Philippines Cancer Control Plan: Nursing Priorities From Nursing Service Delivery Working Group of the Philippine National Childhood Cancer Control Workshop

As a designated focus country of the World Health Organization’s Global Initiative for Childhood Cancer, the Philippines has identified the nurse’s role as a key priority to optimize national cancer outcomes. Nursing care of adults, adolescents, and children with cancer requires specialized knowledge and skills. Nurses provide most direct patient care and are essential to achieving optimal cure rates and quality of life outcomes.1 Lessening the impact of cancer as one of the leading types of noncommunicable disease requires a comprehensive approach in reducing its risks, preventing, and controlling it—including detection, screening, treating disease, and providing access to palliative care.2 Cancer treatment and care are complex and tailored to both disease and age. This requires proficient nursing care in the administration of numerous disease-specific treatment protocols, monitoring for disease- and treatment-related side effects, infection prevention and control, supportive care and management of oncologic emergencies, while considering developmental and family-system factors.3 Health promotion is also vital as at least 42% of newly diagnosed adult cancers are potentially preventable.4 An essential component to improving cancer-related outcomes is a specialized workforce.5 However, in the Philippines, there is limited opportunity for specialized education and advanced roles for cancer nurses. Often nurses receive only introductory pediatric and adult oncology education in undergraduate nursing programs. Upon entering the workforce, a formal specialized orientation program in pediatric and adult oncology concepts and clinical skills is often lacking.6 Instead, nurses most often receive on-the-job training in chemotherapy preparation and administration and nursing management of the complex and vulnerable oncology patient. This contrasts with medical education, which provides a prolonged training period preceding independent practice. Oncology units in large referral centers may have a part-time oncology nurse educator responsible for ongoing education of nurses. To effectively build capacity for quality nursing care delivery of patients and families undergoing treatment for cancer, a targeted and systematic approach to cancer nursing specialization and education is proposed. With the growing number of diagnosed cancer cases each year in the Philippines, the current capacity of the medical workforce is not enough for a safe patient complement of 30 newly diagnosed patients per year for each hematologist-oncologist. An estimate showed that this complement may never be achieved based on the current number of pediatric oncology physician members of the Philippine Society of Pediatric Oncology (PSPO), along with projected additional members from the graduates of current fellowship training programs in the country.7 Therefore, rethinking the path forward to build workforce capacity is necessary. Advanced practice registered nurses (APRNs) have been shown to help augment the physician supply and support reform efforts aimed at expanding access to care. Furthermore, APRNs provide effective and high-quality patient care resulting in good patient outcomes.8 Moreover, the care and outcomes of patients managed by APRNs have been found to be equal to that of patients managed by physicians in a variety of healthcare settings, including primary care, intensive care, cardiology, neonatology, oncology, anesthesiology, and others. The Consensus Model for APRN Regulation defines an advanced practice registered nurse as a nurse who has completed graduate education; passed a national certification examination and maintained continued competence; acquired advanced clinical knowledge and skills; and, whose practice builds upon RN competencies. The APRN model is guided by the LACE regulation elements or licensure (authority to practice), accreditation (degree or certification programs in nursing), certification (achievement of professional standard), and education (graduate degree-granting or postgraduate certificate programs).9 Advanced practice registered nurses are thus one of the best options for increasing the Philippine workforce capacity to achieve comprehensive, safe, quality, and accessible cancer care.7,10 From August 4 to 5, 2017, national pediatric oncology nursing priorities were developed at the inaugural Philippines National Childhood Cancer Control Workshop in Angeles City, Pampanga. The priorities are also relevant to the adult oncology nurse practice setting, and include the following: Promotion of capacity building for quality cancer care and outcomes through enhanced opportunities for nurses’ professional development and specialization (e.g., certified oncology nurses, certified pediatric oncology nurses); Expansion of access to the number of competent cancer health providers through exploration of expanded scope of practice with advanced practice registered nurse (APRN) roles (e.g., nurse practitioner); Prevention and reduction of hospital acquired infections (e.g., through promotion of hand hygiene quality improvement initiatives, etc.); and Promotion of safe nurse working environments and protection against preventable occupational exposure to hazardous drugs (i.e., personal protective equipment for chemotherapy preparation and handling). Given that nursing is at the forefront of cancer care delivery, a focus must also be placed on cancer prevention across the lifespan through the development of health policies, best practices, and advanced practice nursing. Capacity Building Through Specialized Nursing Education and Professional Development In an effort to achieve optimal cancer patient outcomes, the incorporation of targeted pediatric and adult oncology nursing curricula at each point in a nurse’s education is recommended. Upon entry into practice, nurses should receive a formal orientation comprised of didactic and clinical skills specific to the patient population.11 Nursing competence should be verified before nurses caring for patients independently and assessed on a routine basis (e.g., annually and with practice changes).11,12 A dedicated nurse for oncology education will help promote best practices and quality care in the rapidly changing and complex oncology care environment.3,5 Opportunities for professional development through continuing education and oncology nursing certification will foster competence and expertise of the oncology workforce and contribute to improved patient outcomes.13 Furthermore, provision of federal funding to incentivize nursing specialization and professional development is needed. Expand Access to Qualified Cancer Health Care Providers Through the Advanced Practice Registered Nurse Role Presently there is a shortage of oncology physicians required to meet the increasing cancer burden. In pediatric oncology, the rate of pediatric oncologists entering the workforce does not adequately meet the patient demand. It is estimated this gap will only increase in the coming years due to retirement. Further compounding this growing burden is the increasing ability of developing nations to identify and diagnose the children who get cancer that currently never make it to diagnosis.14 At the same time, Filipino nurses are migrating to different countries seeking competitive wages and work. Some opt to shift careers outside of the nursing profession. A proposed solution to the anticipated population health crisis of physician-provider shortage, and abundant supply of nurses seeking employment, is the advanced practice registered nurse role. An advanced practice registered nurse (APRN) is a registered nurse who has attained graduate level education, passed a national certification exam and demonstrates ongoing competence, has obtained an APRN license, has clinical knowledge and skills at an advanced level, and whose practice expands upon foundational registered nurse competencies. APRNs are qualified to assess, diagnose, and manage health-related issues (including prescribing medications and diagnostic tests).9 Adoption of the APRN role would increase the number of qualified health care providers and access to cost-effective quality care across the care continuum within the Philippines. The APRN Consensus Model provides a framework for 4 APRN roles: Nurse practitioner, clinical nurse specialist, nurse midwife, and nurse anesthetist. Expanding the scope of practice of nurses through the APRN role will strengthen the Philippine health system through increasing access to quality health care at primary, secondary, and tertiary levels. This regulation impacts not only oncology, but the entire healthcare delivery system from rural health screening and promotion to complex acute disease management. Included in the APRN Consensus Model are 4 regulation elements: Licensure, accreditation (of degree or certification-granting programs), certification (based on professional standards), and education (completion of a graduate degree or postgraduate certificate program) (LACE).9 Within the Philippines, all education programs must align with the Philippine Qualification Framework (PQF). The PQF complements the LACE standards because it is a quality assured national system that aims to provide employers specific training standards and qualifications that are aligned to industry standards. Furthermore, it ensures that training and educational institutions adhere to specific standards and are accountable for achieving the same. Finally, the PQF supports the development and maintenance of pathways of equivalencies that enable access to qualifications to assist individuals to move easily and readily between different education and training sectors, between these sectors and the labor market, and encourages lifelong learning.15 Promote Safe Working Environments Cancer-directed therapy includes preparation, administration, and handling of hazardous drugs, placing the health professional at risk of exposure. Exposure to chemotherapeutic agents can result in risk for miscarriage, malformations in newborns of exposed pregnant mothers, and secondary cancers.16 It is imperative that health professionals caring for patients with cancer are provided adequate resources for protection against occupational exposure to hazardous drugs.5 Furthermore, facilities where hazardous drugs are prepared, administered, and disposed of should be mandated to meet minimum safety requirements to ensure minimal risk of occupational exposure. Personal protective equipment should be provided for all health care professionals working around hazardous drugs. Biosafety cabinets, closed system transfer devices, institutional policies and procedures, and adequate training of personnel is recommended.11,17 Nurses and other health workers should receive adequate compensation and annual testing for exposure while working in a hazardous environment. Where possible, a trained pharmacist or pharmacy technician is recommended to prepare chemotherapeutic and biotherapeutic medications.1,11 Infection Prevention and Control of the Immunosuppressed Patient A common side effect of cancer-directed treatment is immunosuppression. This places patients at high-risk for life-threatening infectious complications, which could lead to sepsis-related death. Measures to prevent and control infection are essential to cancer care delivery and reducing toxic death. Efforts to prevent and control infection should be integrated throughout the care continuum and practice settings. Quality improvement and educational campaigns are recommended, in addition to adequate resources for infection prevention and care. Hand hygiene campaigns are a vital initial step to preventing the spread of infection.18 In summary, the obvious gaps in specialized education and safe practice standards in oncology nursing care, as well as the competencies expected from graduate nurses to handle high-risk patients with sensitive treatment modalities presents an opportunity to strengthen and scale-up oncology specialization within the Philippines. Furthermore, development of the advanced practice registered nursing role offers a promising solution to the oncology health provider shortage guided by the PQF modeled through the LACE standards. To improve cancer outcomes in the Philippines, a concerted effort is underway to strengthen capacity of nursing specialization and best practices.