key: cord-1049091-c00n2pf1
authors: Kelly, Daniel; Lankshear, Annette; Wiseman, Theresa; Jahn, Patrick; Mall-Roosmäe, Ms Heleri; Rannus, Dr Kristi; Oldenmenger, Dr Wendy; Sharp, Dr Lena
title: The experiences of cancer nurses working in four European countries: A qualitative study
date: 2020-10-14
journal: Eur J Oncol Nurs
DOI: 10.1016/j.ejon.2020.101844
sha: d784668fb11a56101e12fa5d81eebe379086c170
doc_id: 1049091
cord_uid: c00n2pf1

PURPOSE: Cancer nurses across Europe are being tasked with delivery of an increasing number of complex treatments and supportive care interventions as a result of ongoing advances in cancer research, and a rise in cancer incidence due to demographic changes. However, all health systems delivering cancer treatment innovations require access to an educated and motivated nursing workforce to meet demand. This study by the European Oncology Nursing Society examines comparative features of cancer nursing in Estonia, Germany, the Netherlands (NL) and the United Kingdom (UK). METHODS: Descriptive qualitative study using focus groups and individual interviews drawing on the views of cancer nurses, managers and stakeholders from four European countries (n = 97). Data collection was designed around national cancer nursing conferences held in Berlin (Germany), Ede (NL), Harrogate (UK) and Tallinn and Tartu between May 2017 and April 2018. Participants included a mix of nursing grades and specialisms. FINDINGS: According to the participants education and career structure for cancer nursing was most well-developed in the Netherlands and the United Kingdom. In Germany and Estonia developments were taking place at Masters level. None of the countries had recordable qualifications in cancer nursing. Variations existed in terms of advanced practice roles and salary. Workload pressures were common, and were rising, and wellbeing initiatives were not identified. Nurses reported gaining positive feedback from caring for patients. DISCUSSION: As demand for cancer treatment continues to grow there is a need to ensure an adequate supply of cancer nurses with the appropriate education and career structure to support patients. This study provides insights from four countries and suggests the need for better recognition as well as working conditions, education and career structures that advance the potential of the cancer nursing role in Europe.

Advances in biomedical technology coupled with increased cancer incidence and prevalence have resulted in significant expectations placed on the cancer nursing workforce to support people affected by cancer (PABC). Cancer nurses across Europe are being tasked with delivering an increasing number of complex treatments and supportive interventions as a result of ongoing advances in cancer research (Ringborg et al., 2019) . However, all cancer treatment innovations require access to a nursing workforce that is educated and motivated for successful delivery.

There is some evidence in the literature of the extent, nature and efficacy of specialist nursing roles (Bonsall and Cheater, 2008, Morilla-Herrera et al., 2016) . This evidence was systematically reviewed in Phase 1 of a project entitled "Recognising European Cancer Nursing (RECaN)" (Charalambous et al., 2018) . This paper sets out results from the second phase with the purpose of examining comparative features of the working lives of cancer nurses in Estonia, Germany, the Netherlands (NL) and the United Kingdom (UK), including some in specialist and advanced practice roles. By way of introduction and to aid comparison we first set out relevant contextual data for each of these countries.

The incidence of cancer within countries of the Organisation for Economic Co-operation and Development (OECD) alliance is currently in excess of 7.5 million per annum, the disease being responsible for more than 25% of all deaths (OECD, 2019). It also has a significant economic impact, accounting for 5% of health expenditure. The four countries selected for Mammogra phy % women screened 5 Wom Me J o u r n a l P r e -p r o o f

The most recent OECD figures for total nurse staffing show an average of 8.8 per thousand population (OECD, 2019) and Table 1 demonstrates how our four index countries compare. Acquiring information on cancer nurses specifically, however, is more difficult as this qualification is not recorded in any of the four countries although informed estimates do exist. In the UK a 2017 report cited a total registered cancer nursing workforce of 7,680 (Macmillan Cancer Support, 2017) . In Germany, the oncology nursing society (Onkologische Kranken-und Kinderkrankenpflege or KOK) estimates that there are 64,000 nurses currently working in the cancer care sector. In neither NL nor Estonia is there clear government information about the current cancer nursing workforce.

Basic Registered Nurse (RN) education in both NL and UK is already at degree level, and in Estonia students study for 3.5 years in applied (professional) higher education that is equated to a bachelor´s degree. In Germany the vast majority of students undertake a three-year vocational programme although degree programmes are available. At the time of initial data collection, Estonia was an outlier in having no formal post-basic specialised nursing education in cancer, although at the time of writing a Masters-level cancer pathway had just been established. All EU countries have to comply with EU directives on the recognition of professional qualifications including required practice experience, and these will remain a key driver for future developments (Directive All regions (Bundesländer) of Germany offer a post-basic cancer programme of up to two years. These programs are government-controlled, but the lack of a federal structure for a mandated nursing register means that there is no consistent mechanism for ensuring that nurses are up to date (Rafferty et al., 2019) . Both practice and post-registration education are treatment related and with a medical focus and there is little scope for independent practice despite attempts by nursing associations to promote progress in line with other European countries (Deutcher Berufsverband für Pflegeberufe, 2013).

The opportunity to develop prescribing roles and to develop expanded nursing roles mainly in the field of chronic disease has been permitted under the "Nursing-Development Law" (Pflegeweiterentwicklungsgesetz) of 2008, but in fact the first nurses J o u r n a l P r e -p r o o f with prescribing competences will only finish their Bachelor degree in 2020. There are various reasons for the slow progress including the development of a federal structure of nursing chambers and mandatory registration, but additionally the relatively high numbers of German physicians (Table 1) However, as in the UK, cancer nursing is not a recordable qualification on the register and therefore it is the responsibility of employers to ensure that nurses are suitably qualified for the role to which they are appointed. In NL, the rights and responsibilities of advanced practice nurses (APNs) was legally defined in the autumn of 2017, establishing the right to prescribe and to carry out endoscopies, biopsies and minor surgical procedures.

In the UK, significant expansion of the role of the nurse has been ongoing since the early 1970s. By 2017, roles carrying the title Clinical or Cancer Nurse Specialist (CNS) formed 79% of the cancer workforce while 4% were Advanced Nurse Practitioners. A survey in 2017 revealed that of the former, 86% had responsibility for patients with a defined tumour site (Macmillan, 2017) . After many years of clinical innovation but lack of formal regulation (King et al., 2017) , the UK Royal College of Nursing now offers a credentialing framework for advanced nursing practice with the requirement of a relevant Master's degree and an independent prescribing qualification (RCN, 2018).

This paper presents qualitative data from the three-phase RECaN project initiated and undertaken by the European Oncology Nursing Society (EONS) (Campbell et al., 2017) , the first phase of which consisted of a systematic review of nursing roles in cancer (Charalambous et al., 2018) . This second phase was designed to explore the opportunities, challenges and working conditions of cancer nurses in Estonia, Germany, NL and the UK. It also included an exploratory cross-sectional survey, using the Hospital Patient Safety Culture Survey (AHRQ, 2016), to study perceived patient safety culture among cancer nurses and the J o u r n a l P r e -p r o o f results of this were reported separately (Sharp et al., 2019) . This phase was descriptive and followed key principles of qualitative research (DeJonckheere M, Vaughn LM (2019). These included taking a relational and facilitative stance to encourage data collection form the perspective of nurses in each country.

Data collection was designed around national cancer nursing conferences held in Berlin (Germany), Ede (NL), Harrogate (UK) and Tallinn and Tartu (Estonia, where data were also collected during visits to a new cancer centre) between May 2017 and January 2018. The methods used in the different countries were as follows:

• Focus group x1 with managers (FGMan)

• Focus group x1 with clinical nurses (FGClin)

• 5-6 interviews with cancer nurse leaders (INT)

• Meeting with local stakeholders (in Estonia only)

The focus groups and interviews focused on revealing issues of relevance in terms of the development of cancer nursing using the same prompts. Topics included access to education, advanced nursing roles, conditions of service, workload and staffing and work environment.

The study followed the COREQ criteria for qualitative research.

The study protocol was approved by the ethics committee of Cardiff School of Healthcare 

Invitations, participant information sheets and consent forms for the focus groups were sent out in advance by PJ, WO, and HM-R acting as EONS country representatives (in Germany, NL and Estonia respectively) and in the UK by the conference organisers. At each event, and after collecting signed consent forms, two FGDs were conducted, one for clinical cancer nurses and one for cancer nurse managers. All were conducted by AL, DK, PJ, KR, LS, TW J o u r n a l P r e -p r o o f in English with the exception of those held in Germany, where this major barrier to recruitment was revised such that the FGDs were conducted in German by PJ and AL.

All group interactions were recorded using two voice recorders and boundary microphones.

They were then transcribed in full and (for Germany only) translated. In Estonia an additional meeting was also held with around 10 local stakeholders representing University staff, nursing unions and professional associations as well as lead cancer physicians and nurses. This meeting was carefully minuted but not recorded.

Interviews with leaders in the profession were also organised during the same conferences although tight time constraints meant that about half (n= 14) were also carried out subsequently by telephone by AL. Some of these participants had been identified by the EONS country representatives, whilst others arose from serendipitous meetings with senior individuals who showed interest in the study during each conference. All face-to-face interviews took place in a private or semi-private space. Telephone interviews were carried out by Skype call to participants' landlines using Ecamm recording technology that was found to give extremely high-quality, interference-free recordings. All interviews were later transcribed in full and anonymised. It should be noted that the quality of English spoken by respondents was high and quotations are presented verbatim, although sub-optimal language constructions may be evident in some cases.

Transcribed documents were imported into Dedoose 8.0.3.1 and, using a grounded approach based on constructivist theory, data were inductively analysed by theme and subthemes that were then combined and collapsed as necessary during the process of analysis (Nowell et al 2017). As we moved from analysis to synthesis, findings were written up by country in relation to national context and the nature of the healthcare system. Although themes were common across all four countries, there were also different emphases identified that are reported here.

Once completed, each report was sent to the relevant country-based author for checks of accuracy in reporting health policy, legal and statistical data and amendments were made in the light of feedback. All qualitative data together with the country reports were made available to DK and LS who confirmed that the final reports were grounded in the data.

During the study AL was in close contact with each country lead and involved them in reviewing the emerging data and encouraging a reflexive approach to analysis and reporting.

AL & DK also reflected on comparative findings across the four countries and the implications of each.

Results are presented according to response to the questions posed in the focus groups and interviews. The perspective from each country is considered as well as implications more generally for cancer nursing in Europe.

Although we set out to achieve broadly comparable numbers of participants across the four countries, some variation did occur. Attendance of participants at the focus groups and meetings is indicated in Table 2 . Table 2 : numbers attending focus groups and interviews by country

Beyond basic nursing training, Estonian FGD participants confirmed that, at the time of the study, no formal approved specialist cancer education was available and most education was by means of in-service training, self-study or by attending national or international cancer nursing conferences. The modest size of the country, we were told, made it difficult to organise cancer-specific education other than on-the-job or student-centred forms of learning:

"These nurses who are interesting in cancer nursing, they can focus on cancer nursing and all the individual work they do during this programme they do focusing on cancer nursing. So we, as a small country, we can't choose all these different clinical specialities, for example, we don't have enough resources to focus only on cancer or rheumatology. INT5 Estonia German respondents demonstrated a very different picture showing widespread availability of regionally-approved cancer programmes although they also lacked a national system of registration or revalidation. This was seen as a limitation to how cancer nursing was viewed there:

"Yes, really, yes, that's a big problem. You make the education and you make your examination and then you are a nurse, the whole life, … that's a great discussion in Germany at the moment, the last one or two years, that we nurses, we think we need a registration to professionalise our profession and the policy." INT6, Germany

In both the UK and NL ongoing education was an absolute requirement for continued nursing registration and a wide range of Masters-level programmes in cancer nursing are already available. However, in the UK access was made difficult by a nursing shortage which was a challenge when release for study time was requested:

"When you talk about education, … I find that people are called back to wards, they can't go there; an enthusiastic work force who want to be better than they already are but can't … We used to have two-week internal cancer programmes as well as the ones that went on the university. We had all sorts of different types of development. But sadly, not many people are freed up because of numbers." FG Clin, UK In NL each nurse has a personal training budget. A norm of a 50% ratio of qualified cancer nurses to RNs had been established in the country for all clinical settings, although some hospitals were struggling to achieve this because of the high rate of turnover of nurses:

"It goes a lot of time to educating them all so they can work safe and give the same quality of care as an experienced nurse and there is less experienced nurses I think and the young ones stay only for three or four years, so every time you think, now, we are almost at what I want, they are going again." FG Man, NL The variation in availability and access to education was a finding that applied to all four countries. The solution to this issue points to national policy responses that would allow the education and development of a workforce better prepared to meet rising cancer demand. This is the next theme to be reported.

Both the NL and the UK began extending the role of cancer nurses approximately 30 years ago, driven by a shortage of medical staff in the former and in the latter primarily by implementation of the European working time directive that set new limits on the hours to be J o u r n a l P r e -p r o o f worked by junior doctors. In both countries advanced nursing roles were initially met with concern or opposition by both nursing and medical colleagues (King et al 2017) .

Medical opposition in NL was to some extent also driven by financial concerns for those who were not employed wholly by hospitals, but again in both countries, there was a fear that educational opportunities for junior doctors would be lost: "In the University Hospitals, at first, it was very difficult because they said, well, we are a hospital, and we also have to educate physicians and if we have a clinical nurse specialist and they will see those patients, then the doctors who have to learn more won't see." INT2, NL

In the UK CNSs are key workers in the cancer workforce and routinely assess haematological results and patient's suitability for cytotoxic therapy. Here, however, there is still no legal definition of advanced nursing practice, although these roles have developed alongside postgraduate education provision and have often been able to offer more continuity of care than is possible by virtue of regular rotations of junior medical staff:

"On the surgical side we use them so patients get continuity of care because when doctors change every six months it then throws everything up in the air and we find patients aren't getting what they need so the advanced nurse practitioner will make sure that all the new doctors coming on board know what those patients should have" INT2, UK In both countries some highly qualified and experienced ANPs were undertaking independent endoscopic procedures, bone marrow aspiration and biopsies. If they had completed an accredited prescribing programme, they also had prescribing rights and could deal effectively with troublesome symptoms or managing the side-effects of cytotoxic medication. In NL a legal milestone had recently been reached in respect of nurse practitioners: "Yes, well actually it's a kind of celebration here! Because now for about five years it is an experimental role, but now it's not experimental anymore. Now it's the nurse practitioner is a professional and it's written and … September 2017 by law that we are a professional in the health care system and so it's normal." INT3, NL In Germany, we uncovered some frustration amongst cancer nurse leaders there with regard to the very slow development of advanced nursing roles, with one respondent claiming that the country was "like a third world country" when it came to nursing, generally. However, despite the barriers outlined above, nursing practice in Germany had undergone some notable changes in recent years. Nurses had become more involved in assessing, advising and counselling patients prior to discharge and those who had completed a bespoke programme J o u r n a l P r e -p r o o f might, like their colleagues in the UK and NL, be delegated authority to administer chemotherapy treatment provided the hospital carried the legal risk.

One German participant who had completed a Masters degree in Switzerland and then taken up post as an Advanced Nurse Practitioner performing bone marrow aspirates and trephine biopsies, believed they were currently the only one in their oncology field in the country:

"Germany don't know nurses in clinics. This is completely new and we do the myeloma clinic together, so the doctor and me and I am additional there for all the topics about symptom and symptom management, so that's my chance to meet them right at the time point of diagnosis or even a little bit before when the diagnosis is unclear." INT5, Germany Thus, individual CNS and ANP roles were gradually being established in Germany, but respondents, whilst expressing their fundamental willingness to extend their roles, were adamant that they would only support these developments as and when the current acute shortage of nurses was addressed.

At the time of data collection, there was no agreed definition of any advanced roles in cancer nursing in Estonia. If any clinical intervention is needed, the Estonian cancer nurse would refer the patient on to a physician or other healthcare professional. A key net benefit of the gradual introduction of advanced nursing roles in Estonia was that it provided a named link nurse for patients between hospital appointments: "The patient comes first time, gets their diagnosis, then the nurse specialist, as we call it, talk with him or her and also talk about that what kind of side-effects could or may happen … and then they get also in paper the phone number and contacts and then they go home from the hospital. Then they can always call to that nurse … and the nurse will document this and also consult with physician if needed and we have also such kind of cases now that we have also said that you have to go urgently to the emergency department, so we have saved some lives I think, yes, with this consultation." INT1, Estonia

In terms of decision making, these emerging independent nurse roles still appear very constrained when compared with those of their colleagues elsewhere:

"When the patient comes nurse can take (blood work) analysis they can put intravenous cannula and such kind of procedures, they can do it, and after that the nurses are waiting for the doctor's decision." INT3, Estonia

There was said to be some discussion in the country that might result in the conferring of limited prescribing rights to nurses but at the time of writing these are opposed by physicians and do not exist.

Participants from both Germany and Estonia could see potential benefits to patients by having extended nursing roles and could also identify how professional ambitions could be addressed by doing so. However, there were other factors also to be considered before this change might occur, including the central question of remuneration.

Pay showed significant variation across our sample, although the comparison of figures is complex, not only because of variation in cost of living but also because of differences in "I think some Trusts band much higher than others, so certainly I'm based in (name of town), and some of the surrounding areas … what we would class as a basic chemotherapy nurse is a Band 6 and mine are Band 5's … and we do lose staff to that … I don't think it's about pay, the banding, that they are bothered about really. It's about status. It's about having that recognition of the responsibility that they have… The complex treatment that we're giving now is way different to what it was even three years ago when I first started in this role." Despite all four countries being subject to the same EU working time directives, the four countries demonstrate a wide range of working conditions. In NL, the number of hours elapsing between shifts is mandated such that it is not possible to undertake an early shift immediately after a late shift, in accordance with the EU directive that mandates 11 consecutive hours rest in any 24-hour period. On the other hand, nurses in one part of Estonia could work 24-hour shifts without statutory breaks, negotiating rest times with each other as and if workload allowed. In other areas, these long shifts are allowed in exceptional circumstances only. Many staff in the former, we were told, preferred to work these long shifts because it meant less travelling for those who lived some distance from their workplace, and because they, at least notionally, had a significant period of time off between shifts. This last point is linked to pay (a significant number of Estonian nurses have more than one job and many more work significant amounts of overtime) and the 24-hour shift makes both options possible. The clinical nurses in the Estonian focus group confirmed that they did have choice in the shifts they worked and stated that they were used to coping with 24-hour shifts, but when asked a specific question, acknowledged that, having started a shift at 8am, were, by late in the evening, 'exhausted.'

A rising workload was reported across the whole sample, attributed to an expanding ageing population, improved diagnostic techniques and novel treatments that give rise to greater patient acuity in the hospital sector (Macmillan 2017) . That the size of the nursing workforce had not increased commensurate with demand was illustrated by the situation in Germany, where hospitals are experiencing an acute shortage of registered nurses. This was ascribed to lower training numbers, now inadequate in the light of demographic changes, an increase in physician numbers, static levels of pay, a predominantly female profession that does not return to work after maternity leave (because of the difficulties of shift work) and a growing range of occupational choices, especially for the better educated. Once trained, there is a significant loss to the profession-the average length of service was reported to be 7-8 years with one NL respondent suggesting that 3-4 years was more accurate. It was suggested by one respondent that nursing finds itself in a vicious circle in which shortage of nursing staff leads to even further shortages:

"The nurse to patient ratio was much better 10 years ago and…there are young people who are working the first years in hospitals who go away because they say it's too much work, it's too much stress, and …we have to go out of doing the job, not because of the job, but because of the problems that … they are suffering from the lack of nurses." INT1, Germany

Dutch respondents also stated that in many ways nursing was still an attractive profession to new recruits, offering secure employment and a wide variety of roles and specialisms.

Despite this, there was also perceived to be a shortage of available nurses, although it was not clear whether this was an actual reduction in numbers or a relative insufficiency in the light of new roles, changed work patterns, increased workload and higher staffing standards. One FGD participant, the head of oncology services in a small local hospital, noted that patients were usually more ill and therapeutic regimes increasingly individualised, yet articulating the case for more nursing resources for oncology in a general hospital was difficult when all departments were experiencing an increased workload:

"…we are not an oncology centre, we are just an ordinary hospital with everything in it, and we think we are special because we are from oncology, but the other ones think that we ask too much, so how do we make our own position in the hospital, that's the difficulty. FG Man, NL

The net result was that the ability of nurses to offer emotional support to patients, seen as perhaps the most rewarding part of their job, was being compromised. Attempts in the NL have been made in the past to recruit from other countries, but language constraints served to limit the field.

At the time of the study there was no extant cancer plan in Estonia, the last having expired in 2015. Overall, there was a shortage of registered nurses, calculated at 1,000 vacancies from a total of 9,000. Nevertheless, recruitment to nursing programmes appeared healthy, with one Estonian educationalist reporting a three to fourfold rate of applications. One nurse leader told us that they lost a significant number of nurses immediately on graduation, partly to motherhood and partly to other countries. Clinical nurses in Estonia reported that the shortage of cancer staff, across all professions, was endemic:

"We do not have enough doctors and the number of patients is growing and growing and in Estonia the incidence of cancer is rising roughly 2% per year. Every year it rises, rises, rises." FG Man, Estonia At the time of the FGDs, when asked for the one thing that Estonian nurses would wish to be changed, workload was the primary issue mentioned:

"I think our department wants more nurses, but the system is quite closed-minded about that because our department doesn't have the money, so we just have to live with the over hours and the exhaustion. We are always overpopulated with patients…" FG Clin, Estonia It emerged that maintaining and growing the number of increasingly skilled clinical nurse specialists/advanced practitioners to a service with rising numbers of patients was a major problem, especially in large (and expensive) cities. Participants spoke of having, for the first time, to recruit newly qualified nurses into the cancer field. Some UK Trusts had looked abroad, both to Europe and beyond and there were major concerns about the decision of the UK to withdraw from the EU, bringing an end to the free movement of people, including more nurses. Furthermore, recent changes to nurse education in England had both abolished the bursary (a payment of around £6,000 per annum) and mandated that students, rather than the Department of Health, pay university fees -a move widely expected to reduce entrants further. At the time of writing this decision was under review.

One of the most striking features of the discussions with participants across the four countries was the extent to which participants spontaneously shared their love for the work, citing colleagues and patients as key motivators in the workplace:

"The patients are very positive as well and if you do your job well then they give you a positive feedback and that gives you energy that helps you get through the harder times" (murmur of agreement}. FG Clin, Estonia "I like my job because our patients come for longer chemotherapy. Five or seven days or something or sometimes more days. … I like supporting patients in the whole treatment and what I like the most is not the technical part of the work but the psychosocial part of the work. Attentive care." FG Clin, NL

One of the most difficult and emotionally taxing parts of a cancer nurse's job, we were told, is managing the end of active treatment and the transition to palliative care at a point where relatives may not necessarily be ready, even when patients feel that they have had enough: "I sometimes have a problem with, on the one hand, patients finding it difficult to understand the palliative situation… it is always the most difficult thing to say at some point, ok, we're here now at the end, and now it would just be better to focus on palliative related activity." FG Clin, Germany

We did not find evidence of any systematic formal support for cancer nurses across the sample. Clinical supervision was cited by some managers as important in theory to address the emotional support needs of staff, although others stated that individual nurses neither valued nor wanted it. Different approaches had been tried, one involving a member of the J o u r n a l P r e -p r o o f psychology team who led a group at which attendance was said to be compulsory. The value of having someone from outside the unit was stressed by one UK manager:

"They were at first very sceptical but fortunately this chap is … new in post, he's got lots of ideas, he's quite innovative, he's used things like he's taught them mindfulness and things like that and how to relax and I don't go to them, so you know, that's protected time away from me, I don't know what's discussed, I don't know anything." INT5, UK When looked at in totality there was positive feedback about working in an oncology environment by these participants. This did not vary across the countries although other factors did, including pay and access to education. This variation is summarised in Table 3 

This study has provided new insights into the views of cancer nurses working in four European countries. This is important as the demand for cancer nurses globally will only continue to rise (Cummings et al 2018) . The insights provided by this study provide areas for priority action, including rising workloads, access to education and career development, parity on pay and addressing shortages to prevent losing nurses to a system that becomes In a few hospitals in Germany, nurses' roles were gradually being extended, albeit, at the time of the study, without prescribing rights although such a development is legally possible and at least one degree-level prescribing programme is in progress. Nursing shortages were also hampering developments in Estonia, although some nurses who had acquired a specific knowledge base were now offering advice to patients with a wide range of cancers. The latter country's lack of post-basic clinical education had hampered role enhancement and here the development of specialised clinical education was seen as urgent, not only for reasons of patient safety but also to stimulate and motivate young nurses seeking self-improvement. In the meantime, the long hours worked by Estonian nurses, driven partly by shortages and partly by low wages necessitated widespread overtime working, is clearly in breach of the EU working time directive and is a cause for concern, not least because it could make access to post-basic education difficult even if this becomes available.

In none of the four countries were there official records of nurses working in the field of cancer nursing, although estimates had been made in the UK (Macmillan 2017 Continuing professional development for cancer nurses would seem to be self-evidently crucial, given the fast-changing nature of cancer treatment and the potentially lethal effects of errors or adverse events. As more bespoke regimens of molecularly targeted agents, immunotherapy drugs and innovative treatments (CarT cell therapy, MRI Linac) are introduced, education becomes still more vital (Ringborg et al 2019) . It is therefore of some concern to note the limited opportunities for cancer education opportunities in Estonia, as well as the fact that nurses in the UK reported that they were unable to access available education either because they could not be released from the clinical setting or could not be supported financially.

We were struck by the observation of one respondent in Estonia who linked the low status of nurses to their lack of education, arguing that patients placed greater value on the information given by what they may perceive to be better-educated physicians. If, as Brekke and Nyborg argue in their paper on motivation, feeling important to patients is an important motivator for health professionals, increasing access to education may raise both the status and motivation (and by implication retention) even in the absence of salary rises (Brekke and Nyborg, 2010) . Across all four countries there was a common dissatisfaction with nurse's pay. This finding is, of course, always relative. What is an acceptable salary for a single newly qualified nurse working in a relatively well-supervised ward in a small town may seem inadequate for a mature colleague with many years of experience working in an expensive capital city.

Although the NL and UK were found to have the highest salary bands for nurses, including those with specialist skills and qualifications, the current pay of an individual nurse managing complex patient pathways, including the initiation and monitoring of treatments seems hardly excessive when compared to the salaries of physicians, and it may be it is at this end of the scale that change also needs to occur. Although the apparently transparent national salary structure in the UK, and by sector in NL (NFU, 2019) shows rising levels of pay, it is clear that grades can be manipulated by employers by the variation in interpretation of banding criteria (Macmillan Cancer Support, 2017).

It was somewhat surprising, given the demanding nature of cancer nursing, that the data also revealed a generally high level of work satisfaction. There were few examples of formal J o u r n a l P r e -p r o o f support being provided by management; most respondents stating that they enjoyed their autonomy and received specific support both from colleagues who understood the stresses of the job and from the close relationships with a patient group who valued them. It is notable, however, that this opportunity was not always available to those working in high turnover environments.

The main limitation of this study lay in the relatively small sample size in each country, especially given the fact in some pay and conditions are negotiated by region and/or by sector and can vary widely. Data were gathered at nursing conferences and it can be argued that those who attend conferences may not necessarily be representative of the population as a whole. Only in Estonia did we have the opportunity to gather data from participants in a hospital setting. Furthermore, the English language requirement (except in Germany) added an additional layer of selection to the sample. We therefore cannot claim that the experiences in any country are shared universally but suggest that these data highlight issues to be addressed in future research.

At the time of writing an imminent surge in cancer diagnosis and treatment is occurring globally following the dramatic interruption to urgent care caused by COVID 19 (Burki, 2020) . These factors, taken together with existing professional demographics, demand that urgent steps be taken to address cancer nursing workforce deficits on a global scale, as well as in Europe. It is important to consider the risks of exhaustion to the nursing workforce and to explore ways to replenish it.

Given our findings the political voice of nurses across Europe should be heard on policy groups and committees who are likely to impact on the future of cancer care. By working together to share experiences at the European and global level, cancer nurses can engage with national power brokers to gain better recognition and to shape their own future to better meet the needs of the increasing number of people who will face a cancer diagnosis.

This study was funded by the European Cancer Organisation.

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Life expectancy at birth (indicator)

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We wish to thank all the participants and the conference organisers for facilitating data collection.J o u r n a l P r e -p r o o f

None J o u r n a l P r e -p r o o f What is already known about the topic?• Cancer remains a leading cause of death, despite advances in treatment and care. • Increasingly high nursing workloads are evident in Europe alongside workforce shortages. • Major changes taking place in the treatment of cancer require more individualised and targeted treatment approaches. • In some countries, cancer nurses adopt advanced roles that include prescribing and treatment co-ordination, as well as conducting clinical procedures as part of advanced roles.

• Comparative qualitative insights concerning cancer nursing in Estonia, Germany, the Netherlands and the United Kingdom. • None of the countries formally recorded cancer nursing qualifications.• Despite common European Union Directives there are disparities in the availability of specialist cancer nursing education. • Working conditions (hours and pay) vary widely across EU countries.• Despite increasing workloads, a high degree of commitment and job satisfaction was reported by cancer nurses.

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:J o u r n a l P r e -p r o o f