Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)



Research Advisor

Leslie M. McKeon, Ph.D.


Rita M. Carty, Ph.D. Donna K. Hathaway, Ph.D. Susan R. Jacob, Ph.D. Judith A. Wilimas, M.D.


Abandonment, Education, Evaluation, Guatemala, Nursing Program, Pediatric Oncology


There is great disparity between the outcome of childhood cancer in developed and developing countries. Nurses, who comprise the largest group of health care professionals globally, are essential to successful treatment. Pediatric oncology education is generally unavailable for nurses in developing countries. This lack of education is likely to contribute to the disparity in survival rates, as undereducated nurses are unable to meet the demands of pediatric cancer care. A second critical problem in developing countries is the workload of the nurse, with a patient nurse ratio reported as high as 30 patients per one nurse.

In 2006, the quality of nursing care at St. Jude Children’s Research Hospital’s partner site in Guatemala was assessed using standards from six Joint Commission International quality domains. Although quality standards were found lacking in all six domains, the most critical needs with relevance to nursing were identified in the domain of Staff Qualifications and Education. To meet this need, the Guatemalan Nursing Program (GNP) was developed. Because of the critical needs determined by the assessment, the primary focus of the program was improving nursing education and staffing. A secondary focus was on improving all quality standards with relevance to nursing.

This research study was designed to evaluate the GNP’s fidelity and impact on staff, organizational, and clinical outcomes. Staff and organizational outcomes were evaluated using a before and after one group design often used in program evaluation. The clinical outcomes were evaluated using a control site comparison but no randomization and was therefore a quasi-experimental design. Variables analyzed included staff variables of continuing education hours, chemotherapy competency, central venous line care competency, and completion of pediatric oncology nursing education course for newly hired nurses, organizational variables of Joint Commission International standards and patient to nurse ratio, and clinical variables of event free survival and abandonment. Logic model theory provided the conceptual framework for both the development and evaluation of the GNP.

This study substantiated that prior to GNP implementation a lack of education for pediatric oncology nurses existed in Guatemala and demonstrated that a nurse educator can positively impact staff outcomes related to pediatric oncology education. The GNP also positively affected organizational outcomes. Compared to pre program results, the number of Joint Commission International standards met post program increased considerably. In 2006, the patient to nurse ratio was 6 to 8 (average 7) patients per nurse and in 2009, the patient to nurse ratio was 4 to 6 (average 5) patients per nurse. The study found a statistically significant association with an improved CIN of treatment abandonment within the first year of diagnosis. Abandonment of treatment is a critical problem in developing countries. Although many studies have looked at abandonment and its causes; no study has looked at the specific effect of nursing interventions on abandonment. The study did not find an association with improved EFS. However, pediatric oncology patients who abandon treatment die, thus an improvement in abandonment should in time result in improved survival.

Nursing research in developing countries is limited, resulting in unique opportunities to conduct many “first time” studies. Today all components of the health care system are expected to demonstrate their value, and accountability is an important expectation of the health care system. This is even a greater need in developing countries where nursing is given little value and support. Nursing policies that dictate patient to nurse ratios and funding of new nursing positions are determined by the Ministry of Health in most developing countries. Empirical evidence is needed justify changes in policy. Evidence that education and improved staffing impact clinical outcomes has the potential of providing an impetus for a change in nursing policy.