátrica de Centro América

SIOP

International Society of Pediatric Oncology

PODC

Pediatric Oncology in Developing Countries