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\begin{document}

\title{Current Status of Pediatric Oncology Nursing in Africa: Perspective of
African nurses of the International Society of Pediatric Oncology (SIOP
Africa)}



\author[1]{Glenn Afungchwi}%
\author[1]{Elianeth Kiteni}%
\author[1]{Mariam Ndagire}%
\author[1]{Biemba Maliti}%
\author[1]{Rachael Kunkel}%
\author[1]{Julia Challinor}%
\author[1]{Rachel Hollis}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\textbf{Authors:} G.M. Afungchwi\textsuperscript{1}, E.
Kiteni\textsuperscript{2}, M. Ndagire\textsuperscript{3}, B.
Maliti\textsuperscript{4}, R. Kunkel\textsuperscript{5}, J.
Challinor\textsuperscript{6}, R. Hollis\textsuperscript{7}

1 = Cameroon Baptist Convention Health Services, Bamenda, Cameroon

2 = Muhimbili National Hospital, Pediatric Oncology Unit, Tanzania

3 = Uganda Cancer Institute, Kampala, Uganda

4 = Zambia Cancer Diseases Hospital, Lusaka, Zambia

5 = Arkansas Children's Hospital, Arkansas, USA

6 = University of California San Francisco, San Francisco, California,
USA

7 = Leeds Children's Hospital, Leeds, UK

Address correspondences to Dr Glenn Mbah Afungchwi, Cameroon Baptist
Convention Health Services, Department of Pediatric Oncology, Bamenda,
Cameroon. Email: mbahlos@gmail.com Tel: (+237)675959629

\textbf{Current Status of Pediatric Oncology Nursing in Africa:
Perspective of African nurses of the International Society of Pediatric
Oncology (SIOP Africa)}

\textbf{Abstract (250 words)}

As African countries adopt the global goal of improving childhood cancer
survival to 60\% by the year 2030, intentional actions are required to
improve nursing. This paper provides the perspective and amplifies the
voice of African pediatric oncology nurses. It illuminates the room for
improvement and provides a reference point for future comparison. First,
we document findings from a survey of the perceived strengths and
weaknesses conducted in 2017. The main strength was the humanization of
care, while the major weakness was lack of training follow up and
insufficient evidence to guide practice. Next, we report on
nursing-related aspects of a survey to map pediatric oncology services
in Africa. Only 21\% of respondents in the mapping survey reported
having nurses who care for children with cancer at least 75\% of their
time. Many centres do not have allied health workers like dieticians,
play therapists, and psychologists. Furthermore, we share African
pediatric oncology nurses' research priorities identified in a 2019
survey. The top research priorities focused on professional practice and
psychosocial support. In a Delphi survey to identify topics for a
foundational curriculum for nurses new to pediatric oncology, 57 topics
areas were identified and grouped into 12 modules. Finally, we report a
single-question survey from 2022 to obtain the perspective of African
nurses about the state of pediatric oncology nursing across the
continent. The African nurses affirm their dedication to providing
compassionate care, however, noting their vulnerability to harm and
calling for certified training and better specialization recognition and
remuneration.

\textbf{Key words:} Nursing status, Africa, global initiative, childhood
cancer, pediatric oncology

\textbf{Learning points:}

\begin{enumerate}
\tightlist
\item
  The main strength of African pediatric oncology nurses is the
  humanization of care, while the major weakness is insufficient
  evidence to guide practice.
\item
  The priority areas for nursing research for pediatric oncology in
  Africa are professional practice and psychosocial support.
\item
  African pediatric oncology nurses require more training and
  certification that allows recognition of their status as specialized
  nurses.
\item
  African pediatric oncology nurses need more equipment and policies to
  guarantee their safety.
\item
  African pediatric oncology nurses are dedicated to providing
  compassionate care but are under recognized and inadequately
  remunerated.
\end{enumerate}

\textbf{Main text (3981 words)}

\textbf{Introduction}

In 2022, the International Society for Pediatric Oncology (SIOP) Africa
continental Congress provided the opportunity for pediatric oncology
nurses from across the region to meet for the first time since 2019.
This Congress has become an opportunity for the African pediatric
oncology nursing community to network, collaborate and present a shared
voice.

In 2020, the World Health Organisation (WHO), the International Council
of Nursing and Nursing NOW, published the first `State of the World's
Nursing Report' \textsuperscript{1}. This was followed in 2021 by the
World Health Assembly endorsement of the WHO `Global strategic
directions for Nursing and Midwifery', which focused on four policy
areas: nursing education, jobs, leadership and service delivery; all are
pertinent themes for pediatric oncology nurses across
Africa\textsuperscript{2}.

In 2018, the WHO announced the start of the Global Initiative for
Childhood Cancer to save more than one million lives and improve
survival to 60\% worldwide by 2030 \textsuperscript{3}. According to
Denburg and colleagues, ``National governments must be convinced of the
potential for foundational health system strengthening through attention
to childhood cancer care, and the presence and capability of networked
actors primed to amplify public sector investments and catalyze change
on the ground'' \textsuperscript{4}. The WHO Global Initiative for
Childhood Cancer currently includes three focus countries in the African
region: Ghana, Morocco, and Zambia, with Zimbabwe, Senegal and Cameroon
at earlier stages of inclusion \textsuperscript{5}. Ministries of Health
have engaged with WHO and local stakeholders, including non-governmental
organizations, parent groups, and hospitals providing childhood cancer
care, to perform situational analyses and create strategic plans for
strengthening early diagnosis, access to care, sustainable essential
medication supply and improved survivorship. None of these goals is
possible without competent and reasonably resourced nursing care and a
sustainable nursing workforce \textsuperscript{6}.

In July 2019, the African Union held a cancer symposium with the
Organization of African First Ladies for Development (OAFLAD) in Niger
to bring awareness to the increasing cancer burden on the continent and
the need for advocacy, financing, and resource development (including
workforce resources) at an international, regional and local
level\textsuperscript{7}. African nurses are critical partners in this
effort since they are the single largest workforce, have deep community
ties, and, when specialized, have the knowledge and skills to provide
the care required for patients with cancer in their region, including
children and adolescents. Nursing oncology specialization was supported
by a call in 2017, when the WHO passed resolution 70.12, ''Cancer
prevention and control in the context of an integrated approach,''
recognizing cancer as a ''\ldots{}growing public health concern'' and
urging member states to ''\ldots{}facilitate cross-sectoral cooperation
between health professionals, as well as the training of personnel at
all levels of health systems\ldots{}'' (p. 4) among other cancer control
measures\textsuperscript{8}.

This paper is the first to bring the voice of frontline pediatric
oncology nurses in Africa to the global movement to improve children's
cancer care. We begin with African pediatric oncology nurse strengths
and challenges as documented at the 12th SIOP Africa Congress in 2017.
The results of a SIOP Africa mapping exercise data that documented
childhood cancer services, including nursing workforce and nursing
practice-related data are described. Next, we share pediatric oncology
nurse research priorities identified at the 13\textsuperscript{th} SIOP
Africa Congress in 2019 and the start of a nursing initiative to create
a foundational curriculum for nurses new to pediatric oncology on the
continent. Finally, the findings of a survey question to all nurse
attendees at the 14\textsuperscript{th} SIOP Africa Congress in 2022 are
described.

\textbf{Methodology}

In March 2017, a workshop at the 12\textsuperscript{th} Annual SIOP
Africa Congress in Marrakech, Morocco, convened 50 nurses from
Francophone and Anglophone Africa (see Figure 1) to identify the
strengths and weaknesses of the pediatric oncology nursing workforce in
their settings, guided by a projected slide with a table of
Strengths/Weaknesses/Opportunities/Threats (SWOT) in English and French
for analysis \textsuperscript{9}. Time constraints precluded completion
of the exercise, so opportunities and threats were not documented. Two
bilingual moderators led the discussion as the nurses' oral answers were
documented on a flip board for the audience to consider. Suggestions
supported by \textgreater{}80\% of participants were documented.

In 2018, SIOP conducted a mapping exercise by an online survey to
identify global childhood cancer services, beginning in
Africa\textsuperscript{10}\textbackslash{}sout. The only nurse-specific
data was the number of nurses working 75\% of their time in pediatric
oncology units. However, to demonstrate the burden of care for these
nurses, data on allied health professional support available, including
psychologist/psychiatrist, dietician/nutritionist, physiotherapist,
social workers, pharmacist, and palliative care teams were also
extracted from survey responses. Additionally, data regarding
spiritual/religious, volunteer and patient/family support groups were
extracted, and the presence of dedicated pediatric oncology units and
access to pediatric intensive care units.

In March 2019, at the 13\textsuperscript{th}~SIOP Africa Congress in
Cairo, Egypt, 30 nurses from Egypt, Tanzania, Morocco, Uganda and
Cameroon participated in a two-day workshop to identify research
priorities for pediatric oncology nurses~in Africa. Participants formed
small groups~and~submitted research questions to share with the larger
group. Submissions were collected, collated and duplicates
removed.~Responses were thematically coded using ATLAS. ti version 8.
Themes were grouped first by research priorities and second by the
target population.

During the same meeting in Cairo, the nurse attendees initiated a
project to identify the educational priorities of sub-Saharan nurses
caring for children/adolescents with cancer. Following the Congress, an
online Delphi Survey in English and French using REDCap was distributed
to a convenience sample of nurses from sub-Saharan Africa with
experience of at least one year caring for children with
cancer\textsuperscript{11}. The sample was recruited with a snowball
methodology using existing networks of childhood cancer nurses in both
Anglophone and Francophone Africa, as well as an extensive WhatsApp
group of 172 members. In the first round, participants were asked to
identify a minimum of 10 and a maximum of 20 topic areas for inclusion
in a 'foundation' level programme for pediatric oncology nurses. In the
second round, participants were asked to rate the importance of each
topic identified on a five-point Likert scale with the aim of 80\%
consensus on the topics to be addressed. In round three, participants
were presented with a proposed outline framework of a nursing curriculum
and asked to express agreement with the wording and grouping of topics
into modules to develop an outline curriculum framework.

In 2022, at the 14\textsuperscript{th} SIOP Africa Congress in Kampala,
Uganda, approximately 50 nurses gathered once again from Francophone and
Anglophone countries. The nurses were asked to write one sentence in
English about their priority for pediatric oncology nursing in Africa
using an anonymous google form. Comments were collected on a google
form, and inductive thematic analysis was conducted using ATLAS.ti 9.

\textbf{RESULTS}

\textbf{SIOP Africa 2017: Strengths and weaknesses of pediatric oncology
nursing in Africa}

At the 2017 SIOP Africa Congress, the pediatric oncology nurses
identified the humanization of care ``making the patients feel welcome
when arriving and staying at the hospital for childhood cancer
treatment'' as a strength. The nurses mentioned being close to their
patients and sharing their patients' emotions and feelings during their
treatment period. They said they focus on delivering safe care with the
patience and courage to face a challenging patient population. Next, the
nurses mentioned their strengths in pain assessment and control while
caring for children and adolescents with cancer, using validated
assessment tools. The nurses believed they were strong in explaining
cancer care and treatment to their patients and families. Finally, they
mentioned their competence and mastery of nursing practice (professional
competency) for this patient population, as well as their desire to
improve.

The nurses mentioned that pediatric oncology nurses in their settings in
Africa were weak in re-evaluating nursing training, e.g., three months
after training, to determine if there had been any impact on patient
care. Participants believed that reassessing practice after beginning
work with children and adolescents with cancer was essential for
providing high-quality nursing care. Second, the nurses stated they were
weak in knowledge and skills to conduct research and submit manuscripts
for publishing. They further noted a severe lack of evidence about
nursing practice in their various settings across Africa. Poor
documentation of nursing actions was also identified as a weakness. The
nurses believed this impacted patient care and was an issue that needed
to be addressed across Africa. Participants all stated that the shortage
of trained nursing staff was a major cause of their weaknesses. A final
weakness identified in this workshop was the lack of knowledge and
skills to conduct research and submit manuscripts for publishing.

\textbf{2018 SIOP Global Mapping Africa}

In the initial effort of the SIOP Global Mapping Programme
survey\textsuperscript{10}, a total of 109 responses were received from
facilities across 46 African countries. Information about facilities'
physical infrastructure for pediatric oncology is detailed in Table 1.
Only nine responses were from nurses (8.3\%); the rest were primarily
from physicians: heads of division (43.5\%), consultants (41.7\%), and
junior faculty (2.8\%). There was one survey question about how many
nurses care for children with cancer at least 75\% of their time.
Twenty-three participants (21\%) reported that they had no nurse who
cared for children with cancer \textgreater{}75\% of the time at their
centres, 30 (28\%) had 1-5 nurses who did so, 20 (18\%) had 6 -- 10, and
6 (5\%) had 11 -- 15. Ten (9\%) had 16 -- 20 nurses caring for children
\textgreater{}75\% of the time, while seven (6\%) had \textgreater{}20
nurses who do so. For every unit increase in the number of beds, there
was a 10\% reduction in the number of nurses working for more than 75\%
of their time in pediatric oncology. This was, however, not
statistically significant (p = 0.313).

Greater than two-thirds (66\%) of the facilities had a
dietician/nutritionist, physiotherapist, social worker, or pharmacist.
Approximately half (53\%) had volunteers, a palliative care team, a
psychologist, spiritual/religious support, and patient support groups.
One-third or less (28\%) had a play therapist/child life specialist,
bereavement counsellor or schoolteacher (see Table 2). However, the
survey did not ask if these professionals were dedicated only to caring
for children with cancer.

\textbf{SIOP Africa 2019: Research priorities for pediatric oncology
nursing in Africa}

The nurse participants at SIOP Africa 2019 in Cairo, Egypt,
submitted~54~research~questions; 46 were retained once duplicates had
been removed. Eight main themes for research were identified, with the
two most common being professional practice and counselling and
psychosocial support (Fig. 1). The principal research population
priority was nurses, alongside parents and children (Fig. 2).

\textbf{Post-SIOP African Conference 2019: Educational priorities for
nurses new to pediatric oncology nursing in Africa}

Following the 2029 SIOP Africa Congress, 46 nurses from pediatric
oncology facilities in across sub-Saharan Africa (Figure 3) participated
in a Delphi survey to determine educational priorities for an education
programme for nurses new to pediatric oncology.

Fifty-seven topic areas were identified in Round One of the survey with
the most common five including a general introduction to cancer and
treatment modalities, chemotherapy administration and side effects,
tumour lysis syndrome, palliative care, and infection prevention and
control. Two further rounds were carried out, and a consensus was
achieved on a modular curriculum framework with 12 core modules
encompassing the identified topic areas (Table 3).

\textbf{SIOP Africa Congress, Kampala, Uganda 2022: pediatric oncology
nursing in Africa}

Forty-five participants responded to the survey distributed during the
2022 SIOP Africa Congress, providing one sentence each giving their
perspective on pediatric oncology nursing in Africa. Four major themes
were identified including the general nature of pediatric oncology
nursing and nurses in Africa; training and certification; contribution
to improved survival; and need for more recognition and support.

\emph{Theme 1} : General nature of pediatric oncology nursing and nurses
in Africa

Pediatric oncology nursing was defined as a practice that provides
professional holistic care as one participant put it:

Participant 23: ``\emph{Pediatric Oncology Nursing is a specialized
discipline that requires knowledge about pediatric oncology care,
passionate, empathetic, loving, caring and hard working. It entails
holistic care, including psychosocial, emotional, physical, and
spiritual. The Nurse must do their best and hope for the best. All in
all, it is not ordinary nursing, so both the Nurse and the patient
require psychological care.''}

The nurses reported a high level of commitment and motivation to meeting
the care needs of their patients.

Participant 26: ``\emph{The most dedicated and caring people full of
compassion for the little souls in their hands.''}Participant 29:
\emph{``They are determined to serve despite limited resources.''}

However, the nurses lament their vulnerability to harm and
discouragement in their practice and advocate for more attention to
their needs.

Participant 7: \emph{''We are giving it our all and never giving up on
our kids; thus, we need all the support out there for the
job.''}Participant 32: \emph{''Nurses in Africa will love to see more
protective wear/equipment that can be used during chemotherapy to help
protect them from too much exposure.''}

\emph{Theme 2} : Training and certification

The nurses acknowledge the availability of trained colleagues

Participant 45: \emph{''We have qualified and competent pediatric
oncology nurses in Africa.''}

They, however, express the need for more specialized training with
certification for better outcomes.

Participant 36: \emph{``To build the capacity of specialists in
pediatric oncology nursing in Africa so as to improve the cure rates for
children with cancer.''}Participant 1: \emph{``Pediatric oncology nurses
need training and certification so that they can be recognized
worldwide.''}

\emph{Theme 3} : Contribution to improved survival

The nurses believe that despite the limited resources for care at their
disposal, they have contributed significantly to saving the lives of
children with cancer and are to be relied upon for better survival. They
also mention their essential role in palliative care.

Participant 4: \emph{``African nurses are the driving force for
pediatric oncology in Africa. Investing in nurses will help Africa
quickly reach the 60\% by 2030 (GICC).''}Participant 18: \emph{``All
pediatric oncology nurses should be introduced to pediatric palliative
care because it makes a whole positive difference for the patients and
their families.''}

\emph{Theme 4} : Need for more recognition and support

The nurses feel that they are not adequately remunerated and call for
more recognition of their services and resources to support training and
education. Participant 11: \emph{``Pediatric oncology nursing in Africa
is emotionally draining; therefore, the nurses committed to work in this
department need incentives to encourage them to keep at
it.''}Participant 34: \emph{''Africa nurses need the training in
pediatric oncology nursing to better give quality nursing care. They
also need to be members of organizations like SIOP, so they are updated
regularly on new things. SIOP needs to have a deliberate policy where
membership from Africa is exempted from paying membership fees so that
they do not pull out. African countries need financial help to be
conducting orientation to new nurses in pediatric oncology so as to meet
the baseline standards.''}

\textbf{Discussion:}

The WHO GICC is building momentum within the speciality of pediatric
oncology nursing. This paper provides the perspective and amplifies the
voice of African pediatric oncology nurses and their advocacy to
prioritize services for children with cancer at national, regional and
international levels.

The most fundamental and essential concepts in pediatric oncology
nursing are compassion and compassionate care. Pehlivan and G\selectlanguage{ngerman}üner argue
that ``compassionate behaviour requires understanding others' value,
establishing a relationship with them, and responding in a way that is
meaningful for that person'' \textsuperscript{12}. A patient, parent and
healthcare provider empirical model demonstrates four key domains in
pediatric oncology compassion care (beneficence, human relating, seeking
to understand, and attending to needs) \textsuperscript{13}. The four
domains align with those which nurses described as their strengths
during the 2017 SIOP Africa Congress (humanization of care for children,
empathy for the patients during their treatment period, pain assessment
and control using validated tools and good communication skills) despite
the challenges they face in their hospital settings. Sedaghati et al.
further report that the majority of oncology nurses have positive
attitudes towards empathic behaviour with cancer
patients\textsuperscript{14}.

Educational opportunities such as Project ECHO Seminars for nurses in
sub-Saharan Africa, and nurse training activities within the Francophone
Africa Pediatric Oncology Group (GFAOP) and the Collaborative Network
for Childhood Cancer Care and Research (CANCaRe Africa) have enhanced
access to expertise in the care of children with cancer and contributed
to enhancing pediatric oncology nurses' knowledge and skills in
Africa\textsuperscript{15--17}. Good communication skills during cancer
care and treatment are an important aspect of nursing children and
adolescents with cancer and their families; the nurses believed this was
also their strong point. For example, Graetz et al. found that ``nurses,
rather than psychosocial providers, provide most of the counselling and
are available to clarify information discussed by the physician'' (p. 4)
in Uganda \textsuperscript{18}.

In many settings, nurses take on roles otherwise undertaken by allied
health and social care professionals. The SIOP Global Mapping Programme
survey of childhood cancer services in Africa provided the first 'bird's
eye view' of where services exist and pediatric oncology nurses
practice, often in highly challenging circumstances with limited
resources \textsuperscript{10}. The data provided by nurses themselves
were limited, echoing the general paucity of publications on the
experiences and aspirations of African pediatric oncology nurses. This
is compounded by barriers including limited access to training and
education, lack of professional resources and the hurdles faced through
publication. This is further evidenced by a literature review of
pediatric oncology nursing research in LMICs 2008 -- 2018, which found
only six publications from Africa \textsuperscript{19}.

Results of the global mapping survey demonstrated marked disparities
between countries on the continent, where some have highly specialized
services while others have none \textsuperscript{10}. For pediatric
oncology nurses to deliver quality nursing care to their patients, they
require systems and programs developed to support this. However, more
than 74.6\% of the centres across Africa had only basic services with
very few state-of-the-art services. Sirohi et al. note ``Initiatives are
being undertaken in LMICs {[}low- and middle-income countries{]} to
deliver optimal cancer care by developing cancer centres, but many of
these initiatives are currently fragmented and uncoordinated. The
challenges of quality, value, affordability, and equality that cancer
centres in HICs {[}high-income countries{]} face are multiplied in
LMICs.''\textsuperscript{20}. To improve pediatric cancer outcomes,
there is the need to strengthen training and diagnostic capacities,
develop cancer registries and establish research
databases\textsuperscript{21}.

Despite the limited exposure to and participation in research, nurses
participating in the 2019 13\textsuperscript{th} SIOP Africa Congress
research priorities exercise showed a desire to base their nursing
practice on evidence. In order to build that evidence base, nurses
required further training,~mentoring and funding to engage in research
and generate appropriate evidence for practice in consideration of
local, resource-limited practice environments. From the identified
thematic areas, the two commonest research areas identified were issues
surrounding professional practice and counselling/psychosocial support
for patients and families. Pediatric oncology nursing practice is
culturally and context-driven and requires locally acquired evidence to
support best practices \textsuperscript{25}. African nurses have a key
role to play in current and future clinical trials, as evidenced in
HICs\textsuperscript{26}, but will require capacity building to be able
to do so \textsuperscript{27}. Access to research training, availability
of funding and protected time are key steps to guide and motivate
clinical nurses as well as academic nurses to participate in
research\textsuperscript{25}.

The SIOP baseline nursing standards recommend that pediatric oncology
nurses should not rotate in other service units \textsuperscript{24}.
However, from the African mapping survey, only 23\% of facilities had
fixed nurse staffing in pediatric oncology units. The rotation of
experienced pediatric oncology nurses away from oncology units means
taking away the expertise, knowledge and experience which is integral to
successful mentorship and quality care. Rotation, therefore, compromises
the quality of care given to pediatric oncology patients and can also be
stressful for the nurses. The nature of cancer and the treatment process
itself often leaves the children quite ill, requiring critical care in
intensive care units (ICU). About 38.0\% of the African facilities had
no pediatric ICU available; unfortunately, the few facilities with an
ICU had limited equipment and personnel with pediatric oncology
experience. Only one-fifth of the facilities had a pediatric intensive
care unit with all necessary equipment and personnel with pediatric
intensive care expertise. According to Zinter et al., ``up to 38\% of
children with cancer require pediatric intensive care unit (PICU)
admission within three years of a cancer diagnosis, {[}even in HIC,{]}
with reported PICU mortality of 13-27\% far exceeding that of the
general PICU population'' (p. 1536) \textsuperscript{28}. The lack of
ICU services or specialized staff across Africa may explain the causes
of some preventable deaths among children with cancer.

Competencies are fundamental to quality nursing practice and involve the
application of critical thinking, knowledge, technical, and
interpersonal skills demonstrated in the actual performance of skills in
a defined context \textsuperscript{29}. The need for competent pediatric
oncology nurses is one aspect of care that is universally acknowledged
as essential to all such strategies \textsuperscript{24}. The
development of training programmes for specialization in pediatric
oncology nursing on the African continent cannot be overemphasized in
order to have competent specialists with better outcomes to care as was
reinforced in the recent Lancet Oncology Commission on cancer in
sub-Saharan Africa \textsuperscript{30}. Having sufficient theoretical,
and clinical experience and attitude can be significant in improving the
morale of the nurses \textsuperscript{31}. The 2019 Delphi survey
following the 2019 SIOP Congress in Cairo, Egypt, further underscores
the importance of training as revealed by general consensus on priority
areas of education vital for nurses new to pediatric oncology nursing
that was condensed into a 12-module curriculum framework. This framework
was piloted in Ghana in November 2021 and lead facilitators were trained
in Malawi, in March 2022.

A good rapport between the Nurse and family enhances the Nurse's ability
to tailor their care to each individual child and helps the Nurse to
know what small things they could do for the child that would make a big
difference \textsuperscript{32}. During the 2022 SIOP Africa Congress in
Kampala, Uganda, a survey regarding impressions of nurses about
pediatric oncology nursing in Africa demonstrated the holistic nature of
nursing care for children with cancer and high level of commitment and
motivation from nurses to meeting the care needs of their patients.
Nukpezah et al. stated that ``\ldots{}pediatric oncology nurses mustn't
become task orientated\ldots{} and lose sight of the holistic and human
aspects of pediatric oncology nursing caring practice'' (p.
7)\textsuperscript{31}.

Successful and effective pediatric cancer care and treatment requires
quality care delivered by skilled professional Nurses. Professional
requirements include not only specialization but psychological support
and motivation to uphold an unwavering commitment to meeting the needs
children with cancer and their families, and thereby contributing
positively to better survival as espoused in the WHO
\emph{CureALL}framework of the GICC initiative \textsuperscript{33}. The
need for the expansion of educational programmes, the development of
evidence-based practices for health promotion and well-being as well as
guidance to enhance and standardize the nursing care of children with
cancer have been recognized as key initiatives for improving pediatric
oncology nursing \textsuperscript{34}. The requirement for specialized
training with certification was echoed again by SIOP Africa nurses to
improve the numbers of available qualified and competent pediatric
oncology nurses. However, the high demands of pediatric oncology nursing
in resource-limited settings are not appropriately recognized and
remunerated. This can be improved by encouraging membership to the
relevant professional bodies such as SIOP that engender growth and
development in clinical, educational, leadership and research areas that
have already been alluded to as requiring investment and growth.

This paper has presented published and unpublished evidence from data
gathered over the last five years through a range of activities led by
African pediatric oncology nurses themselves. The work provides a
baseline of the current situation, articulates professional priorities,
and sets goals for moving forward to strengthen pediatric oncology
nursing development and improve the care of children/adolescents with
cancer and their families in Africa.

\textbf{Acknowledgements:}

All nurses of SIOP Africa

\textbf{Declaration of interest statement:}

The authors have no conflicts of interest to declare.

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Table 1: Details of 109 pediatric oncology facilities reporting on the
SIOP Global Mapping Project survey from 46 African countries.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{What type of dedicated pediatric oncology programme does your
hospital have?} &\tabularnewline
\midrule
\endhead
Pilot projects & 10.1\%\tabularnewline
Some basic oncology & 24.2\%\tabularnewline
Established oncology programme with most basic services and a few
state-of-the-art services & 40.4\%\tabularnewline
Pediatric oncology programme with all essential services and most
state-of-the-art services & 14.1\%\tabularnewline
State-of-the-art services and some highly specialized services (e.g.,
proton beam radiation therapy, MIBG therapy, phase I studies) &
3.0\%\tabularnewline
Don't know & 8.1\%\tabularnewline
\textbf{Dedicated pediatric oncology ward?} &\tabularnewline
No pediatric oncology inpatient ward & 19.2\%\tabularnewline
Area of the hospital where children with cancer are admitted when
possible; frequent overflow to other wards; no fixed staff &
14.1\%\tabularnewline
Pediatric oncology inpatient ward available to most patients with
limited, fixed staff (e.g., oncology nurse permanently assigned) &
23.2\%\tabularnewline
Pediatric oncology inpatient ward separate from inpatient units for
other patients; sufficient beds such that oncology patients rarely
require admission to other wards & 34.3\%\tabularnewline
Subspecialised pediatric oncology wards (e.g., transplant,
neuro-oncology, acute myeloid leukaemia) & 8.1\%\tabularnewline
Don't know & 1.0\%\tabularnewline
\textbf{Do children with cancer have access to pediatric intensive care
facilities at your hospital?} &\tabularnewline
Intensive care unit present; limited equipment and personnel with
limited pediatric experience & 38\%\tabularnewline
Mechanical ventilators, inotropes, central venous access, dialysis;
personnel with some pediatric experience & 16\%\tabularnewline
Pediatric intensive care unit with all necessary equipment and personnel
with pediatric intensive care expertise & 19\%\tabularnewline
Advanced cardiopulmonary support available (extracorporeal membrane
oxygenation) & 4\%\tabularnewline
No & 21\%\tabularnewline
Don't know & 2.0\%\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2:} Presence of allied health workers in 109 facilities in
46 African countries responding to the SIOP Africa Mapping Survey 2018.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Support Services & Have Resource & Don't Have Resource & Don't
Know\tabularnewline
\textbf{Pharmacist} & 91\% & 8\% & 1\%\tabularnewline
\textbf{Social Worker} & 81\% & 15\% & 4\%\tabularnewline
\textbf{Physiotherapist} & 78\% & 18\% & 4\%\tabularnewline
\textbf{Dietitian} & 66\% & 30\% & 4\%\tabularnewline
\textbf{Volunteers} & 53\% & 44\% & 3\%\tabularnewline
\textbf{Patient Support Group} & 49\% & 49\% & 2\%\tabularnewline
\textbf{Psychologist} & 45\% & 51\% & 3\%\tabularnewline
\textbf{Palliative Care} & 43\% & 53\% & 4\%\tabularnewline
\textbf{Spiritual/Religious} & 40\% & 53\% & 7\%\tabularnewline
\textbf{School Teacher} & 33\% & 63\% & 4\%\tabularnewline
\textbf{Child Life Worker/ Play Specialist} & 28\% & 70\% &
2\%\tabularnewline
\textbf{Bereavement} & 23\% & 70\% & 7\%\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3:} Final topic results of sub-Saharan Africa Nurses
Network Delphi survey 2019.\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\textbf{Module 1:} General introduction to cancer\tabularnewline
\midrule
\endhead
\textbf{Module 2:} Diagnosis of cancer\tabularnewline
\textbf{Module 3:} Cancer treatment modalities\tabularnewline
\textbf{Module 4:} Management of chemotherapy side
effects\tabularnewline
\textbf{Module 5:} Pediatric oncological emergencies\tabularnewline
\textbf{Module 6:} Care of the sick child\tabularnewline
\textbf{Module 7:} Providing safe care\tabularnewline
\textbf{Module 8:} Psychosocial care\tabularnewline
\textbf{Module 9:} Nutritional support for children with
cancer\tabularnewline
\textbf{Module 10:} Palliative and supportive care to a child with
cancer\tabularnewline
\textbf{Module 11:} Outpatient and follow up care\tabularnewline
\textbf{Module 12:} Pediatric oncology nursing and the role of the
Nurse\tabularnewline
\bottomrule
\end{longtable}

{[}CHART{]}

{[}CHART{]}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1:} Priority research topics for pediatric oncology
nursing in Africa as identified by nurses participating in the 2019
13\textsuperscript{th} SIOP Africa Congress, in Cairo, Egypt.

\textbf{Figure 2} : Research targets for pediatric oncology nursing in
Africa as identified by nurses participating in the 2019
13\textsuperscript{th} SIOP Africa Congress, in Cairo, Egypt.

\textbf{Figure 3:} Countries of the pediatric oncology nurses
participating in the educational priorities for pediatric oncology
nurses Delphi survey for sub-Saharan Africa, SIOP Africa meeting 2019,
in Cairo, Egypt.

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