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The future of cancer nursing in Europe: Addressing professional issues in education, research, policy and practice

Open AccessPublished:January 24, 2023DOI:https://doi.org/10.1016/j.ejon.2023.102271

      Abstract

      Cancer nursing has evolved to meet the demands of rising cancer incidence, newer and more complex treatment options, and the emergence of specialist roles supporting patients from pre-diagnosis, through treatment, survivorship and end of life care. Nurses are involved in direct and in-direct care of people at risk of, living with and after cancer in diverse contexts. As a result, nurses are positioned to have a significant influence on the processes and outcomes of cancer care, through education, research, policy, practice and leadership. However, nursing and cancer care face challenges, arising from workforce shortages, under-investment in services and under-representation in decision-making. This paper discusses the evolution of cancer nursing across education, policy, research, profession and practice, and sets an agenda for innovation and disruption across these domains to ensure sustainability of cancer care services and care for people living with and after cancer. We argue for the continued advancement of cancer nursing with critical focus on identifying and addressing inequities in role recognition and access to specialist cancer nursing education throughout Europe. Partnership, exchange of learning, and co-design will be central to progressing education, evidence and policy to support future growth in the cancer nursing workforce and embed cancer nurses in research and policy setting at local, national and international levels.

      Keywords

      1. Introduction

      Europe accounts for a tenth of the world's population with 446.8 million, and 25% of the world's cancer cases (
      European Commission
      Europe's Beating Cancer Plan.
      ;
      • Eurostat
      Population and Population Change Statistics.
      ). In 2020, 2.7 million people in the European Union were diagnosed with cancer, and another 1.3 million people lost their lives to the disease (
      European Commission
      Europe's Beating Cancer Plan.
      ). Without intervention, it is projected that the mortality rates attributed to cancer will increase by 24% by 2035 (
      European Commission
      Europe's Beating Cancer Plan.
      ). As a result, there have been strong mandates at European level to tackle the burden of cancer, both across Europe and at national level (
      European Commission
      Europe's Beating Cancer Plan.
      ,
      European Commission
      European Missions: Cancer Implementation Plan.
      ). As the largest group of healthcare providers (50%), nurses interact with people throughout their lifespan more than any other profession (
      World Health Organisation
      Nursing and Midwifery.
      ). This offers great opportunities to impact people's health and contribute to the mission of the European Beating Cancer Plan and EU Cancer Mission (
      European Commission
      Europe's Beating Cancer Plan.
      ,
      European Commission
      European Missions: Cancer Implementation Plan.
      ).
      Nurses can be seen as the backbone of the healthcare system (
      • Bvumbwe T.M.
      • Mtshali N.G.
      A middle-range model for improving quality of nursing education in Malawi.
      ). Cancer nurses play an important and often-varied role caring for people affected by cancer. Nurses are often the first point of contact for people who are diagnosed with cancer within the healthcare system, and play a pivotal role in cancer care and services (
      • Mitema A.
      • Maree L.
      • Young A.
      Cancer treatment in Africa: the importance of the role of nursing.
      ). There is a growing body of evidence that care delivered by cancer nurses has a positive impact on quality of care and patient outcomes (
      • Campbell P.
      • Torrens C.
      • Kelly D.
      • Charalambous A.
      • Domenech‐Climent N.
      • Nohavova I.
      • Östlund U.
      • Patiraki E.
      • Salisbury D.
      • Sharp L.
      Recognizing European cancer nursing: protocol for a systematic review and meta‐analysis of the evidence of effectiveness and value of cancer nursing.
      ;
      • Charalambous A.
      • Wells M.
      • Campbell P.
      • Torrens C.
      • Östlund U.
      • Oldenmenger W.
      • Patiraki E.
      • Sharp L.
      • Nohavova I.
      • Domenech-Climent N.
      A scoping review of trials of interventions led or delivered by cancer nurses.
      ;
      • Kelly D.
      • Campbell P.
      • Torrens C.
      • Charalambous A.
      • Östlund U.
      • Eicher M.
      • Larsson M.
      • Nohavova I.
      • Olsson C.
      • Simpson M.
      • Patiraki E.
      • Sharp L.
      • Wiseman T.
      • Oldenmenger W.
      • Wells M.
      The effectiveness of nurse-led interventions for cancer symptom management 2000–2018: a systematic review and meta-analysis.
      ;
      • Tuominen L.
      • Stolt M.
      • Meretoja R.
      • Leino-Kilpi H.
      Effectiveness of nursing interventions among patients with cancer: an overview of systematic reviews.
      ). Cancer nurses provide essential nursing care, patient, family and community education and support, administer, monitor and evaluate treatment outcomes, identify and manage complications, provide supportive and palliative care, and collaborate on clinical research (
      European Oncology Nursing Society
      EONS Occupational Safety Survey.
      ;
      • Young A.M.
      • Charalambous A.
      • Owen R.I.
      • Njodzeka B.
      • Oldenmenger W.H.
      • Alqudimat M.R.
      • So W.K.W.
      Essential oncology nursing care along the cancer continuum.
      ).
      Cancer nursing is evolving as a profession to meet the demands of rising cancer incidence, newer and more complex treatment options, and the emergence of specialist roles supporting patients from pre-diagnosis, through treatment, survivorship and end of life care (
      • Charalambous A.
      • Wells M.
      • Campbell P.
      • Torrens C.
      • Östlund U.
      • Oldenmenger W.
      • Patiraki E.
      • Sharp L.
      • Nohavova I.
      • Domenech-Climent N.
      A scoping review of trials of interventions led or delivered by cancer nurses.
      ;
      • Miller K.D.
      • Nogueira L.
      • Devasia T.
      • Mariotto A.B.
      • Yabroff K.R.
      • Jemal A.
      • Kramer J.
      • Siegel R.L.
      Cancer treatment and survivorship statistics, 2022.
      ). This evolution has occurred against the backdrop of significant innovation and investment in cancer care and therapies over the past four decades, which have positively impacted on cancer survival rates and outcomes in some regions of the world (
      • Miller K.D.
      • Nogueira L.
      • Devasia T.
      • Mariotto A.B.
      • Yabroff K.R.
      • Jemal A.
      • Kramer J.
      • Siegel R.L.
      Cancer treatment and survivorship statistics, 2022.
      ;
      • Wild C.P.
      • Weiderpass E.
      • Stewart B.W.
      World Cancer Report: Cancer Research for Cancer Prevention.
      ). Innovation, by its definition, refers to new interventions which have the potential to drive change (
      • Fuller R.
      • Hansen A.
      Disruption ahead: navigating and leading the future of nursing.
      ;
      • Wild C.P.
      • Weiderpass E.
      • Stewart B.W.
      World Cancer Report: Cancer Research for Cancer Prevention.
      ). Many innovations introduced in cancer care and cancer nursing build upon existing processes and practices, with the objective of adding value for patients, healthcare professionals and the systems tasked with delivery of cancer care (
      • Campbell C.
      • Nowell A.
      • Karagheusian K.
      • Giroux J.
      • Kiteley C.
      • Martelli L.
      • McQuestion M.
      • Quinn M.
      • Rowe Samadhin Y.P.
      • Touw M.
      • Moody L.
      Practical innovation: advanced practice nurses in cancer care.
      ;
      • Fuller R.
      • Hansen A.
      Disruption ahead: navigating and leading the future of nursing.
      ).
      Beyond the healthcare industry, “innovation” has become synonymous with “disruption” (
      • Callander S.
      • Matouschek N.
      The novelty of innovation: competition, disruption, and antitrust policy.
      ;
      • Christensen C.M.
      • Raynor M.E.
      • McDonald R.
      What is disruptive innovation.
      ;
      • Millar C.
      • Lockett M.
      • Ladd T.
      Disruption: technology, innovation and society.
      ). While several notably disruptive innovations have emerged in cancer treatment over the past decade (e.g. CAR-T, Robotic Surgery, etc), rarely is innovation within healthcare systems and cancer care disruptive, such that it results in reforming services or patterns of care so dramatically that they are radically different or distinct from preceding services (
      • Fuller R.
      • Hansen A.
      Disruption ahead: navigating and leading the future of nursing.
      ). Nevertheless, innovations in cancer prevention, treatment and care continue to evolve, increasing the complexity of cancer care delivery, and the needs of people living with and after cancer (
      • Boland V.
      • Drury A.
      • Sheaf G.
      • Brady A.M.
      Living with or beyond lymphoma: a rapid review of the unmet needs of lymphoma survivors.
      ;
      • Hart N.H.
      • Crawford-Williams F.
      • Crichton M.
      • Yee J.
      • Smith T.J.
      • Koczwara B.
      • Fitch M.I.
      • Crawford G.B.
      • Mukhopadhyay S.
      • Mahony J.
      Unmet Supportive Care Needs of People with Advanced Cancer and Their Caregivers: a Systematic Scoping Review.
      ). Therefore, the impact of emerging treatments and technologies on the care and outcomes of the person living with cancer should be at the forefront, regardless of the degree of disruption arising from the innovation (
      European Commission
      European Missions: Cancer Implementation Plan.
      ). Furthermore, the impact of such innovations upon the education, practice and emerging needs of the cancer care workforce should be a key consideration in the implementation of new approaches to care, particularly in the face of emerging challenges for cancer care (
      • Challinor J.M.
      • Galassi A.L.
      • Al-Ruzzieh M.A.
      • Bigirimana J.B.
      • Buswell L.
      • So W.K.
      • Steinberg A.B.
      • Williams M.
      Nursing's potential to address the growing cancer burden in low-and middle-income countries.
      ).
      Nurses are the largest profession within the cancer care and healthcare workforce, and work in diverse settings throughout cancer care services across practice, administration, research, education, policy, management and leadership (
      World Health Organisation
      State of the World's Nursing 2020: Investing in Education, Jobs and Leadership.
      ). Despite this, the nursing profession faces significant challenges, including workforce shortages, under-investment and under-representation in decision-making (
      • Challinor J.M.
      • Galassi A.L.
      • Al-Ruzzieh M.A.
      • Bigirimana J.B.
      • Buswell L.
      • So W.K.
      • Steinberg A.B.
      • Williams M.
      Nursing's potential to address the growing cancer burden in low-and middle-income countries.
      ;
      • Iro E.
      • Catton H.
      The future of nursing.
      ;
      World Health Organisation
      State of the World's Nursing 2020: Investing in Education, Jobs and Leadership.
      ). The recruitment and retention of nurses has been further impacted by the COVID-19 pandemic. Since the onset of the pandemic, there has been increasing turnover intention within the nursing workforce, attributable to the emotional impact of the pandemic on healthcare workers, and organisational resilience and system responses, adding to a deteriorating outlook on the global shortfall in nurses forecasted prior to the pandemic (
      • Buchan J.
      • Catton H.
      • Shaffer F.A.
      Sustain and Retain in 2022 and beyond: the Global Nursing Workforce and the COVID-19 Pandemic.
      ;
      • Falatah R.
      The impact of the coronavirus disease (COVID-19) pandemic on nurses' turnover intention: an integrative review.
      ;
      World Health Organisation
      State of the World's Nursing 2020: Investing in Education, Jobs and Leadership.
      ;
      • Wynne R.
      • Davidson P.M.
      • Duffield C.
      • Jackson D.
      • Ferguson C.
      Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper.
      ). These developments represent a significant threat to the future of cancer nursing. Given the dispersal and diversity of cancer nursing roles throughout the cancer care health system, the implications of changing workforces will have a detrimental impact on service delivery, patient care and patient outcomes (
      World Health Organisation
      State of the World's Nursing 2020: Investing in Education, Jobs and Leadership.
      ).
      How the forthcoming challenges in cancer care and healthcare systems are addressed will not simply be a case of health and education systems doing more of the same. Meaningful system and policy responses to the challenges facing nursing will require meaningful engagement and involvement of nurses, and truly disruptive innovation across nurse education, practice, policy, research and leadership. Furthermore, ensuring equal and consistent recognition and value of the role and unique contributions of the nursing workforce will be vital. Considering the diversity of nursing roles, horizontally throughout the cancer trajectory, and vertically from bedside to leadership, nurses will be integral to the development and implementation of innovation, with roles as influencers, validators and strategic advisors in healthcare innovation and disruption (
      • Fuller R.
      • Hansen A.
      Disruption ahead: navigating and leading the future of nursing.
      ). This manuscript will discuss the evolution of cancer nursing across education, policy, research, profession and practice, and set an agenda and recommendations for future directions for innovation and disruption to ensure sustainability of cancer care services and care for people living with and after cancer.

      2. Education

      Nurse education has undergone a significant transformation over the past 150 years, in parallel to significant political, social, technological and professional changes; from the first nurse training programmes established by religious orders in the mid-1800s, to apprenticeship training in the 1900s (
      • Helmstadter C.
      • Godden J.
      Nursing before Nightingale, 1815-1988.
      ;
      • McDonald L.
      ). EEC directives introduced in 1977 mandated mutual recognition of the professional qualifications of nurses (
      Directive 77/452/EEC
      Council Directive 77/452/EEC concerning the mutual recognition of diplomas, certificates and other evidence of the formal qualifications of nurses responsible for general care, including measures to facilitate the effective exercise of this right of establishment and freedom to provide services.
      ), the specific requirements of nurse training programmes (
      Directive 77/453/EEC
      Council Directive 77/453/EEC concerning the coordination of provisions laid down by Law, Regulation or Administrative Action in respect of the activities of nurses responsible for general care.
      ) and comparable and compatible education standards across Europe (
      Bologna Process Committee
      The Bologna Declaration, Joint Declaration of the European Ministers of Education Convened in Bologna a on 19 June 1999.
      ). The 1977 EEC Directives and Bologna Declaration have underpinned some of the most significant developments in nurse education in Europe, including transition to degree-based education, and specialist postgraduate qualifications available in some parts of the word today (
      • Loughrey M.
      A Centure of Service: A History of the Irish Nurses and Midwives Organisation, 1919-2019.
      ;
      • O'Dwyer P.
      Looking back... Moving forward: the educational preparation of nurses in Ireland.
      ).
      There is a wealth of research which highlights the benefits of nurses educated to bachelor degree level for more positive healthcare outcomes for patients (
      • Aiken L.H.
      • Clarke S.P.
      • Sloane D.M.
      • Lake E.T.
      • Cheney T.
      Effects of hospital care environment on patient mortality and nurse outcomes.
      ,
      • Aiken L.H.
      • Sloane D.
      • Griffiths P.
      • Rafferty A.M.
      • Bruyneel L.
      • McHugh M.
      • Maier C.B.
      • Moreno-Casbas T.
      • Ball J.E.
      • Ausserhofer D.
      • Sermeus W.
      Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care.
      ;
      • Ball J.E.
      • Bruyneel L.
      • Aiken L.H.
      • Sermeus W.
      • Sloane D.M.
      • Rafferty A.M.
      • Lindqvist R.
      • Tishelman C.
      • Griffiths P.
      Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study.
      ). Despite this, rhetoric suggesting degree programmes erode the quality of nursing care remains pervasive, even 24 years since the Bologna Process (;
      • Dean S.
      Are Our Busy Doctors and Nurses Losing Empathy for Patients?.
      ; ). Much of this discourse coincides with critique of underfunded and under-resourced health systems contributing to clinical safety issues, and burnout among health professionals, which have been further exacerbated by the COVID-19 pandemic (
      • Buchan J.
      • Catton H.
      • Shaffer F.A.
      Sustain and Retain in 2022 and beyond: the Global Nursing Workforce and the COVID-19 Pandemic.
      ;
      • Challinor J.M.
      • Alqudimat M.R.
      • Teixeira T.O.
      • Oldenmenger W.H.
      Oncology nursing workforce: challenges, solutions, and future strategies.
      ;
      • Falatah R.
      The impact of the coronavirus disease (COVID-19) pandemic on nurses' turnover intention: an integrative review.
      ;
      • Furlow B.
      Information overload and unsustainable workloads in the era of electronic health records.
      ;
      • Mansour S.
      • Tremblay D.-G.
      How can we decrease burnout and safety workaround behaviors in health care organizations? The role of psychosocial safety climate.
      ;
      World Health Organisation
      State of the World's Nursing 2020: Investing in Education, Jobs and Leadership.
      ;
      • Wynne R.
      • Davidson P.M.
      • Duffield C.
      • Jackson D.
      • Ferguson C.
      Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper.
      ). Forecasted shortages in the nursing workforce, and cancer workforce shortages create an increasing need for interventions which serve to attract and retain nurses (
      • Challinor J.M.
      • Alqudimat M.R.
      • Teixeira T.O.
      • Oldenmenger W.H.
      Oncology nursing workforce: challenges, solutions, and future strategies.
      ;
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ). In the context of increasing incidence of cancer, and improving survival rates, specialist cancer nurses will continue to play a critical role in care and support for people at risk of cancer, and living with and after cancer, underlining the particular need to increase recruitment and retention of nurses to the specialist field of cancer care (
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ;
      • Pilleron S.
      • Soto-Perez-de-Celis E.
      • Vignat J.
      • Ferlay J.
      • Soerjomataram I.
      • Bray F.
      • Sarfati D.
      Estimated global cancer incidence in the oldest adults in 2018 and projections to 2050.
      ;
      • Sung H.
      • Ferlay J.
      • Siegel R.L.
      • Laversanne M.
      • Soerjomataram I.
      • Jemal A.
      • Bray F.
      Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
      ).
      Cancer care is a highly specialised field of nursing practice, which requires a higher level of training and competence, beyond undergraduate education (
      • Challinor J.M.
      • Galassi A.L.
      • Al-Ruzzieh M.A.
      • Bigirimana J.B.
      • Buswell L.
      • So W.K.
      • Steinberg A.B.
      • Williams M.
      Nursing's potential to address the growing cancer burden in low-and middle-income countries.
      ;
      • Ross J.G.
      • Burrell S.A.
      Standardized patient simulation to facilitate learning in evidence-based oncology symptom management.
      ). There is consensus that specialist education in cancer nursing (and other specialist areas of nursing) should be competence-based (
      Breast Cancer Now
      What Excellent Care Looks like.
      ;
      European Oncology Nursing Society
      ;
      • Royal College of Nursing
      A Competency Framework for Nurses Providing Care to People with Breast Cancer.
      ,
      • Royal College of Nursing
      Career Pathway and Education Framework for Cancer Nursing.
      ;
      • Vila C.
      • Reñones C.
      • Ferro T.
      • Peñuelas M.
      • Del Mar Jiménez M.
      • Rodríguez-Lescure Á.
      • Muñoz M.
      • Colomer R.
      Advanced breast cancer clinical nursing curriculum: review and recommendations.
      ). However, throughout Europe, there remains little agreement regarding the specialist role of cancer nurses, and the elements of education and training which are required for specialization and the continued growth of the profession (
      • Campbell P.
      • Torrens C.
      • Kelly D.
      • Charalambous A.
      • Domenech‐Climent N.
      • Nohavova I.
      • Östlund U.
      • Patiraki E.
      • Salisbury D.
      • Sharp L.
      Recognizing European cancer nursing: protocol for a systematic review and meta‐analysis of the evidence of effectiveness and value of cancer nursing.
      ;
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ,
      • Kelly D.
      • Campbell P.
      • Torrens C.
      • Charalambous A.
      • Östlund U.
      • Eicher M.
      • Larsson M.
      • Nohavova I.
      • Olsson C.
      • Simpson M.
      • Patiraki E.
      • Sharp L.
      • Wiseman T.
      • Oldenmenger W.
      • Wells M.
      The effectiveness of nurse-led interventions for cancer symptom management 2000–2018: a systematic review and meta-analysis.
      ). The implementation of specialised training in oncology nursing differs greatly between eastern and western Europe (
      • Challinor J.M.
      • Alqudimat M.R.
      • Teixeira T.O.
      • Oldenmenger W.H.
      Oncology nursing workforce: challenges, solutions, and future strategies.
      ;
      • European Oncology Nursing Society (EONS)
      EONS Cancer Nursing Index 2020.
      ;
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ). Economic and linguistic disparities throughout the European region present further barriers to specialist education, hindering mobility and access to specialist training provided within the European region (
      • Drury A.
      • Diez de Los Rios C.
      The education, training & support needs of young cancer nurses.
      ). Furthermore, a lack of cross-recognition of professional registrations between countries within Europe creates additional barriers for those who wish to undertake specialist clinical programmes in oncology in countries where they are available (
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ).
      Cancer care and cancer nursing roles are becoming increasingly complex, and there is a growing requirement for specialist and advanced practice nursing in the area of oncology to address service demands (
      • Campbell K.
      • Taylor V.
      • Douglas S.
      Effectiveness of online cancer education for nurses and allied health professionals; a systematic review using Kirkpatrick evaluation framework.
      ;
      • Challinor J.M.
      • Alqudimat M.R.
      • Teixeira T.O.
      • Oldenmenger W.H.
      Oncology nursing workforce: challenges, solutions, and future strategies.
      ;
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ). Specialist education and training will remain key factors to enable advancement of nursing practice throughout Europe into the future, to ensure that cancer nurses are prepared to meet the varied, often long-term and end-of-life care needs of people affected by cancer (
      • Klemp J.R.
      • Frazier L.M.
      • Glennon C.
      • Trunecek J.
      • Irwin M.
      Improving cancer survivorship care: oncology nurses' educational needs and preferred methods of learning.
      ). However, when considered in the context of economic, linguistic and geographical barriers both within Europe, and internationally, we must evaluate whether current approaches to basic nursing education, and subsequent specialist education of cancer nurses, and the cancer workforce more broadly, are fit for purpose. This has implications not only in Europe, but across the world, and particularly in low and middle income countries, where the burden of cancer is predicted to increase by more than 60% by 2030 and deficits in the nursing workforce will be most significant (
      • Azad A.
      • Min J.G.
      • Syed S.
      • Anderson S.
      Continued nursing education in low-income and middle-income countries: a narrative synthesis.
      ;
      • Challinor J.M.
      • Galassi A.L.
      • Al-Ruzzieh M.A.
      • Bigirimana J.B.
      • Buswell L.
      • So W.K.
      • Steinberg A.B.
      • Williams M.
      Nursing's potential to address the growing cancer burden in low-and middle-income countries.
      ;
      • Duncan K.
      • Cira M.K.
      • Barango P.
      • Trimble E.L.
      Challenges and opportunities in the creation and implementation of cancer-control plans in Africa.
      ).
      Workforce capacity-building for cancer nurses will be fundamentally underpinned by initiatives that enhance access to basic and specialist nurse education. However, nurse education has been shaped by dominant ideologies, from its earliest iterations as assistants to physicians (
      • Group T.M.
      • Roberts J.I.
      Nursing, Physician Control, and the Medical Monopoly: Historical Perspectives on Gendered Inequality in Roles, Rights, and Range of Practice.
      ); as nurse education has evolved, discourses have been heavily influenced by power relations, patriarchy, colonialism and heteronormative perspectives (
      • Browne A.J.
      The influence of liberal political ideology on nursing science.
      ). These discourses are core to the socialisation of nurses and cancer nurses; and a failure to recognise diversity within the nursing workforce will result in the marginalisation of underrepresented groups, both within our profession and patient population, in a political landscape where workforce diversity has been labelled a priority (
      • Shalala D.
      • Bolton L.
      • Bleich M.
      • Brennan T.
      • Campbell R.
      • Devlin L.
      ).
      To ensure high-quality nurse education, training and care, clinical and higher education institutions must make a commitment to developing cultures that value diversity and inclusion (
      • Cary M.P.
      • Randolph S.D.
      • Broome M.E.
      • Carter B.M.
      Creating a culture that values diversity and inclusion: an action-oriented framework for schools of nursing.
      ). There are several national and international standards and competency frameworks which provide guidance regarding the fundamental knowledge, skills and competencies required by nurses who care for people affected by cancer (
      Breast Cancer Now
      What Excellent Care Looks like.
      ;
      European Oncology Nursing Society
      ;
      • Lubejko B.G.
      • Wilson B.J.
      Oncology Nursing: Scope and Standards of Practice.
      ;
      • Macmillan
      Macmillan Competency Framework for Nurses.
      ;
      • Royal College of Nursing
      A Competency Framework for Nurses Providing Care to People with Breast Cancer.
      ,
      • Royal College of Nursing
      Career Pathway and Education Framework for Cancer Nursing.
      ). However, there remains challenges to the consistent implementation of educational standards, and nurses’ access to specialist education, particularly within the European region where nursing practice and educational requirements are regulated at a national level (
      • Challinor J.M.
      • Alqudimat M.R.
      • Teixeira T.O.
      • Oldenmenger W.H.
      Oncology nursing workforce: challenges, solutions, and future strategies.
      ;
      • Drury A.
      • Diez de Los Rios C.
      The education, training & support needs of young cancer nurses.
      ;
      • Drury A.
      • Dowling M.
      • Diez de los Rios de la Serna C.
      • Erdem S.
      • Aroyo V.
      • Wiseman T.
      • Bağçivan G.
      Advanced breast cancer education for cancer nurses: a systematic review.
      ;
      • Drury A.
      • Torcato Parreira S.
      • Diez de Los Rios C.
      The development and evaluation of a professional development series for early career cancer nurses in Europe.
      ;
      • European Oncology Nursing Society (EONS)
      EONS Cancer Nursing Index 2020.
      ;
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ;
      • Lahtinen P.
      • Leino-Kilpi H.
      • Salminen L.
      Nursing education in the European higher education area – variations in implementation.
      ). Furthermore, there are gaps in evidence demonstrating the clinical and educational effectiveness of cancer nursing education frameworks (
      • Campbell K.
      • Taylor V.
      • Douglas S.
      Effectiveness of online cancer education for nurses and allied health professionals; a systematic review using Kirkpatrick evaluation framework.
      ).
      In the context of nurse education, a shift is required to recognise and cater to diversity in learning styles and enhance access to (and accessibility of) basic and specialist education in nursing. Disruption is essential to ensure equity in the distribution of knowledge, resources and power to foster inclusive approaches to nurse education and professional development (
      • Gilmore J.P.
      • Halligan P.
      • Browne F.
      Pedagogy as social justice–Universal Design of Learning in nurse education.
      ). Three key strategies are required to promote equity in nursing education, particularly at graduate level: 1) enhanced accessibility of education; 2) recognition of specialist cancer nursing qualifications, 3) development and co-design of open access education for cancer nurses. Universal design for learning (UDL) is one mechanism to support inclusion and accessibility in learning. UDL advocates for teaching and learning strategies which enables students to engage with learning based on needs and strengths, and to acquire and demonstrate essential skills, knowledge and competence in a variety of ways, via multiple means of i) engagement, ii) representation and iii) expression, providing greater opportunities for learner success (
      • Cast C.
      Universal Design for Learning Guidelines Version 2.0.
      ;
      • Gilmore J.P.
      • Halligan P.
      • Browne F.
      Pedagogy as social justice–Universal Design of Learning in nurse education.
      ).
      Evaluation of clinical competence is a critical feature of specialist nursing education. However, it will remain difficult to achieve role recognition and development of specialist and advanced practice nursing roles in cancer care in countries where such qualifications are not available or not recognised. In countries where specialist cancer nursing qualifications are unavailable or remain unrecognised, digital micro-credentials and continuing professional development programmes provide a valuable opportunity for personal and professional development. However, practical, economic and linguistic considerations are key to ensure the accessibility of these programmes to nurses who need them most will be critical to their value and success (
      • Drury A.
      • Diez de Los Rios C.
      The education, training & support needs of young cancer nurses.
      ;
      • Drury A.
      • Torcato Parreira S.
      • Diez de Los Rios C.
      The development and evaluation of a professional development series for early career cancer nurses in Europe.
      ). Low and Middle Income Countries (LMICs) represent those with some of the greatest need, with cancer burden estimated by more than 60% by 2040 (
      International Agency for Research on Cancer
      Cancer Tomorrow.
      ). Therefore, development of programmes must take into consideration the needs of LMICs where there is a significant need for capacity-building within the cancer nursing workforce, to support development of core, specialist and advanced practice skills and expansion in the scope of nursing practice (
      • Challinor J.M.
      • Alqudimat M.R.
      • Teixeira T.O.
      • Oldenmenger W.H.
      Oncology nursing workforce: challenges, solutions, and future strategies.
      ).
      Consultation with experts by profession and experience in specialist areas of cancer nursing and use of co-design methodology will ensure that curricula developed within the sphere of cancer nursing will be relevant and sensitive to the diversity of needs of nurses and patient groups throughout European countries, and beyond (
      • Drury A.
      • Dowling M.
      • Diez de los Rios de la Serna C.
      • Erdem S.
      • Aroyo V.
      • Wiseman T.
      • Bağçivan G.
      Advanced breast cancer education for cancer nurses: a systematic review.
      ,
      • Drury A.
      • Diez de Los Rios C.
      • Bağçivan G.
      • Dowling M.
      • Kotronoulas G.
      • Shewbridge A.
      • Sheehan S.
      • Erdem S.
      • Aroyo V.
      • Wiseman T.
      Consensus views on advanced breast cancer education curriculum for cancer nurses: a delphi study.
      ,
      • Drury A.
      • Torcato Parreira S.
      • Diez de Los Rios C.
      The development and evaluation of a professional development series for early career cancer nurses in Europe.
      ). Investment and innovation will be necessary to find creative solutions to barriers of competence assessment within remote learning programmes. The development and implementation of clinical and academic nursing fellowships, simulation-based learning and assessment, and formal mentoring programmes each offer potential solutions to these challenges; however, policymakers, regulators and employers must be engaged in the development and implementation processes to ensure that the product of such initiatives can impact the development and advancement of nursing roles (
      • Ann de Villiers A.
      • Blackburn L.M.
      • Birkhimer D.
      • Brophy L.R.
      • Tippett J.
      • Meade K.
      • Brown C.G.
      The development of an oncology clinical nurse specialist fellowship program.
      ;
      • Gillett C.
      • Mason S.
      • Fleming L.
      • Mayer D.K.
      • Bryant A.L.
      An academic-practice partnership during COVID-19 pandemic: transitioning from a clinical to virtual fellowship.
      ;
      • La Cerra C.
      • Dante A.
      • Caponnetto V.
      • Franconi I.
      • Gaxhja E.
      • Petrucci C.
      • Alfes C.M.
      • Lancia L.
      Effects of high-fidelity simulation based on life-threatening clinical condition scenarios on learning outcomes of undergraduate and postgraduate nursing students: a systematic review and meta-analysis.
      ;
      • Lee M.H.
      • Chung M.H.
      • Han C.S.
      • Lee J.H.
      • Choi Y.R.
      • Choi E.M.
      • Lim H.K.
      • Cha Y.D.
      Comparison of effects of intraoperative esmolol and ketamine infusion on acute postoperative pain after remifentanil-based anesthesia in patients undergoing laparoscopic cholecystectomy.
      ;
      • Loke J.C.F.
      • Lee B.K.
      • Noor A.M.
      • Loh S.
      High fidelity full sized human patient simulation manikins: effects on decision making skills of nursing students.
      ;
      • Mazzella Ebstein A.M.
      • Barton-Burke M.
      • Fessele K.L.
      A model for building research capacity and infrastructure in oncology: a nursing research fellowship.
      ;
      • Motola I.
      • Devine L.A.
      • Chung H.S.
      • Sullivan J.E.
      • Issenberg S.B.
      Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82.
      ;
      • Struksnes S.
      • Engelien R.I.
      Nursing students' conception of clinical skills training before and after their first clinical placement: a quantitative, evaluative study.
      ).

      3. Research

      The transition of nursing qualifications to university level education across the Europe, has created a need for a new nursing workforce capable of engaging in teaching, learning, research and scholarly activities (
      • Jackson D.
      • Peters K.
      • Andrew S.
      • Salamonson Y.
      • Halcomb E.J.
      If you haven't got a PhD, you're not going to get a job”: the PhD as a hurdle to continuing academic employment in nursing.
      ). Nursing is a relatively new entrant to academia, and critiques of nursing as lacking a theoretical evidence base are extensive, compounded by a dearth of doctorally-prepared nursing academics (
      • Carroll M.
      Report of the Commission on Nursing: a Blueprint for the Future.
      ;
      • Kessenich C.R.
      • Guyatt G.H.
      • DiCenso A.
      Teaching nursing students evidence-based nursing.
      ;
      • Ketefian S.
      • Redman R.W.
      A critical examination of developments in nursing doctoral education in the United States.
      ;
      • McInerney P.
      • Suleman F.
      Exploring knowledge, attitudes, and barriers toward the use of evidence‐based practice amongst academic health care practitioners in their teaching in a south African university: a pilot study.
      ;
      • McNamara M.S.
      What lies beneath? The underlying principles structuring the field of academic nursing in Ireland.
      ;
      • McNamara M.S.
      • Fealy G.
      • Geraghty R.
      Nurse tutors' tales of transition: a clash of legitimation codes?.
      ;
      • Pravikoff D.S.
      • Tanner A.B.
      • Pierce S.T.
      Readiness of US Nurses for Evidence-Based Practice: many don't understand or value research and have had little or no training to help them find evidence on which to base their practice.
      ;
      • Yam B.M.C.
      From Vocation to Profession: the Quest for Professionalization of Nursing.
      ). Over the last two decades, nursing academics have endeavoured to advance nursing science, and significant efforts were made to support nursing faculty to achieve PhD-level education (
      • Begley C.
      • McCarron M.
      • Huntley-Moore S.
      • Condell S.
      • Higgins A.
      Successful research capacity building in academic nursing and midwifery in Ireland: an exemplar.
      ;
      • Finotto S.
      • Carpanoni M.
      • Turroni E.C.
      • Camellini R.
      • Mecugni D.
      Teaching evidence-based practice: developing a curriculum model to foster evidence-based practice in undergraduate student nurses.
      ). These developments are providing a new foundation for nursing knowledge, and driving continued developments within the profession, including increasingly autonomous nursing roles (
      • Department of Health
      A Policy on the Development of Graduate to Advanced Nursing and Midwifery Practice.
      ;
      • Heale R.
      • Rieck Buckley C.
      An international perspective of advanced practice nursing regulation.
      ).
      Undergraduate and postgraduate nursing programmes include research modules; however, these modules are often delivered independent of clinical theory modules, and there are limited efforts to integrate research into clinical research modules (
      • Horntvedt M.-E.T.
      • Nordsteien A.
      • Fermann T.
      • Severinsson E.
      Strategies for teaching evidence-based practice in nursing education: a thematic literature review.
      ). The ability to critique and interpret research is a basic nursing competence, and at specialist and advanced practice levels, competence in the design and conduct of clinical research and evidence translation are core skills (
      European Oncology Nursing Society
      ;
      • Lal M.M.
      Why nursing research matters.
      ;
      • Latter K.A.
      • Purser S.
      • Chisholm S.
      • Robinson E.
      Divisional review of the nurse specialist role.
      ;
      • Lubejko B.G.
      • Wilson B.J.
      Oncology Nursing: Scope and Standards of Practice.
      ;
      • Royal College of Nursing
      A Competency Framework for Nurses Providing Care to People with Breast Cancer.
      ,
      • Royal College of Nursing
      Career Pathway and Education Framework for Cancer Nursing.
      ). Yet, the segregation of evidence critique from clinical practice curriculum appears to contribute to issues including students' undervaluing the importance of evidence to support practice, use of poor-quality sources and misinterpretation of research in practice-based assessments. While nurses’ express interest in research activity, there remains barriers to nurse-led research activity, including time, research culture, mentorship, leadership, funding, research supports and confidence in research skills (
      • Cordrey T.
      • King E.
      • Pilkington E.
      • Gore K.
      • Gustafson O.
      Exploring research capacity and culture of allied health professionals: a mixed methods evaluation.
      ;
      • Scarsini S.
      • Narduzzi B.
      • Cadorin L.
      • Palese A.
      Perceived barriers and enablers of nursing research in the Italian context: findings from a systematic review.
      ;
      • Siedlecki S.L.
      • Albert N.M.
      Research-active clinical nurses: against all odds.
      ). Furthermore, nurses roles in clinical research are often conceptualised as supporting, rather than leadership roles; and it is imperative that the distinction between clinical research nursing roles and nursing research roles are clearly articulated if the expectation for clinical nurses to be engaged in research to support quality improvement is to be realised (
      • Flocke S.A.
      • Antognoli E.
      • Daly B.J.
      • Jackson B.
      • Fulton S.E.
      • Liu T.M.
      • Surdam J.
      • Manne S.
      • Meropol N.J.
      The role of oncology nurses in discussing clinical trials.
      ;
      • Jones H.
      Clinical research nurse or nurse researcher?.
      ).
      Nurses play a key role in cancer prevention, cancer care, survivorship and palliative and end of life care; and nursing research has played a pivotal role in advancing understanding of the experiences of people who are living with and after cancer and in the development and implementation of interventions to promote quality of life at all stages of the cancer trajectory (
      • Campbell K.
      • Taylor V.
      • Douglas S.
      Effectiveness of online cancer education for nurses and allied health professionals; a systematic review using Kirkpatrick evaluation framework.
      ,
      • Campbell C.
      • Nowell A.
      • Karagheusian K.
      • Giroux J.
      • Kiteley C.
      • Martelli L.
      • McQuestion M.
      • Quinn M.
      • Rowe Samadhin Y.P.
      • Touw M.
      • Moody L.
      Practical innovation: advanced practice nurses in cancer care.
      ;
      • Ives Erickson J.
      • Pappas S.
      The value of nursing research.
      ;
      • Lal M.M.
      Why nursing research matters.
      ). Despite the presence of research teaching within nursing curricula, studies have demonstrated that between 0% and 5% of specialist nurses time is spent on research activity, and as low as 2% in the oncology context (
      • Latter K.A.
      • Purser S.
      • Chisholm S.
      • Robinson E.
      Divisional review of the nurse specialist role.
      ). Further factors influencing nurses’ engagement in research activity arise from underdevelopment of research training programmes, opportunities for clinical-academic career pathways, and access to funding to support nurse-led research (
      • Cordrey T.
      • King E.
      • Pilkington E.
      • Gore K.
      • Gustafson O.
      Exploring research capacity and culture of allied health professionals: a mixed methods evaluation.
      ;
      • Ferguson C.
      • Henshall C.
      • Albert N.M.
      Global perspectives on under-funding for clinical research training fellowships in nursing.
      ;
      • Scarsini S.
      • Narduzzi B.
      • Cadorin L.
      • Palese A.
      Perceived barriers and enablers of nursing research in the Italian context: findings from a systematic review.
      ). More than three-quarters of nursing publications indexed in Web of Science between 2009 and 2017 did not declare research funding support (
      • Kokol P.
      • Železnik D.
      • Završnik J.
      • Blažun Vošner H.
      Nursing research literature production in terms of the scope of country and health determinants: a bibliometric study.
      ). However, nursing studies with funding published within this period were predominantly undertaken within the USA, UK and Australia (
      • Kokol P.
      • Železnik D.
      • Završnik J.
      • Blažun Vošner H.
      Nursing research literature production in terms of the scope of country and health determinants: a bibliometric study.
      ;
      • Zhu R.
      • Liu M.
      • Su Y.
      • Meng X.
      • Han S.
      • Duan Z.
      A bibliometric analysis of publication of funded studies in nursing research from Web of Science, 2008–2018.
      ).
      Considering the barriers to nursing research, and disparities in the geographical location of published nursing research, strategies must be developed to enhance the representation of the diversity of nursing researchers within research funding, research conduct and dissemination. There are disparities in access to specialist nursing education and implementation of specialist roles within Europe (
      • Campbell K.
      • Taylor V.
      • Douglas S.
      Effectiveness of online cancer education for nurses and allied health professionals; a systematic review using Kirkpatrick evaluation framework.
      ,
      • Campbell C.
      • Nowell A.
      • Karagheusian K.
      • Giroux J.
      • Kiteley C.
      • Martelli L.
      • McQuestion M.
      • Quinn M.
      • Rowe Samadhin Y.P.
      • Touw M.
      • Moody L.
      Practical innovation: advanced practice nurses in cancer care.
      ;
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ). These disparities in research education and training undoubtedly contribute to discrepancies in nurse-led research within countries which are most underserved. Furthermore, within the European area, hetrogeneity in languages and English literacy may also present a further barrier to dissemination (
      • Drury A.
      • Diez de Los Rios C.
      The education, training & support needs of young cancer nurses.
      ;
      • Drury A.
      • Torcato Parreira S.
      • Diez de Los Rios C.
      The development and evaluation of a professional development series for early career cancer nurses in Europe.
      ).
      As a first step towards addressing the education-practice gap, greater innovation is required in research teaching practices to support interest and application of knowledge and skills; the principles of universal design for learning again have relevance in this context, supporting students to develop confidence in critical appraisal skills through formative peer assessment strategies (
      • De Brún A.
      • Rogers L.
      • Drury A.
      • Gilmore B.
      Evaluation of a formative peer assessment in research methods teaching using an online platform: a mixed methods pre-post study.
      ). In countries with limited access to specialist education, particularly Masters-level education, efforts are needed to provide access to research training, funding and mentorship through international partnerships which can support the development of resarch capacity within nursing for these countries. With research identified as a core nursing competency, there is a need for clinical organisations to integrate research activity within nursing roles, through evidence-based practice initiatives and supporting nurses to engage in research at all levels of nursing, for example through buy out of clinical time and seed funding. Mentorship and access to research support infrastructure are a fundamental barrier to clinical research activity among nurses (
      • Cordrey T.
      • King E.
      • Pilkington E.
      • Gore K.
      • Gustafson O.
      Exploring research capacity and culture of allied health professionals: a mixed methods evaluation.
      ;
      • Scarsini S.
      • Narduzzi B.
      • Cadorin L.
      • Palese A.
      Perceived barriers and enablers of nursing research in the Italian context: findings from a systematic review.
      ;
      • Siedlecki S.L.
      • Albert N.M.
      Research-active clinical nurses: against all odds.
      ). Providing clear pathways for nurses working within clinical settings to secure mentorship for research activity is essential; collaboration agreements with academic partners and strategic investment in clinical-academic appointments provide opportunity to integrate mentorship and access to research infrastructure (
      • Ferguson C.
      • Henshall C.
      • Albert N.M.
      Global perspectives on under-funding for clinical research training fellowships in nursing.
      ). Finally, efforts must be made to evaluate and articulate the impact of nursing research; to demonstrate return on investment, and value of nurse-led cancer research to society (
      • Campbell K.
      • Taylor V.
      • Douglas S.
      Effectiveness of online cancer education for nurses and allied health professionals; a systematic review using Kirkpatrick evaluation framework.
      ).

      4. Policy

      Nurses are often at the forefront of policy implementation, and are uniquely positioned to see the impact of health policy on people at risk of cancer, and people living with and after cancer, and their families, and the general public in various contexts (
      • Kunaviktikul W.
      Moving towards the greater involvement of nurses in policy development.
      ). Nurses interact with people throughout the lifespan, and are equipped with skills to identify, understand, and act on issues and inequities that influence health and wellbeing, including social, cultural and economic determinants of health (
      • Edmonson C.
      • McCarthy C.
      • Trent-Adams S.
      • McCain C.
      • Marshall J.
      Emerging global health issues: a nurse's role.
      ). These skills and experiences, in combination with specialist, higher level education position nurses as powerful advocates for change within their workplace, nursing organisations, government agencies, or directly with political stakeholders to address health inequities (
      • Alhassan A.
      • Kumi-Kyereme A.
      • Wombeogo M.
      • Fuseini A.-G.
      Nurse Participation in Political Activities: Level and Practices of Registered Nurses in Tamale.
      ;
      • Brokaw J.J.
      The nursing profession's potential impact on policy and politics.
      ;
      • Kunaviktikul W.
      Moving towards the greater involvement of nurses in policy development.
      ;
      • Sarnkwawkum P.
      • Oumtanee A.
      Being nurse-politicians in Thailand: a phenomenological research.
      ). National and international organisations advocate for greater activism from the within the nursing profession and greater opportunities for nurses to influence policy (
      • Boschma G.
      International nursing history: the International Council of Nurses history collective and beyond.
      ;
      International Council of Nurses
      Going, going, gone: nurses in policy-making positions at WHO.
      ,
      International Council of Nurses
      International Council of Nurses Strategic Plan 2019-2023.
      ;
      • Khoury C.M.
      • Blizzard R.
      • Moore L.W.
      • Hassmiller S.
      Nursing leadership from bedside to boardroom: a Gallup national survey of opinion leaders.
      ;
      • Salvage J.
      • White J.
      Nursing leadership and health policy: everybody's business.
      ;
      World Health Organisation
      State of the World's Nursing 2020: Investing in Education, Jobs and Leadership.
      ).
      Despite the recognised value of nursing contributions to policy making, and an increasingly skilled and educated nursing workforce, several studies highlight the limited involvement or influence of nurses in policy making at local, national and international levels, even at advanced practice and leadership levels (
      • AbuAlRub R.
      • Foudeh F.
      Jordanian Nurses' involvement in health policy: perceived benefits and barriers.
      ;
      • Ahoya C.
      Political efficacy and political participation among nurses in tertiary hospitals, the Republic of Kenya.
      ;
      • Juma P.A.
      • Edwards N.
      • Spitzer D.
      Kenyan nurses involvement in national policy development processes.
      ;
      • O'Rourke N.C.
      • Crawford S.L.
      • Morris N.S.
      • Pulcini J.
      Political efficacy and participation of nurse practitioners.
      ;
      • Rasheed S.P.
      • Younas A.
      • Mehdi F.
      Challenges, extent of involvement, and the impact of nurses' involvement in politics and policy making in in last two decades: an integrative review.
      ). Factors that influence nursing engagement in policy making include power dynamics influenced by professional and managerial hierarchies, confidence, education, motivation, interest and understanding of the processes and opportunities for involvement in policy (
      • AbuAlRub R.
      • Foudeh F.
      Jordanian Nurses' involvement in health policy: perceived benefits and barriers.
      ;
      • Ahoya C.
      Political efficacy and political participation among nurses in tertiary hospitals, the Republic of Kenya.
      ;
      • Asuquo E.F.
      Nurses leadership in research and policy in Nigeria: a myth or reality?.
      ;
      • Hajizadeh A.
      • Zamanzadeh V.
      • Kakemam E.
      • Bahreini R.
      • Khodayari-Zarnaq R.
      Factors influencing nurses participation in the health policy-making process: a systematic review.
      ;
      • Juma P.A.
      • Edwards N.
      • Spitzer D.
      Kenyan nurses involvement in national policy development processes.
      ;
      • Rasheed S.P.
      • Younas A.
      • Mehdi F.
      Challenges, extent of involvement, and the impact of nurses' involvement in politics and policy making in in last two decades: an integrative review.
      ;
      • Shariff N.
      Factors that act as facilitators and barriers to nurse leaders' participation in health policy development.
      ). Where opportunities arise for nurses to become involved in formal policy initiatives, their views may be undervalued, marginalised or overlooked within political fora, or adopt passive roles within policy development and implementation (
      • Alhassan A.
      • Kumi-Kyereme A.
      • Wombeogo M.
      • Fuseini A.-G.
      Nurse Participation in Political Activities: Level and Practices of Registered Nurses in Tamale.
      ;
      • Asuquo E.F.
      Nurses leadership in research and policy in Nigeria: a myth or reality?.
      ;
      • Hajizadeh A.
      • Zamanzadeh V.
      • Kakemam E.
      • Bahreini R.
      • Khodayari-Zarnaq R.
      Factors influencing nurses participation in the health policy-making process: a systematic review.
      ;
      • Juma P.A.
      • Edwards N.
      • Spitzer D.
      Kenyan nurses involvement in national policy development processes.
      ;
      • O'Rourke N.C.
      • Crawford S.L.
      • Morris N.S.
      • Pulcini J.
      Political efficacy and participation of nurse practitioners.
      ;
      • Rasheed S.P.
      • Younas A.
      • Mehdi F.
      Challenges, extent of involvement, and the impact of nurses' involvement in politics and policy making in in last two decades: an integrative review.
      ;
      • Shariff N.
      Factors that act as facilitators and barriers to nurse leaders' participation in health policy development.
      ).
      Nurses have the potential to play a critical role as change agents (
      • Sarnkwawkum P.
      • Oumtanee A.
      Being nurse-politicians in Thailand: a phenomenological research.
      ). However, to actualise this potential impact, efforts are needed to position, empower and engage nurses at all levels. As a first step towards fostering a culture of policy engagement among nurses is to showcase and role model nursing activism in policy making at all levels. Acculturation to nursing roles in policy making and socialisation to political activism at formative points during education and initiation to the workforce are essential to support this. The COVID-19 pandemic has disrupted nursing roles, and spawned much activism within nursing practice and engagement in policymaking to effect positive adaptations to the healthcare services, and ensure continuity and quality of service delivery for cancer patients (
      • Turale S.
      • Meechamnan C.
      • Kunaviktikul W.
      Challenging times: ethics, nursing and the COVID‐19 pandemic.
      ). Despite the impact of the pandemic on nurses’ engagement in policy making; nursing leadership in policy development prior to, and independent of the pandemic must not be overlooked. The evidence of impact of nursing research, clinical practice and advocacy efforts on advances in national and international policies related to patient safety, occupational safety and recognition of specialist cancer nursing roles are extensive (
      • Aiken L.H.
      • Sermeus W.
      • Van den Heede K.
      • Sloane D.M.
      • Busse R.
      • McKee M.
      • Bruyneel L.
      • Rafferty A.M.
      • Griffiths P.
      • Moreno-Casbas M.T.
      • Tishelman C.
      • Scott A.
      • Brzostek T.
      • Kinnunen J.
      • Schwendimann R.
      • Heinen M.
      • Zikos D.
      • Sjetne I.S.
      • Smith H.L.
      • Kutney-Lee A.
      Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.
      ; ;
      European Oncology Nursing Society (EONS)
      EONS at the European Parliament – Getting Our Voice Heard where it Matters.
      ,
      • European Oncology Nursing Society (EONS)
      EONS Cancer Nursing Index 2020.
      ;
      • Kutney-Lee A.
      • Stimpfel A.W.
      • Sloane D.M.
      • Cimiotti J.P.
      • Quinn L.W.
      • Aiken L.H.
      Changes in patient and nurse outcomes associated with magnet hospital recognition.
      ;
      • McHugh M.D.
      • Kelly L.A.
      • Smith H.L.
      • Wu E.S.
      • Vanak J.M.
      • Aiken L.H.
      Lower mortality in magnet hospitals.
      ;
      • Sharp L.
      • Rannus K.
      • Olofsson A.
      • Kelly D.
      • Oldenmenger W.H.
      Patient safety culture among European cancer nurses-An exploratory, cross-sectional survey comparing data from Estonia, Germany, Netherlands, and United Kingdom.
      ;
      • Ullgren H.
      • Sharp L.
      • Fowler M.N.
      CN29 patient and occupational safety in Europe, a survey by the European oncology nursing society, part II.
      ;
      • Ullgren H.
      • Sharp L.
      • Fowler M.N.
      • Conceicao F.
      • Crombez P.
      • Hálfdánardóttir H.
      • Khmaladze A.
      • Protogiros D.
      • Theologia T.A.
      • van Klinken M.
      CN21 patient and occupational safety in Europe: a survey by the European oncology nursing society.
      ).
      As we shift to a new cancer policy landscape, we must take this opportunity to consider where nursing fits within national, European and international policy initiatives. The EU Cancer Mission (
      European Commission
      Mission on Cancer: Implementation Plan.
      ) and Europe's Beating Cancer Plan (
      European Commission
      Europe's Beating Cancer Plan.
      ) provide a significant foundation for research and innovation in the field of cancer care in Europe; the potential for nursing to contribute to the implementation of these major European strategies must be leveraged. Nurses have a significant role to play in cancer prevention, early detection, promotion of equitable cancer care and ourcomes, and improving quality of life and delivery of high-quality cancer care from diagnosis to survivorship (
      • Charalambous A.
      • Wells M.
      • Campbell P.
      • Torrens C.
      • Östlund U.
      • Oldenmenger W.
      • Patiraki E.
      • Sharp L.
      • Nohavova I.
      • Domenech-Climent N.
      A scoping review of trials of interventions led or delivered by cancer nurses.
      ;
      • Kelly D.
      • Campbell P.
      • Torrens C.
      • Charalambous A.
      • Östlund U.
      • Eicher M.
      • Larsson M.
      • Nohavova I.
      • Olsson C.
      • Simpson M.
      • Patiraki E.
      • Sharp L.
      • Wiseman T.
      • Oldenmenger W.
      • Wells M.
      The effectiveness of nurse-led interventions for cancer symptom management 2000–2018: a systematic review and meta-analysis.
      ;
      • Sarnkwawkum P.
      • Oumtanee A.
      Being nurse-politicians in Thailand: a phenomenological research.
      ). The European Cancer Groundshot, Europe's Beating Cancer Plan and EU Cancer Mission make strategic recommendations to address under-funded and under-researched topics in cancer care, including cancer prevention, quality of life and cancer survivorship (
      European Commission
      Europe's Beating Cancer Plan.
      ,
      European Commission
      European Missions: Cancer Implementation Plan.
      ;
      • Lawler M.
      • Davies L.
      • Oberst S.
      • Oliver K.
      • Eggermont A.
      • Schmutz A.
      • La Vecchia C.
      • Allemani C.
      • Lievens Y.
      • Naredi P.
      • Cufer T.
      • Aggarwal A.
      • Aapro M.
      • Apostolidis K.
      • Baird A.-M.
      • Cardoso F.
      • Charalambous A.
      • Coleman M.P.
      • Costa A.
      • Crul M.
      • Dégi C.L.
      • Di Nicolantonio F.
      • Erdem S.
      • Geanta M.
      • Geissler J.
      • Jassem J.
      • Jagielska B.
      • Jonsson B.
      • Kelly D.
      • Kelm O.
      • Kolarova T.
      • Kutluk T.
      • Lewison G.
      • Meunier F.
      • Pelouchova J.
      • Philip T.
      • Price R.
      • Rau B.
      • Rubio I.T.
      • Selby P.
      • Južnič Sotlar M.
      • Spurrier-Bernard G.
      • Van Hoeve J.C.
      • Vrdoljak E.
      • Westerhuis W.
      • Wojciechowska U.
      • Sullivan R.
      European Groundshot—addressing Europe's cancer research challenges: a Lancet Oncology Commission.
      ); areas which have been the domain and long-standing priorities of nursing research and clinical practice (
      • Bradford N.
      • Pitt E.
      • Alexander K.
      of Australia, C.N.S., Committee, R
      Research Priorities of Australian Cancer Nurses: A National Consensus Survey.
      ;
      • Jones R.A.
      • Hirschey R.
      • Campbell G.
      • Cooley M.E.
      • Somayaji D.
      • Lally R.
      • Rueter E.K.
      • Gullatte M.M.
      Update to 2019-2022 ONS research agenda: rapid review to promote equity in oncology healthcare access and workforce development.
      ;
      • Von Ah D.
      Research Agenda of the Oncology Nursing Society: 2019–2022.
      ;
      • Zanville N.Z.
      • Cohen B.
      • Gray T.F.
      • Phillips J.
      • Linder L.
      • Starkweather A.
      • Yeager K.A.
      • Cooley M.E.
      The oncology nursing society rapid review and research priorities for cancer care in the context of COVID-19.
      ).
      With strong frameworks in place to support advancement in these strategic priority areas, there is a significant opportunity to leverage this agenda to advance nursing practice, including specialist education, role recognition and leverage funding streams to support strategic programmes which have short- and long-term impacts on policy and patient outcomes at all levels. To ensure the pathway to impact and translation of learning from innovations in nursing practice and research are realised, engagement in the development of timely and targeted policy briefs is essential (
      • Benton D.C.
      • Watkins M.J.
      • Beasley C.J.
      • Ferguson S.L.
      • Holloway A.
      Evidence into action: a policy brief exemplar supporting attainment of nursing now.
      ). The nursing workforce must now mobilise to ensure that the imminent implementation of European cancer policy is influenced and shaped by nurses at national and international levels. A critical priority to achieve this is to undertake a comprehensive priority-setting exercise for cancer nursing throughout Europe and at national levels which are aligned with national and European policies to ensure nursing is positioned to leverage the opportunities (
      European Commission
      Europe's Beating Cancer Plan.
      ,
      European Commission
      European Missions: Cancer Implementation Plan.
      ;
      • Lawler M.
      • Davies L.
      • Oberst S.
      • Oliver K.
      • Eggermont A.
      • Schmutz A.
      • La Vecchia C.
      • Allemani C.
      • Lievens Y.
      • Naredi P.
      • Cufer T.
      • Aggarwal A.
      • Aapro M.
      • Apostolidis K.
      • Baird A.-M.
      • Cardoso F.
      • Charalambous A.
      • Coleman M.P.
      • Costa A.
      • Crul M.
      • Dégi C.L.
      • Di Nicolantonio F.
      • Erdem S.
      • Geanta M.
      • Geissler J.
      • Jassem J.
      • Jagielska B.
      • Jonsson B.
      • Kelly D.
      • Kelm O.
      • Kolarova T.
      • Kutluk T.
      • Lewison G.
      • Meunier F.
      • Pelouchova J.
      • Philip T.
      • Price R.
      • Rau B.
      • Rubio I.T.
      • Selby P.
      • Južnič Sotlar M.
      • Spurrier-Bernard G.
      • Van Hoeve J.C.
      • Vrdoljak E.
      • Westerhuis W.
      • Wojciechowska U.
      • Sullivan R.
      European Groundshot—addressing Europe's cancer research challenges: a Lancet Oncology Commission.
      ).

      5. Profession and practice

      As nursing faces unprecedented workforce shortages over the coming decade, it is essential that the nursing profession, regulators, employers and governments recognise the potential contributions of nurses at all points in their career from newly qualified nurse to advanced practice and leadership roles (
      • Challinor J.M.
      • Galassi A.L.
      • Al-Ruzzieh M.A.
      • Bigirimana J.B.
      • Buswell L.
      • So W.K.
      • Steinberg A.B.
      • Williams M.
      Nursing's potential to address the growing cancer burden in low-and middle-income countries.
      ;
      • Iro E.
      • Catton H.
      The future of nursing.
      ;
      World Health Organisation
      State of the World's Nursing 2020: Investing in Education, Jobs and Leadership.
      ). The last three decades have seen significant developments in cancer treatment modalities and care models which have influenced the expansion and diversification of cancer nursing roles, including greater substitution of roles and more independent roles for nurses throughout the cancer continuum (
      • Department of Health
      A Policy on the Development of Graduate to Advanced Nursing and Midwifery Practice.
      ;
      • Heale R.
      • Rieck Buckley C.
      An international perspective of advanced practice nursing regulation.
      ;
      • Kelly D.
      • Campbell P.
      • Torrens C.
      • Charalambous A.
      • Östlund U.
      • Eicher M.
      • Larsson M.
      • Nohavova I.
      • Olsson C.
      • Simpson M.
      • Patiraki E.
      • Sharp L.
      • Wiseman T.
      • Oldenmenger W.
      • Wells M.
      The effectiveness of nurse-led interventions for cancer symptom management 2000–2018: a systematic review and meta-analysis.
      ;
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ;
      • Young A.M.
      • Charalambous A.
      • Owen R.I.
      • Njodzeka B.
      • Oldenmenger W.H.
      • Alqudimat M.R.
      • So W.K.W.
      Essential oncology nursing care along the cancer continuum.
      ). Increasingly complex and personalised cancer treatments, nurse-led models of care and transitions to out-patient-based care have created need for an increasingly specialised cancer nursing workforce internationally (
      • Clauser S.B.
      • Wagner E.H.
      • Bowles E.J.A.
      • Tuzzio L.
      • Greene S.M.
      Improving modern cancer care through information technology.
      ;
      • Latter S.
      • Hopkinson J.B.
      • Lowson E.
      • Hughes J.A.
      • Hughes J.
      • Duke S.
      • Anstey S.
      • Bennett M.I.
      • May C.
      • Smith P.
      Supporting carers to manage pain medication in cancer patients at the end of life: a feasibility trial.
      ). However, there are emerging challenges surrounding nursing roles, particularly in countries where “nurse” is not a consistently protected title (
      • Carter N.
      Clinical nurse specialists and nurse practitioners: title confusion and lack of role clarity.
      ;
      • Leary A.
      • Maclaine K.
      • Trevatt P.
      • Radford M.
      • Punshon G.
      Variation in job titles within the nursing workforce.
      ). In the absence of a protected title for nursing, confusion in role and registration requirements, qualification, and scope of practice have arisen, undermining the recognition of specialist and advanced practice roles in nursing (
      • Leary A.
      • Maclaine K.
      • Trevatt P.
      • Radford M.
      • Punshon G.
      Variation in job titles within the nursing workforce.
      ). Furthermore, this creates a basis for the erosion of nursing roles, particularly leadership roles; to address nursing workforce shortages; in the absence of a protected title, healthcare and other workers who are not registered nurses can and have been recruited to fill nursing vacancies (
      • Leary A.
      • Maclaine K.
      • Trevatt P.
      • Radford M.
      • Punshon G.
      Variation in job titles within the nursing workforce.
      ).
      In the face of emerging workforce challenges, the contribution of registered nurses to patient care must not be overlooked. Europe makes a significant contribution to the evidence-base for nurse-led cancer care addressing physical and psychological wellbeing (
      • Charalambous A.
      • Wells M.
      • Campbell P.
      • Torrens C.
      • Östlund U.
      • Oldenmenger W.
      • Patiraki E.
      • Sharp L.
      • Nohavova I.
      • Domenech-Climent N.
      A scoping review of trials of interventions led or delivered by cancer nurses.
      ). More than half of clinical trial studies evidencing nurse-led cancer care originated within Europe, utilising face-to-face, online and telephone-based care models involving direct patient care, psychological support, teaching, assessment, monitoring and case management (
      • Charalambous A.
      • Wells M.
      • Campbell P.
      • Torrens C.
      • Östlund U.
      • Oldenmenger W.
      • Patiraki E.
      • Sharp L.
      • Nohavova I.
      • Domenech-Climent N.
      A scoping review of trials of interventions led or delivered by cancer nurses.
      ). These interventions showed significant effectiveness across several cancer symptoms including fatigue, nausea and vomiting, constipation, depression, anxiety and mood when compared with usual care (
      • Kelly D.
      • Campbell P.
      • Torrens C.
      • Charalambous A.
      • Östlund U.
      • Eicher M.
      • Larsson M.
      • Nohavova I.
      • Olsson C.
      • Simpson M.
      • Patiraki E.
      • Sharp L.
      • Wiseman T.
      • Oldenmenger W.
      • Wells M.
      The effectiveness of nurse-led interventions for cancer symptom management 2000–2018: a systematic review and meta-analysis.
      ). However, it is difficult to compare the outcomes of the intervention studies due to heterogeneity in outcome measures. To ensure the impact of cancer nursing interventions are effectively captured, a minimum core dataset for measuring the outcomes of cancer nursing interventions is essential to strengthen the quality of nurse-led intervention studies. Furthermore, multi-national studies, including countries with varying recognition of specialist and advanced cancer nursing roles is necessary to understand disparities in care and provide a greater evidence-base for specialist and advanced practice capacity-building within these countries.
      Given the evidence for the positive impact of nurse-led interventions on symptom management and supportive care outcomes for patients with cancer, there is a basis to argue that well-trained cancer nurses are a core component in the delivery effective supportive cancer care (
      • Kelly D.
      • Campbell P.
      • Torrens C.
      • Charalambous A.
      • Östlund U.
      • Eicher M.
      • Larsson M.
      • Nohavova I.
      • Olsson C.
      • Simpson M.
      • Patiraki E.
      • Sharp L.
      • Wiseman T.
      • Oldenmenger W.
      • Wells M.
      The effectiveness of nurse-led interventions for cancer symptom management 2000–2018: a systematic review and meta-analysis.
      ). However, in the absence of consistent access to specialist cancer nurses throughout Europe, the recruitment and retention of cancer nurses must be a priority to ensure the achievements in cancer-related outcomes can be sustained (
      Breast Cancer Now
      The Unsurvivors Report.
      ). While pay and conditions are often the focus of narratives surrounding workforce retention, issues of recruitment and retention are often more complex (
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ;
      • Lagerlund M.
      • Sharp L.
      • Lindqvist R.
      • Runesdotter S.
      • Tishelman C.
      Intention to leave the workplace among nurses working with cancer patients in acute care hospitals in Sweden.
      ). For example, among early career nurses, adjustment and acculturation to the profession, access to continuing professional development, access to mentorship and supportive practice environments are factors which influence intention to leave nursing (
      • Cosgrave C.
      • Maple M.
      • Hussain R.
      An explanation of turnover intention among early-career nursing and allied health professionals working in rural and remote Australia - findings from a grounded theory study.
      ;
      • Flinkman M.
      • Salanterä S.
      Early career experiences and perceptions – a qualitative exploration of the turnover of young registered nurses and intention to leave the nursing profession in Finland.
      ;
      • Hussein R.
      • Everett B.
      • Ramjan L.M.
      • Hu W.
      • Salamonson Y.
      New graduate nurses' experiences in a clinical specialty: a follow up study of newcomer perceptions of transitional support.
      ;
      • Kelly D.
      • Lankshear A.
      • Wiseman T.
      • Jahn P.
      • Mall-Roosmäe H.
      • Rannus K.
      • Oldenmenger W.
      • Sharp L.
      The experiences of cancer nurses working in four European countries: a qualitative study.
      ;
      • Laschinger H.K.S.
      • Finegan J.
      • Wilk P.
      New graduate burnout: the impact of professional practice environment, workplace civility, and empowerment.
      ;
      • Mazzella Ebstein A.M.
      • Sanzero Eller L.
      • Tan K.S.
      • Cherniss C.
      • Ruggiero J.S.
      • Cimiotti J.P.
      The relationships between coping, occupational stress, and emotional intelligence in newly hired oncology nurses.
      ;
      • Price S.
      • Reichert C.
      The importance of continuing professional development to career satisfaction and patient care: meeting the needs of novice to mid- to late-career nurses throughout their career span.
      ;
      • Rudman A.
      • Gustavsson J.P.
      Early-career burnout among new graduate nurses: a prospective observational study of intra-individual change trajectories.
      ;
      • Sexton K.A.
      • Hunt C.E.
      • Cox K.S.
      • Teasley S.L.
      • Carroll C.A.
      Differentiating the workplace needs of nurses by academic preparation and years in nursing.
      ). Meanwhile, interventions to address retention of early career nurses may only superficially address these issues, focusing on short-term objectives through orientation and internship, rather than long-term career planning (
      • Barhate B.
      • Dirani K.M.
      Career aspirations of generation Z: a systematic literature review.
      ;
      • Brook J.
      • Aitken L.
      • Webb R.
      • MacLaren J.
      • Salmon D.
      Characteristics of successful interventions to reduce turnover and increase retention of early career nurses: a systematic review.
      ;
      • Drury A.
      • Diez de Los Rios C.
      The education, training & support needs of young cancer nurses.
      ). Interventions to address recruitment and retention require targeted, co-designed interventions for the specific populations they wish to serve. Understanding the diversity of the unmet needs experienced within the cancer nursing workforce is essential to the tailoring of interventions to support retention of cancer nurses, and in the longer-term, the advancement of the profession.

      6. Conclusion

      The impact and legacy of the COVID-19 pandemic have created significant challenges for the nursing workforce, following significant evolution and advancement in cancer nursing roles and recognition (
      • Charalambous A.
      • Wells M.
      • Campbell P.
      • Torrens C.
      • Östlund U.
      • Oldenmenger W.
      • Patiraki E.
      • Sharp L.
      • Nohavova I.
      • Domenech-Climent N.
      A scoping review of trials of interventions led or delivered by cancer nurses.
      ;
      • Miller K.D.
      • Nogueira L.
      • Devasia T.
      • Mariotto A.B.
      • Yabroff K.R.
      • Jemal A.
      • Kramer J.
      • Siegel R.L.
      Cancer treatment and survivorship statistics, 2022.
      ;
      • Wild C.P.
      • Weiderpass E.
      • Stewart B.W.
      World Cancer Report: Cancer Research for Cancer Prevention.
      ). As we look to the future for cancer nursing, we must combine and leverage learning from the pandemic, integrating the achievements in progression of cancer nursing and the spirit of disruption and innovation within healthcare which has been sparked by the pandemic. While we argue for the continued advancement of cancer nursing; the focus must shift to addressing inequities in the role recognition and access to specialist education throughout Europe and globally. Partnership, exchange of learning, and co-design will be central to progressing education, evidence and policy to underpin shifts in recognition of cancer nursing, support growth in the cancer nursing workforce and embed cancer nurses in policy setting at local, national and international levels. To achieve this vision for cancer nursing; we propose that disruption is needed to shift the status quo, and ensure that activities which seek to build nursing capacity in education, research, policy and practice contexts are relevant and sensitive to diversity within the nursing workforce, and the patients, families and communities they serve.

      Credit statement

      All authors were responsible for the conceptualisation of this manuscript (AD, VS, LS, HU, JdM, WO). All authors contributed to the literature searches and development of the manuscript (AD, VS, LS, HU, JdM, WO). AD prepared the draft manuscript. All authors (AD, VS, LS, HU, JdM, WO) critically reviewed and approved the paper. AD is guarantor.

      Uncited references

      Directive 2022/431
      Directive 2022/431 - Amendment of Directive 2004/37/EC on the Protection of Workers from the Risks Related to Exposure to Carcinogens or Mutagens at Work, in: European Commission.

      Declaration of competing interest

      AD, JdM, WO and VS are Board Member of the European Oncology Nursing Society (EONS), AD is chair of the Research Working Group of EONS, HU is a chair of the Advocacy Working Group of EONS. LS is the former President of EONS.

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