CC BY-NC-ND 4.0 · Indian J Med Paediatr Oncol 2022; 43(03): 280-284
DOI: 10.1055/s-0042-1748938
Policy Brief

Florence Nightingale Needs Your Attention: A Framework for Improving Pediatric Oncology Nursing in Low- and Middle-Income Countries

1   Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
Sanjeeva Gunasekera
2   Department of Pediatric Oncology, National Cancer Institute, Colombo, Sri Lanka
Catherine G. Lam
3   Health Systems and Asia Pacific Regional Programs, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
4   Global Nursing, Global Pediatric Medicine Department, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
Scott C. Howard
5   College of Nursing, University of Tennessee College of Health Sciences, Memphis, Tennessee, United States
› Author Affiliations

Executive Summary

  • Children with cancer in low- and middle-income countries (LMIC) succumb to their disease four times more often than those in high-income countries (HIC).[1]

  • Ninety percent of all pediatric cancers occur in LMIC.[2]

  • In HIC, more than 80% of children with cancer are cured, but in LMIC only 26% survive.[3]

  • Nurses play a vital role in the care of children with cancer.

  • Causes of low survival in LMIC include shortage of dedicated pediatric cancer centers, trained pediatric oncology team members, inadequate supportive care, abandonment of treatment, excess relapse due to poor adherence, and lack of understanding as well as capacity to implement complex treatment requirements.

  • Pediatric oncology nurses play a key role in mitigating these causes of excess treatment failure.[1] [4]

  • Pediatric oncology nursing in LMIC faces a crisis from workforce shortage and lack of standards.

  • The shortage of pediatric oncology nurses in LMIC results from low salaries, lack of career progression, lack of training opportunities, limited structured training programs, long irregular working hours, unsafe working conditions, and in some cases lack of respect for the profession.[5] [6]

  • Baseline standards for pediatric oncology nursing care are well established, but most hospitals in LMIC do not meet the standards.[7]

  • The time for action is now.

  • There is an urgent need to ensure that baseline standards for pediatric oncology nurses are met in LMIC to achieve the World Health Organization's (WHO) goal of improving childhood cancer survival in LMIC to 60% by 2030.[8]

  • Effective interventions proven to improve pediatric oncology nursing and empower nurses in LMIC include onsite subspecialty oncology nurse education and mentoring, implementation of a career ladder with concrete steps for advancement, and adherence to safety standards for handling of chemotherapy as well as blood products.[7]

Venkatraman Radhakrishnan and Sanjeeva Gunasekera equally contributed to the manuscript (Co-first authors)

Publication History

Article published online:
02 July 2022

© 2022. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

  • References

  • 1 Lam CG, Howard SC, Bouffet E, Pritchard-Jones K. Science and health for all children with cancer. Science 2019; 363 (6432): 1182-1186
  • 2 Atun R, Bhakta N, Denburg A. et al. Sustainable care for children with cancer: a Lancet Oncology Commission. Lancet Oncol 2020; 21 (04) e185-e224
  • 3 Ward ZJ, Yeh JM, Bhakta N, Frazier AL, Girardi F, Atun R. Global childhood cancer survival estimates and priority-setting: a simulation-based analysis. Lancet Oncol 2019; 20 (07) 972-983
  • 4 Day SW, Garcia J, Antillon F. et al. A sustainable model for pediatric oncology nursing education in low-income countries. Pediatr Blood Cancer 2012; 58 (02) 163-166
  • 5 Morrissey L, Lurvey M, Sullivan C. et al. Disparities in the delivery of pediatric oncology nursing care by country income classification: international survey results. Pediatr Blood Cancer 2019; 66 (06) e27663
  • 6 Drennan VM, Ross F. Global nurse shortages-the facts, the impact and action for change. Br Med Bull 2019; 130 (01) 25-37
  • 7 Day S, Hollis R, Challinor J, Bevilacqua G, Bosomprah E. SIOP PODC Nursing Working Group. Baseline standards for paediatric oncology nursing care in low to middle income countries: position statement of the SIOP PODC Nursing Working Group. Lancet Oncol 2014; 15 (07) 681-682
  • 8 World Health Organization Global initiative for childhood cancer. Accessed on April 12, 2022 at:
  • 9 Haddad LM, Annamaraju P, Toney-Butler TJ. Nursing Shortage. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020
  • 10 Ministry of Health Nutrition and Indigenous Medicine Sri Lanka and WHO. Health Labour Market Analysis: Sri Lanka; 2018
  • 11 Abebe L, Bender A, Pittini R. Building the case for nurses' continuous professional development in Ethiopia: a qualitative study of the sick kids-Ethiopia Paediatrics Perioperative Nursing Training Program. Ethiop J Health Sci 2018; 28 (05) 607-614
  • 12 Garner SL, Conroy SF, Bader SG. Nurse migration from India: a literature review. Int J Nurs Stud 2015; 52 (12) 1879-1890
  • 13 Toh SG, Ang E, Devi MK. Systematic review on the relationship between the nursing shortage and job satisfaction, stress and burnout levels among nurses in oncology/haematology settings. Int J Evid-Based Healthc 2012; 10 (02) 126-141
  • 14 Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care 2007; 45 (12) 1195-1204
  • 15 Pergert P, Sullivan CE, Adde M. et al. An ethical imperative: Safety and specialization as nursing priorities of WHO Global Initiative for Childhood Cancer. Pediatr Blood Cancer 2020; 67 (04) e28143
  • 16 Sullivan CE, Morrissey L, Day SW, Chen Y, Shirey M, Landier W. Predictors of hospitals' nonachievement of baseline nursing standards for pediatric oncology. Cancer Nurs 2020; 43 (04) E197-E206
  • 17 Challinor JM, Galassi AL, Al-Ruzzieh MA. et al. Nursing's potential to address the growing cancer burden in low- and middle-income countries. J Glob Oncol 2016; 2 (03) 154-163
  • 18 Buser JM. The need for hematology nurse education in low- and middle-income countries: a community case study in Tanzania. Front Public Health 2017; 5: 65
  • 19 Hopkins J, Burns E, Eden T. International twinning partnerships: An effective method of improving diagnosis, treatment and care for children with cancer in low-middle income countries. J Cancer Policy 2013; 1 (01) e8-e19
  • 20 Day SW, Sullivan CE, Morrissey L. et al. Development and content validation of an instrument to measure baseline standards for pediatric oncology nursing in low- and middle-income countries. J Pediatr Oncol Nurs 2021; 38 (04) 213-224