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Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography
Pain Management Nursing xxx (xxxx) xxx
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Original Article
Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography Lister Nyareso Onsongo, PhD, RN From the Lecturer School of Nursing, Kenyatta University, Kenya
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 March 2019 Received in revised form 5 August 2019 Accepted 27 August 2019
Background: Up to 80% of cancer patients in Kenya suffer from untreated moderate to severe pain. Aim: This study explored barriers to cancer pain management among nurses caring for oncology patients in Kenya. This was part of a larger study whose primary objective was to understand the role of nursing subculture on cancer pain management. Design: A focused ethnographic was used in this study. Settings: An oncology private unit in large referral hospital in Kenya. Participants: Twenty-five (n ¼ 25) nurses participated in this study. Methods: Semi- structured interviews and observations were used to collect data. Nurses were recruited through purposive, snowball sampling strategy. Content analysis led to identification of key barriers to optimal cancer pain management. Results: Organizational, cognitive, professional and patient/family related barriers to cancer pain management were noted. Specifically, barriers such as lack of accessibility to pain management guidelines and training, professional collaboration, restrictive dispensing guidelines, and opioid related fears were identified. Conclusions: Interventions should streamline palliative care training and implementation of pain management guidelines in both units. Interventions should consider the influence of different subcultures while implementing pain management policies and training. © 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
Cancer pain is an international public health problem that millions of cancer patients experience at some stage of their disease (Neufeld, Elnahal, & Alvarez, 2017; O'Brien, Schwartz, & Plattner, 2018). The World Health Organization (WHO) estimates that 5.5 million people globally receive no treatment or marginal treatment for their cancer pain (Krakauer, Wenk, Buitrago, Jenkins, & Scholten, 2010). In 2011, 2.7 million people died with unrelieved moderate or severe pain from cancer and HIV, and people in developing countries made up more than 99% of those deaths (American Cancer Society, 2015). The prevalence of cancer pain is higher in low- and middle-income countries because most patients there (88%-95%) are diagnosed with advanced forms of cancer (Ferlay et al., 2012; Mercadante, 2014; Reville & Foxwell, 2014). The WHO estimates that of the 20,000 people who died from cancer in Kenya in 2010, 80% of them suffered from untreated moderate to severe pain (ACS, 2015). Address correspondence to Lister Nyareso Onsongo, PhD, RN, Lecturer School of Nursing, Kenyatta University Kenya, Nairobi, Kenya. E-mail address: [email protected].
The increase in cancer cases in Kenya is a formidable challenge to the health infrastructure. Like most developing countries, Kenya has a shortage of healthcare workers and facilities to diagnose and treat cancer. Healthcare facilities in Kenya are made up of private, faith-based, and public hospitals. There are 4 radiotherapy centers, located in urban areas. Only one public hospital is equipped to provide the 3 major cancer treatments: surgery, radiotherapy, and chemotherapy (Makau-Barasa et al., 2017). Unfortunately, regardless of the higher prevalence of cancer patients (70%) and cancer pain in developing countries, their average consumption of opioids, specifically morphine, is much lower (7%; O'Brien et al., 2018). Developed countries (i.e., North America and Europe) consume 68% of the world's total morphine (Foley, 2011; Seya, Gelders, Achara, Milani, & Scholten, 2011). In 2010, morphine consumption was approximately 70 mg per person in the United States, whereas developing countries reported consumption of less than 0.1 mg per person annually (ACS, 2015; Swarm et al., 2013). The Kenyan government acknowledges that cancer pain is a public health problem and has included morphine in the Essential Drug List to improve pain management (O’Brien,
https://doi.org/10.1016/j.pmn.2019.08.006 1524-9042/© 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
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L.N. Onsongo / Pain Management Nursing xxx (xxxx) xxx
Mwangi-Powell, Adewole, Soyannwo, & Amandua, 2013). Pain management guidelines adopted by the Kenyan government recommend the use of the WHO analgesic ladder as a basic step (WHO, 2019). Despite advances in policies, education, and pain management options, inadequate pain relief in cancer patients is widely recognized. Studies have shown that culture guides members' thinking, decisions, and actions, and has a significant influence on patients' perspectives and nurses' pain management practices (Chatchumni, Namvongprom, Eriksson, & Mazaheri 2016; Magnusson & Fennell, 2011; Narayan, 2010). Lack of knowledge and negative attitudes among healthcare professionals and patients in regard to opioid use have been reported in the literature globally (Al-Atiyyat & Vallerand, 2018; Machira, Kariuki, & Martindale, 2013; O'Brien et al., 2018; Wang, & Tsai, 2010). Organizational barriers, such as lack of storage facilities; dysfunctional supply systems for essential drugs, such as morphine; and restrictive regulations are also highlighted in various studies (Duthey & Scholten, 2014; Husain, Brown, & Maurer, 2014). Nonetheless, nurses play a key role in cancer pain management, because they spend more time with the patientsand can monitor them closely. Nurses' subcultures shape predispositions to respond in a generally positive or negative way to their patients’ pain (Avallin et al., 2018; Chatchumni et al., 2016). However, no study to date has investigated the role of nursing subculture in cancer pain management in Kenya. Based on this background, we conducted a focused ethnographic study whose primary objective was to understand the role of nursing subculture on cancer pain management. This paper presents barriers to cancer pain management from the perspective of nurses across an oncology and private unit. Methods Design and Setting A focused ethnography approach was used to explore nurses’ perceptions of barriers to cancer pain management. The primary field site was an 1800-bed government tertiary facility located in a large city in Kenya. Approximately 10% of the hospital beds are found in the private wing of the hospital. The hospital attends to a high volume of patients annually (70,000 inpatients). The adult oncology unit has a bed capacity of 30 and provides care at a subsidized rate to patients who cannot afford care in the private wing. Patients in the oncology unit must have a referral from a lower-level hospital in order for them to be admitted into the oncology unit. The private unit is a medical-surgical unit with a bed capacity of 25. The private unit admits oncology patients through private physicians without their having to go through the referral system. Admission to the oncology unit can take as long as 6 months. Patients with resources choose to be admitted through the private unit since the process is easier. Population and Sampling Technique Nurses working in both the oncology and private units providing direct care to cancer patients were targeted for this study. Purposive sampling was used to recruit nurses. The researcher approached the nurse managers with a letter of approval for data collection. Initially, referrals for eligible potential participants who were interested in the study were received from the nurse managers in both units. During observations, a snowballing approach was also used, whereby nurse participants were asked to refer other potential nurse participants for the study. Inclusion criteria required nurses who spent at least 50% of clinical duties providing care to cancer patients and had worked in the unit for 6 months or more.
Data Collection The researcher collected, transcribed, and analyzed the data. Data collection occurred over 4 months of field immersion on both units from August 2016 to December 2016. Semi-structured interviews were audio recorded (with permission) and lasted approximately 45 minutes. Questions were open-ended and elicited challenges related to pain management. For example, questions such as the following were asked: “Think of a time when you experienced difficulty managing cancer pain. Looking back, what issues contributed to the difficulties?” “What hinders the incorporation or use of the pain management guidelines in your practice?” All interviews were transcribed verbatim. Interviews were scheduled at the nurses’ convenience and took place in the boardrooms in each unit. Field notes were taken during observations and dictated immediately after leaving the field, and later transcribed. The researcher reflected between the observation sessions. Observation data were compared and contrasted with data from interviews. All interviews were conducted in English; however, some participants spoke Swahili during the interview. The researcher translated all Swahili words into English. Nurses were given a $10 gift certificate for agreeing to participate in the study. Data Analysis Data analysis was conducted concurrently with data collection to identify new issues that could be addressed during the subsequent interviews. The general principles of qualitative content analysis by Graneheim and Lundman (2004) guided this analysis. These principles included the following: (1) transcription of interviews and observation sessions; (2) reading the whole text for a general perception of the content; (3) determining the meaning units and the initial codes; (4) forming comprehensive categories by classifying initial codes with similarities; and (5) forming the main category of themes. NVivo software version 11 was used to manage data. Rigor I ensured rigor and trustworthiness of this study by using participants’ quotes to establish descriptive validity, keeping a reflective journal and audit trail, and engaging in peer review and debriefing (Baillie, 2015; Creswell, 2013). I also maintained engagement with my graduate advisory committee, which included qualitative and pain management specialists in the research process. This engagement cued me to revise my original category headings to reflect my findings precisely. Ethics Approval was obtained from both the University of Iowa Institutional Review Board (IRB) and the Hospital's Ethics Committee before data collection. Participants who agreed to be formally interviewed gave verbal consent. Participants and locations were deidentified to protect confidentiality. To ensure anonymity, I assigned pseudonyms to the nurses who participated in the interviews. Results The total sample (n ¼ 25; Table 1) included nurses from both oncology and private units. Significant organizational, cognitive, professional, and patient- or family-related barriers to cancer pain management among nurses are reflected in Table 2. PN and GN below refers to a nurse working in the private and general unit respetively.
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
L.N. Onsongo / Pain Management Nursing xxx (xxxx) xxx Table 1 Participants Demographics Variable
Sex Male Female Age 21-30 31-40 41-50 51> Work status Permanent Locum Unit Oncology Private Education Certificate (ERN)* Diploma (RN) Baccalaureate (BScN) Higher Diploma *
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Table 2 Barriers to Cancer Pain Management in Oncology and Private Units (N ¼ 25) n (%)
%
Theme
25
100
Organizational related barriers Accessibility to pain management guidelines Restrictive dispensing procedures for opioids Inconsistency in training Staffing & workload Unavailability of supplies Lack of specialized unit Cognitive barriers Pain is difficult to manage Fear of opioid-related side effects Nurse burnout Professional related barriers Lack of formal recognition as specialists Physicians as a barrier Lack of professional collaboration Patient/family related barriers Delayed treatment Patient/family factors
6 19
24 76
4 8 6 7
16 32 24 28
22 3
88 12
12 13
48 52
6 9 9 1
24 36 36 4
All worked in the oncology unit.
OU n (%) 1 (4) 0 3 (12) 7 (28) 0 0
PU n (%) 8 3 10 4 2 12
3 (12) 4 (16) 3 (12) 11 (44) 0 0 2 (8) 0
(32) (12) (40) (16) (8) (48)
3 (12) 8 (32) 8 (32) 0 8 (32) 4 (16) 5 (20) 5 (20)
OU ¼ oncology unit; PU ¼ private unit.
they worked with you, they are people who just talk but they don't do. Learning from someone like that makes you wonder.”
Organizational Barriers Accessibility to Pain Management Guidelines Nurses on the private unit report that access to cancer pain management guidelines is limited, although pain management guidelines were available in the palliative care department. Some nurses believed that cancer pain management is outside their scope of practice because their main role is to administer medication as ordered and monitor patients. According to the nurses, focusing on pain management is an additional task that can be accomplished by someone else. Other nurses felt that if the guidelines were within reach, it would be easier for them to advocate for patients, especially when physicians are resistant. PN8: “I don't find the guidelines necessary because we are not prescribing. We just observe and report. The palliative care team is always available anyway. Sometimes, you know, when you are not given a certain responsibility you don't add yourself some more.” Restrictive Dispensing Procedures for Opioids Nurses are restricted to ordering opioids only on two specific days of the week. For orders outside of these days, charge nurses are required to explain in writing why they are needed. Nurses feel that the hospital policy for ordering on specific days is unreasonable and restrictive. The pharmacy on the private unit does not stock opioids consistently. Nurses were observed obtaining morphine from other medication rooms if theirs was lacking. PN9: “I think that we shouldn't have time limits on when to order; it should be open, so we can order anytime, because at times we can go out of the ward stock. We even go and borrow in another ward, so it is a waste of time.” Inconsistency in Training Training on pain management is offered irregularly. Furthermore, nurses feel that the trainers should be experts from outside, but the current trainers are their colleagues whose practice is not any different from their own when they worked as bedside nurses. Consequently they do not take them seriously. PN2: “The training is inconsistent. They should get someone from outside to train us. When you see your colleague training you and you know they did not provide pain management when
Nurses feel that once they attend any training, the application is not reinforced in practice. Nurses report that at times, they are trained to perform a specific activity (e.g., a pain assessment), but there is no reinforcement or follow-up from management to ensure that the nurses are doing it correctly or doing it at all. PN3: “They need to implement what we have learned in training immediately in practice. If you wait too long to implement anything after training, we forget. Training will fix the attitude. You know, not everybody understands cancer pain.” Most nurses on the oncology unit have undergone palliative care training. Nurses who have not undergone training report that this lack of training makes their practice difficult. They rely on their colleagues who have attended palliative care classes for information. GN12: “Some of us have not been trained on palliative care, you just learn on the job, which has been very difficult, so lack of training is a challenge we are still waiting [to have resolved].” Only one nurse on the private unit had attended palliative care training during the study. The nurse worked both as a permanent staff nurse and extra hours as a palliative care nurse. When she worked as a staff nurse, her practice was similar to that of other nurses on the unit, that is, she prioritized tasks to be completed and not pain management. Staffing and Workload The heavy workload in this hospital has a negative effect on nurses' cancer pain management practices. Patient-to-nurse ratios are low regardless of the number of patients or the acuity of patients on the unit. Nurses are overwhelmed with various tasks that must be accomplished on each shift. I observed that nurses often delayed or missed administering pain medication. Nurses complain that they perform tasks that can be delegated to non-nursing staff, which takes time away from patient care. Nurses often must juggle patient care, clerical work, and other issues arising during the shift. The hospital does not employ nursing assistants or unit clerks. GN8: “Due to the workload, timeliness is an issue; for instance, morphine is QID [four times a day]; we often forget to give
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
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L.N. Onsongo / Pain Management Nursing xxx (xxxx) xxx
because we are used to giving other medication at 6 a.m., 2 p.m., and 9 p.m. So, we tend to forget about morphine. We have too many procedures during the day and few nurses on nights. If they gave us enough staff, we will give morphine on time.” PN7: “The acuity of the patients doesn't matter; staffing is the same or even less.” Based on my observations, in rare situations in which nurses had fewer patients on the unit with the same number of staff, providing an opportunity for individualized care, there was no difference in nurses’ approach to pain management. PN2: “If you are not used to doing something like managing pain, it will not come automatically. Even if the patients are few, you will still do the regular things [but] you can't go that extra mile; in fact, when the workload is less, we tend to relax more.”
Lack of a Specialized Oncology Unit The private unit does not have a specialized oncology unit for cancer patients. Cancer patients are mixed with other patients. Nurses believe having one unit that is specifically dedicated to oncology patients would optimize care. PN4: “The mixture of patients is unfortunate, but if the private wing developed an oncology ward, trained more palliative care nurses, and equipped the unit with enough personnel, then our work will be easier. Currently, with the mixture of patients, pain takes a back seat. Most patients will report that their bed was not changed, so we prioritize non-nursing issues to please patients and their relatives.”
Unavailability of Supplies Nurses often spend time looking for medication (morphine) or supplies such as saline, especially on weekends, nights, or public holidays in the private unit. Nurses at times hide their own stash so they can use it on their next shift. Looking for items took nurses’ time away from patient care. This practice was not observed on the oncology unit. PN4: “We really have a challenge with pharmacy in this unit. They have a great shortage because you cannot get anything urgently from this pharmacy. Sometimes we have to plead with pharmacy to supply morphine; it is a challenge. It makes it difficult to advocate for patients.”
Cognitive Barriers Pain is Difficult to Manage Nurses in both units acknowledge that pain is the most common complaint among cancer patients, and yet the most difficult to manage, because pain is a subjective experience and is timeconsuming to treat. The variance in patients’ response and inability to differentiate the different types of pain complicates cancer pain management for nurses. GN12: “Management of cancer pain is difficult; it is hard to understand clearly what kind of pain the patient is experiencing.” PN11: “Cancer pain is difficult, it is persistent.”
Fear of Opioid-related Side Effects Most nurses in the private unit and two nurses in the oncology unit reported fear of addiction to opioids, particularly morphine.
Nurses admit that even though they have never witnessed any addiction, they fear that patients can become addicted to morphine. Fears of addiction arise when a patient asks for pro re nata (as-needed) analgesics frequently, or if a patient knows the type of analgesic they want. To prevent patients from getting addicted to morphine, nurses confess to adjusting opioid doses or substituting opioids with a mild analgesic. PN11: “Sometimes I might not give morphine so much because I believe the more I give, the more the patient will be addicted. I know I'm supposed to give morphine after 4 hours. If you ask for more in between I will give paracetamol because I don't want you to be addicted.” Nurses in the private unit also report fear of respiratory depression when administering morphine to patients with lung cancer or patients at the end of life. Nurses felt that administering morphine to these types of patients would accelerate their death. Only two nurses in the oncology unit reported fears of morphine, the two nurses who did not have palliative care training. PN6: “We are hesitant sometimes because we feel like we are facilitating the patient to die slowly. We might cause respiratory distress, and then actually in a way we are speeding up the death process. We have patients who die in pain; everybody is usually afraid to give morphine, we just fear, it's a dilemma.”
Nurse Burnout Low staffing, high workload, and negative attitudes may contribute to nurse burnout in both units. On the private wing, most nurses are contemplating various options that would get them out of the nursing profession. Most nurses confess that they are tired of working as bedside nurses. Some nurses mentioned going back to school for a different degree or getting advanced degrees so they can stop practicing as bedside nurses, while others are planning to leave the country due to limited professional development opportunities in Kenya. Nurses view transfers to the oncology unit as a demotion or punishment by management. Nurses are transferred to the oncology unit by management involuntarily. The negative attitude toward working in the oncology unit played a negative role in pain management. GN12: “Some of us were transferred to the oncology unit involuntarily; personally I didn't want to work here. My perception of the oncology ward is not good. You know, I worked in maternity where people are always happy. Mortalities are very rare [in maternity], but the experiences here [oncology] are not good; for example, this young guy who was doing very well two years ago, now he is back, and he is blind, and the cancer has spread. It is depressing. I even don't want to talk to him.”
Professional Barriers Lack of Formal Recognition as Specialists Nurses on the oncology unit feel that the hospital does not recognize them as specialists. Nurses who work in other units, such as the intensive care unit (ICU), within the same hospital are paid 15% extra as a form of recognition for providing specialized care. The nurses are not certified as oncology nurses, although they consider themselves specialists due to their experience working in the unit. GN1: “Lack of motivation; sometimes, you know, most people want money for motivation. In the ICU they are usually given
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
L.N. Onsongo / Pain Management Nursing xxx (xxxx) xxx
allowances that we don't get as oncology nurses, but we are also a specialized unit. So we feel we are not recognized, yet most nurses in the other departments don't want to work on the oncology unit.”
Physicians as a Barrier Every patient on the private unit is admitted by a private physician. Nurses have identified some physicians as a barrier to cancer pain management. Nurses report that since they know the physicians who do not like prescribing analgesics, they ignore their patients’ reports of pain. According to the nurses, some physicians often fear that analgesics, especially opioids, will hinder a proper assessment of pain, and patients may develop tolerance to the medication. Other physicians believe that interventions for cancer pain will mask the progress of cancer treatment. PN1: “Some of the physicians don't want to order pain medicine; they say if we give a cancer patient morphine and their condition worsens, you are not able to assess the patient.” Some cancer patients on the private unit are not aware of their cancer diagnosis. It is not unusual for relatives to know the diagnosis while the patient does not. Certain physicians believe that it is not necessary for a patient to know their diagnosis. Nurses feel conflicted and note that the lack of transparency affects their approach to these patients. The oncology unit did not raise any concerns about disclosure, since all patients are aware that they are being admitted to the unit for some form of cancer treatment. P4: “Patients should be told the truth instead of relatives. Sometimes patients ask you when their pain will go away. As a nurse, you can't respond because you can't discuss their primary diagnosis first. It is a challenge.”
Lack of Professional Collaboration Some nurses on the private unit feel that they deserve the same respect as physicians. Thus they refuse to do rounds with physicians because they believe they will be perceived as assistants rather than equals. As a result of this refusal, there is a communication breakdown that affects patient care. Nurses in the oncology unit had a collaborative approach with other healthcare providers in their unit. PN3: “When these doctors come to review patients, most of the time they go alone. There is a negative attitude nurses have that when you accompany a doctor into the patient's room you are like a maid.”
Patient/Family Barriers Delayed Treatment Nurses reported that most cancer patients treated in this hospital are at advanced stages of their diseases. Reasons for late presentation include long waiting times for treatment, since the oncology ward can accommodate only 30 patients. During the study period, only one radiotherapy machine was in working condition. Other patients are not able to pay for treatment. Although treatment at this referral hospital is subsidized by the government, patients must provide their own transport, accommodation, and meals while waiting for a hospital bed. PN1: “People believe that this hospital is very cheap; they have used all their money in other hospitals and then the doctors
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send them here. By the time they get here, the disease is advanced. So the prognosis is not good.”
Patient and Family Barriers Nurses on the private unit view patients and family members as a barrier to cancer pain management. Nurses believe that some patients do not want to leave the hospital, and that they thus exaggerate their pain levels so they can stay longer. Nurses note that patients’ relatives on the private unit can be demanding and tend to ask for pain medication even when the patient does not need it. Nurses often believe that patients are addicted to opioids whenever patients or their family member ask for pain medication frequently. PN9: “Relatives interrupt a lot. They can be so nagging, you are not able to figure out if it's the patient's genuine pain or the relatives.” Patients’ beliefs are also reported as barriers. Some patients do not believe in oral medication; they prefer an alternate route of administration because they believe it will work better and faster. Nurses indicate that patients from certain communities believe intramuscular injections are better than oral medications. PN7: “Patients from other cultures believe that if you don't give an injection then you have not treated their pain. So some nurses give normal saline injections to calm the patients down. We give the placebos for psychological pain.”
Discussion This is the first study in Kenya identifying barriers to cancer pain management from the perspective of different nursing subcultures. Using data obtained through observation and semistructured interviews, I investigated shared and individual barriers to cancer pain management. A unique finding in this study is that more barriers are noted in the private unit. Ideally, the private unit should have reported fewer barriers, considering they have more resources and do not employ enrolled nurses (the lowest cadre in the Kenyan system). Given that patients in the private unit are in equally advanced stages of their disease when compared to patients in the general unit, one can infer that the different subcultures in each unit, and not the resources or educational level of nurses, shape nursing perceptions and practices of cancer pain management. Overall, this study corroborates known barriers that prevent nurses from providing effective cancer pain management, such as lack of training in pain management, patients with advanced disease, fear of opioids, workload, burnout, lack of specialization, lack of clear pain policies, and negative attitudes. All of the following have been reported in previous studies (Al Khalaileh & AlQadire, 2012; Breuer et al., 2011; Saini & Bhatnagar, 2016). As Wild and Mitchell (2000) suggest, good pain outcomes occur in nursing units where nurses have positive attitudes. However, a number of misconceptions and negative attitudes limit positive patient outcomes. Evidence that nurses fear administration of opioids has been found in other studies (Kaki et al., 2009; Yava et al., 2013) despite the availability of clinical guidelines on management of side effects. Lack of access to pain management guidelines and palliative care training may explain why most nurses in the private unit fear administering morphine. In developed countries such as the United States, high levels of opioid consumption and prescription drug abuse have created barriers such as providers fearing overprescribing or lawsuits related to opioids. These barriers affect optimum pain control,
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
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L.N. Onsongo / Pain Management Nursing xxx (xxxx) xxx
especially for cancer patients (Foxwell, Uritsky, & Meghani, 2019). On the other hand, it has been suggested that opioid availability is a barrier to cancer pain management in developing countries (Saini & Bhatnagar, 2016). This conjecture is not supported by the findings in this study. Opioid availability is no longer an issue of concern for this hospital; rather, consistency in dispensing on the private unit and physician reluctance to prescribe were reported barriers. Regardless of morphine availability, nurses need additional evidence-based education to alleviate their negative beliefs regarding opioids. Education should take into consideration the existing barriers in different subcultures that prevent providers from using opioids. Previous studies have shown that lack of collaboration with physicians has negative consequences for pain management (Egan & Cornally, 2013). Findings in the present study reveal a lack of collaboration among the healthcare professionals in the private unit; these are congruent to findings previously reported in the literature (DeSilva & Rolls, 2011; McCarthy & Riley, 2012). The institution should put mechanisms in place to ensure teamwork and collaboration. Burnout has a negative effect on the quality of care provided to patients (Lee & Akhtar, 2011). Factors such as workload, lack of debriefing sessions, and lack of career progression within this institution may contribute to burnout and nurses leaving their jobs. Our findings are similar to those of a recent review which suggested that there is a negative relationship among nursing retention, stress, and burnout among oncology nurses (Toh, Ang, & Devi, 2012). Although the nursing shortage is a global problem, subSaharan Africa is worst hit. Findings in this study suggest that improvements in working conditions may improve nurse retention, quality of pain management, and welfare among nurses in this institution. Lack of specialization also needs consideration; a culture in which specialization is not valued may explain findings of this study. Kenya's government institutions did not offer any oncology nursing training programs during the study period. Currently, one private hospital with a hospice program is offering 4-week clinical placements for community college students. Lack of training in the universities where physicians and BSN nurses are trained is a concern. This finding bears some resemblance to findings by Harding et al. (2014) and Selman et al. (2013) highlighting the lack of specialists as a barrier to cancer pain management in developing countries. Specialization and availability of specialists can improve pain management practices and alleviate some of the barriers that currently exist (Kwon, 2014; LeBaron, Bohnenkamp, & Reed, 2011). The study has implications for nursing practice in developing countries. The failure to take into consideration the role of nursing subculture in cancer pain management, even with the availability of evidence-based cancer pain management guidelines and pain medication, is a possible explanation as to why barriers to cancer pain management continue to exist. Finally, the study has implications beyond pain management. Evaluating different subcultures in nursing provides a useful mechanism for examining different aspects of nursing practice. Such examination can enhance understanding of how practices in different nursing units within the same facility are formed and maintained. Limitations One researcher conducted, transcribed, and analyzed interviews. This could be considered a limitation; however, the researcher used representative quotations from the transcribed text, and also sought guidance from experts in pain management and qualitative research during the research process.
Conclusion This study took place in one government hospital in Kenya, and thus may be most relevant to similar care settings. Barriers reported by nurses in this study can apply generally to developing countries, and are not unique to public hospitals or to Kenya. For example, concerns regarding lack of specialization in oncology nursing are likely to be pertinent for most nurses in developing countries, irrespective of specific practice setting. The current study focused specifically on identifying barriers to cancer pain management in the two units, and asserts that cancer pain management practices can be improved when nurses in a subculture share the same beliefs, knowledge, skills, and attitudes towards pain management. This can be achieved through consistency in training and availability of pain management policies. For instance, an individual nurse armed with new knowledge regarding cancer pain management is less likely to consistently apply this knowledge in practice if it is inconsistent with the nursing subculture predominant on the specific unit. For practices to be changed, tailored interventions are needed for specific units, taking into consideration the nurses’ subculture in each unit.
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Original Article
Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography Lister Nyareso Onsongo, PhD, RN From the Lecturer School of Nursing, Kenyatta University, Kenya
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 March 2019 Received in revised form 5 August 2019 Accepted 27 August 2019
Background: Up to 80% of cancer patients in Kenya suffer from untreated moderate to severe pain. Aim: This study explored barriers to cancer pain management among nurses caring for oncology patients in Kenya. This was part of a larger study whose primary objective was to understand the role of nursing subculture on cancer pain management. Design: A focused ethnographic was used in this study. Settings: An oncology private unit in large referral hospital in Kenya. Participants: Twenty-five (n ¼ 25) nurses participated in this study. Methods: Semi- structured interviews and observations were used to collect data. Nurses were recruited through purposive, snowball sampling strategy. Content analysis led to identification of key barriers to optimal cancer pain management. Results: Organizational, cognitive, professional and patient/family related barriers to cancer pain management were noted. Specifically, barriers such as lack of accessibility to pain management guidelines and training, professional collaboration, restrictive dispensing guidelines, and opioid related fears were identified. Conclusions: Interventions should streamline palliative care training and implementation of pain management guidelines in both units. Interventions should consider the influence of different subcultures while implementing pain management policies and training. © 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
Cancer pain is an international public health problem that millions of cancer patients experience at some stage of their disease (Neufeld, Elnahal, & Alvarez, 2017; O'Brien, Schwartz, & Plattner, 2018). The World Health Organization (WHO) estimates that 5.5 million people globally receive no treatment or marginal treatment for their cancer pain (Krakauer, Wenk, Buitrago, Jenkins, & Scholten, 2010). In 2011, 2.7 million people died with unrelieved moderate or severe pain from cancer and HIV, and people in developing countries made up more than 99% of those deaths (American Cancer Society, 2015). The prevalence of cancer pain is higher in low- and middle-income countries because most patients there (88%-95%) are diagnosed with advanced forms of cancer (Ferlay et al., 2012; Mercadante, 2014; Reville & Foxwell, 2014). The WHO estimates that of the 20,000 people who died from cancer in Kenya in 2010, 80% of them suffered from untreated moderate to severe pain (ACS, 2015). Address correspondence to Lister Nyareso Onsongo, PhD, RN, Lecturer School of Nursing, Kenyatta University Kenya, Nairobi, Kenya. E-mail address: [email protected].
The increase in cancer cases in Kenya is a formidable challenge to the health infrastructure. Like most developing countries, Kenya has a shortage of healthcare workers and facilities to diagnose and treat cancer. Healthcare facilities in Kenya are made up of private, faith-based, and public hospitals. There are 4 radiotherapy centers, located in urban areas. Only one public hospital is equipped to provide the 3 major cancer treatments: surgery, radiotherapy, and chemotherapy (Makau-Barasa et al., 2017). Unfortunately, regardless of the higher prevalence of cancer patients (70%) and cancer pain in developing countries, their average consumption of opioids, specifically morphine, is much lower (7%; O'Brien et al., 2018). Developed countries (i.e., North America and Europe) consume 68% of the world's total morphine (Foley, 2011; Seya, Gelders, Achara, Milani, & Scholten, 2011). In 2010, morphine consumption was approximately 70 mg per person in the United States, whereas developing countries reported consumption of less than 0.1 mg per person annually (ACS, 2015; Swarm et al., 2013). The Kenyan government acknowledges that cancer pain is a public health problem and has included morphine in the Essential Drug List to improve pain management (O’Brien,
https://doi.org/10.1016/j.pmn.2019.08.006 1524-9042/© 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
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L.N. Onsongo / Pain Management Nursing xxx (xxxx) xxx
Mwangi-Powell, Adewole, Soyannwo, & Amandua, 2013). Pain management guidelines adopted by the Kenyan government recommend the use of the WHO analgesic ladder as a basic step (WHO, 2019). Despite advances in policies, education, and pain management options, inadequate pain relief in cancer patients is widely recognized. Studies have shown that culture guides members' thinking, decisions, and actions, and has a significant influence on patients' perspectives and nurses' pain management practices (Chatchumni, Namvongprom, Eriksson, & Mazaheri 2016; Magnusson & Fennell, 2011; Narayan, 2010). Lack of knowledge and negative attitudes among healthcare professionals and patients in regard to opioid use have been reported in the literature globally (Al-Atiyyat & Vallerand, 2018; Machira, Kariuki, & Martindale, 2013; O'Brien et al., 2018; Wang, & Tsai, 2010). Organizational barriers, such as lack of storage facilities; dysfunctional supply systems for essential drugs, such as morphine; and restrictive regulations are also highlighted in various studies (Duthey & Scholten, 2014; Husain, Brown, & Maurer, 2014). Nonetheless, nurses play a key role in cancer pain management, because they spend more time with the patientsand can monitor them closely. Nurses' subcultures shape predispositions to respond in a generally positive or negative way to their patients’ pain (Avallin et al., 2018; Chatchumni et al., 2016). However, no study to date has investigated the role of nursing subculture in cancer pain management in Kenya. Based on this background, we conducted a focused ethnographic study whose primary objective was to understand the role of nursing subculture on cancer pain management. This paper presents barriers to cancer pain management from the perspective of nurses across an oncology and private unit. Methods Design and Setting A focused ethnography approach was used to explore nurses’ perceptions of barriers to cancer pain management. The primary field site was an 1800-bed government tertiary facility located in a large city in Kenya. Approximately 10% of the hospital beds are found in the private wing of the hospital. The hospital attends to a high volume of patients annually (70,000 inpatients). The adult oncology unit has a bed capacity of 30 and provides care at a subsidized rate to patients who cannot afford care in the private wing. Patients in the oncology unit must have a referral from a lower-level hospital in order for them to be admitted into the oncology unit. The private unit is a medical-surgical unit with a bed capacity of 25. The private unit admits oncology patients through private physicians without their having to go through the referral system. Admission to the oncology unit can take as long as 6 months. Patients with resources choose to be admitted through the private unit since the process is easier. Population and Sampling Technique Nurses working in both the oncology and private units providing direct care to cancer patients were targeted for this study. Purposive sampling was used to recruit nurses. The researcher approached the nurse managers with a letter of approval for data collection. Initially, referrals for eligible potential participants who were interested in the study were received from the nurse managers in both units. During observations, a snowballing approach was also used, whereby nurse participants were asked to refer other potential nurse participants for the study. Inclusion criteria required nurses who spent at least 50% of clinical duties providing care to cancer patients and had worked in the unit for 6 months or more.
Data Collection The researcher collected, transcribed, and analyzed the data. Data collection occurred over 4 months of field immersion on both units from August 2016 to December 2016. Semi-structured interviews were audio recorded (with permission) and lasted approximately 45 minutes. Questions were open-ended and elicited challenges related to pain management. For example, questions such as the following were asked: “Think of a time when you experienced difficulty managing cancer pain. Looking back, what issues contributed to the difficulties?” “What hinders the incorporation or use of the pain management guidelines in your practice?” All interviews were transcribed verbatim. Interviews were scheduled at the nurses’ convenience and took place in the boardrooms in each unit. Field notes were taken during observations and dictated immediately after leaving the field, and later transcribed. The researcher reflected between the observation sessions. Observation data were compared and contrasted with data from interviews. All interviews were conducted in English; however, some participants spoke Swahili during the interview. The researcher translated all Swahili words into English. Nurses were given a $10 gift certificate for agreeing to participate in the study. Data Analysis Data analysis was conducted concurrently with data collection to identify new issues that could be addressed during the subsequent interviews. The general principles of qualitative content analysis by Graneheim and Lundman (2004) guided this analysis. These principles included the following: (1) transcription of interviews and observation sessions; (2) reading the whole text for a general perception of the content; (3) determining the meaning units and the initial codes; (4) forming comprehensive categories by classifying initial codes with similarities; and (5) forming the main category of themes. NVivo software version 11 was used to manage data. Rigor I ensured rigor and trustworthiness of this study by using participants’ quotes to establish descriptive validity, keeping a reflective journal and audit trail, and engaging in peer review and debriefing (Baillie, 2015; Creswell, 2013). I also maintained engagement with my graduate advisory committee, which included qualitative and pain management specialists in the research process. This engagement cued me to revise my original category headings to reflect my findings precisely. Ethics Approval was obtained from both the University of Iowa Institutional Review Board (IRB) and the Hospital's Ethics Committee before data collection. Participants who agreed to be formally interviewed gave verbal consent. Participants and locations were deidentified to protect confidentiality. To ensure anonymity, I assigned pseudonyms to the nurses who participated in the interviews. Results The total sample (n ¼ 25; Table 1) included nurses from both oncology and private units. Significant organizational, cognitive, professional, and patient- or family-related barriers to cancer pain management among nurses are reflected in Table 2. PN and GN below refers to a nurse working in the private and general unit respetively.
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
L.N. Onsongo / Pain Management Nursing xxx (xxxx) xxx Table 1 Participants Demographics Variable
Sex Male Female Age 21-30 31-40 41-50 51> Work status Permanent Locum Unit Oncology Private Education Certificate (ERN)* Diploma (RN) Baccalaureate (BScN) Higher Diploma *
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Table 2 Barriers to Cancer Pain Management in Oncology and Private Units (N ¼ 25) n (%)
%
Theme
25
100
Organizational related barriers Accessibility to pain management guidelines Restrictive dispensing procedures for opioids Inconsistency in training Staffing & workload Unavailability of supplies Lack of specialized unit Cognitive barriers Pain is difficult to manage Fear of opioid-related side effects Nurse burnout Professional related barriers Lack of formal recognition as specialists Physicians as a barrier Lack of professional collaboration Patient/family related barriers Delayed treatment Patient/family factors
6 19
24 76
4 8 6 7
16 32 24 28
22 3
88 12
12 13
48 52
6 9 9 1
24 36 36 4
All worked in the oncology unit.
OU n (%) 1 (4) 0 3 (12) 7 (28) 0 0
PU n (%) 8 3 10 4 2 12
3 (12) 4 (16) 3 (12) 11 (44) 0 0 2 (8) 0
(32) (12) (40) (16) (8) (48)
3 (12) 8 (32) 8 (32) 0 8 (32) 4 (16) 5 (20) 5 (20)
OU ¼ oncology unit; PU ¼ private unit.
they worked with you, they are people who just talk but they don't do. Learning from someone like that makes you wonder.”
Organizational Barriers Accessibility to Pain Management Guidelines Nurses on the private unit report that access to cancer pain management guidelines is limited, although pain management guidelines were available in the palliative care department. Some nurses believed that cancer pain management is outside their scope of practice because their main role is to administer medication as ordered and monitor patients. According to the nurses, focusing on pain management is an additional task that can be accomplished by someone else. Other nurses felt that if the guidelines were within reach, it would be easier for them to advocate for patients, especially when physicians are resistant. PN8: “I don't find the guidelines necessary because we are not prescribing. We just observe and report. The palliative care team is always available anyway. Sometimes, you know, when you are not given a certain responsibility you don't add yourself some more.” Restrictive Dispensing Procedures for Opioids Nurses are restricted to ordering opioids only on two specific days of the week. For orders outside of these days, charge nurses are required to explain in writing why they are needed. Nurses feel that the hospital policy for ordering on specific days is unreasonable and restrictive. The pharmacy on the private unit does not stock opioids consistently. Nurses were observed obtaining morphine from other medication rooms if theirs was lacking. PN9: “I think that we shouldn't have time limits on when to order; it should be open, so we can order anytime, because at times we can go out of the ward stock. We even go and borrow in another ward, so it is a waste of time.” Inconsistency in Training Training on pain management is offered irregularly. Furthermore, nurses feel that the trainers should be experts from outside, but the current trainers are their colleagues whose practice is not any different from their own when they worked as bedside nurses. Consequently they do not take them seriously. PN2: “The training is inconsistent. They should get someone from outside to train us. When you see your colleague training you and you know they did not provide pain management when
Nurses feel that once they attend any training, the application is not reinforced in practice. Nurses report that at times, they are trained to perform a specific activity (e.g., a pain assessment), but there is no reinforcement or follow-up from management to ensure that the nurses are doing it correctly or doing it at all. PN3: “They need to implement what we have learned in training immediately in practice. If you wait too long to implement anything after training, we forget. Training will fix the attitude. You know, not everybody understands cancer pain.” Most nurses on the oncology unit have undergone palliative care training. Nurses who have not undergone training report that this lack of training makes their practice difficult. They rely on their colleagues who have attended palliative care classes for information. GN12: “Some of us have not been trained on palliative care, you just learn on the job, which has been very difficult, so lack of training is a challenge we are still waiting [to have resolved].” Only one nurse on the private unit had attended palliative care training during the study. The nurse worked both as a permanent staff nurse and extra hours as a palliative care nurse. When she worked as a staff nurse, her practice was similar to that of other nurses on the unit, that is, she prioritized tasks to be completed and not pain management. Staffing and Workload The heavy workload in this hospital has a negative effect on nurses' cancer pain management practices. Patient-to-nurse ratios are low regardless of the number of patients or the acuity of patients on the unit. Nurses are overwhelmed with various tasks that must be accomplished on each shift. I observed that nurses often delayed or missed administering pain medication. Nurses complain that they perform tasks that can be delegated to non-nursing staff, which takes time away from patient care. Nurses often must juggle patient care, clerical work, and other issues arising during the shift. The hospital does not employ nursing assistants or unit clerks. GN8: “Due to the workload, timeliness is an issue; for instance, morphine is QID [four times a day]; we often forget to give
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
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L.N. Onsongo / Pain Management Nursing xxx (xxxx) xxx
because we are used to giving other medication at 6 a.m., 2 p.m., and 9 p.m. So, we tend to forget about morphine. We have too many procedures during the day and few nurses on nights. If they gave us enough staff, we will give morphine on time.” PN7: “The acuity of the patients doesn't matter; staffing is the same or even less.” Based on my observations, in rare situations in which nurses had fewer patients on the unit with the same number of staff, providing an opportunity for individualized care, there was no difference in nurses’ approach to pain management. PN2: “If you are not used to doing something like managing pain, it will not come automatically. Even if the patients are few, you will still do the regular things [but] you can't go that extra mile; in fact, when the workload is less, we tend to relax more.”
Lack of a Specialized Oncology Unit The private unit does not have a specialized oncology unit for cancer patients. Cancer patients are mixed with other patients. Nurses believe having one unit that is specifically dedicated to oncology patients would optimize care. PN4: “The mixture of patients is unfortunate, but if the private wing developed an oncology ward, trained more palliative care nurses, and equipped the unit with enough personnel, then our work will be easier. Currently, with the mixture of patients, pain takes a back seat. Most patients will report that their bed was not changed, so we prioritize non-nursing issues to please patients and their relatives.”
Unavailability of Supplies Nurses often spend time looking for medication (morphine) or supplies such as saline, especially on weekends, nights, or public holidays in the private unit. Nurses at times hide their own stash so they can use it on their next shift. Looking for items took nurses’ time away from patient care. This practice was not observed on the oncology unit. PN4: “We really have a challenge with pharmacy in this unit. They have a great shortage because you cannot get anything urgently from this pharmacy. Sometimes we have to plead with pharmacy to supply morphine; it is a challenge. It makes it difficult to advocate for patients.”
Cognitive Barriers Pain is Difficult to Manage Nurses in both units acknowledge that pain is the most common complaint among cancer patients, and yet the most difficult to manage, because pain is a subjective experience and is timeconsuming to treat. The variance in patients’ response and inability to differentiate the different types of pain complicates cancer pain management for nurses. GN12: “Management of cancer pain is difficult; it is hard to understand clearly what kind of pain the patient is experiencing.” PN11: “Cancer pain is difficult, it is persistent.”
Fear of Opioid-related Side Effects Most nurses in the private unit and two nurses in the oncology unit reported fear of addiction to opioids, particularly morphine.
Nurses admit that even though they have never witnessed any addiction, they fear that patients can become addicted to morphine. Fears of addiction arise when a patient asks for pro re nata (as-needed) analgesics frequently, or if a patient knows the type of analgesic they want. To prevent patients from getting addicted to morphine, nurses confess to adjusting opioid doses or substituting opioids with a mild analgesic. PN11: “Sometimes I might not give morphine so much because I believe the more I give, the more the patient will be addicted. I know I'm supposed to give morphine after 4 hours. If you ask for more in between I will give paracetamol because I don't want you to be addicted.” Nurses in the private unit also report fear of respiratory depression when administering morphine to patients with lung cancer or patients at the end of life. Nurses felt that administering morphine to these types of patients would accelerate their death. Only two nurses in the oncology unit reported fears of morphine, the two nurses who did not have palliative care training. PN6: “We are hesitant sometimes because we feel like we are facilitating the patient to die slowly. We might cause respiratory distress, and then actually in a way we are speeding up the death process. We have patients who die in pain; everybody is usually afraid to give morphine, we just fear, it's a dilemma.”
Nurse Burnout Low staffing, high workload, and negative attitudes may contribute to nurse burnout in both units. On the private wing, most nurses are contemplating various options that would get them out of the nursing profession. Most nurses confess that they are tired of working as bedside nurses. Some nurses mentioned going back to school for a different degree or getting advanced degrees so they can stop practicing as bedside nurses, while others are planning to leave the country due to limited professional development opportunities in Kenya. Nurses view transfers to the oncology unit as a demotion or punishment by management. Nurses are transferred to the oncology unit by management involuntarily. The negative attitude toward working in the oncology unit played a negative role in pain management. GN12: “Some of us were transferred to the oncology unit involuntarily; personally I didn't want to work here. My perception of the oncology ward is not good. You know, I worked in maternity where people are always happy. Mortalities are very rare [in maternity], but the experiences here [oncology] are not good; for example, this young guy who was doing very well two years ago, now he is back, and he is blind, and the cancer has spread. It is depressing. I even don't want to talk to him.”
Professional Barriers Lack of Formal Recognition as Specialists Nurses on the oncology unit feel that the hospital does not recognize them as specialists. Nurses who work in other units, such as the intensive care unit (ICU), within the same hospital are paid 15% extra as a form of recognition for providing specialized care. The nurses are not certified as oncology nurses, although they consider themselves specialists due to their experience working in the unit. GN1: “Lack of motivation; sometimes, you know, most people want money for motivation. In the ICU they are usually given
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allowances that we don't get as oncology nurses, but we are also a specialized unit. So we feel we are not recognized, yet most nurses in the other departments don't want to work on the oncology unit.”
Physicians as a Barrier Every patient on the private unit is admitted by a private physician. Nurses have identified some physicians as a barrier to cancer pain management. Nurses report that since they know the physicians who do not like prescribing analgesics, they ignore their patients’ reports of pain. According to the nurses, some physicians often fear that analgesics, especially opioids, will hinder a proper assessment of pain, and patients may develop tolerance to the medication. Other physicians believe that interventions for cancer pain will mask the progress of cancer treatment. PN1: “Some of the physicians don't want to order pain medicine; they say if we give a cancer patient morphine and their condition worsens, you are not able to assess the patient.” Some cancer patients on the private unit are not aware of their cancer diagnosis. It is not unusual for relatives to know the diagnosis while the patient does not. Certain physicians believe that it is not necessary for a patient to know their diagnosis. Nurses feel conflicted and note that the lack of transparency affects their approach to these patients. The oncology unit did not raise any concerns about disclosure, since all patients are aware that they are being admitted to the unit for some form of cancer treatment. P4: “Patients should be told the truth instead of relatives. Sometimes patients ask you when their pain will go away. As a nurse, you can't respond because you can't discuss their primary diagnosis first. It is a challenge.”
Lack of Professional Collaboration Some nurses on the private unit feel that they deserve the same respect as physicians. Thus they refuse to do rounds with physicians because they believe they will be perceived as assistants rather than equals. As a result of this refusal, there is a communication breakdown that affects patient care. Nurses in the oncology unit had a collaborative approach with other healthcare providers in their unit. PN3: “When these doctors come to review patients, most of the time they go alone. There is a negative attitude nurses have that when you accompany a doctor into the patient's room you are like a maid.”
Patient/Family Barriers Delayed Treatment Nurses reported that most cancer patients treated in this hospital are at advanced stages of their diseases. Reasons for late presentation include long waiting times for treatment, since the oncology ward can accommodate only 30 patients. During the study period, only one radiotherapy machine was in working condition. Other patients are not able to pay for treatment. Although treatment at this referral hospital is subsidized by the government, patients must provide their own transport, accommodation, and meals while waiting for a hospital bed. PN1: “People believe that this hospital is very cheap; they have used all their money in other hospitals and then the doctors
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send them here. By the time they get here, the disease is advanced. So the prognosis is not good.”
Patient and Family Barriers Nurses on the private unit view patients and family members as a barrier to cancer pain management. Nurses believe that some patients do not want to leave the hospital, and that they thus exaggerate their pain levels so they can stay longer. Nurses note that patients’ relatives on the private unit can be demanding and tend to ask for pain medication even when the patient does not need it. Nurses often believe that patients are addicted to opioids whenever patients or their family member ask for pain medication frequently. PN9: “Relatives interrupt a lot. They can be so nagging, you are not able to figure out if it's the patient's genuine pain or the relatives.” Patients’ beliefs are also reported as barriers. Some patients do not believe in oral medication; they prefer an alternate route of administration because they believe it will work better and faster. Nurses indicate that patients from certain communities believe intramuscular injections are better than oral medications. PN7: “Patients from other cultures believe that if you don't give an injection then you have not treated their pain. So some nurses give normal saline injections to calm the patients down. We give the placebos for psychological pain.”
Discussion This is the first study in Kenya identifying barriers to cancer pain management from the perspective of different nursing subcultures. Using data obtained through observation and semistructured interviews, I investigated shared and individual barriers to cancer pain management. A unique finding in this study is that more barriers are noted in the private unit. Ideally, the private unit should have reported fewer barriers, considering they have more resources and do not employ enrolled nurses (the lowest cadre in the Kenyan system). Given that patients in the private unit are in equally advanced stages of their disease when compared to patients in the general unit, one can infer that the different subcultures in each unit, and not the resources or educational level of nurses, shape nursing perceptions and practices of cancer pain management. Overall, this study corroborates known barriers that prevent nurses from providing effective cancer pain management, such as lack of training in pain management, patients with advanced disease, fear of opioids, workload, burnout, lack of specialization, lack of clear pain policies, and negative attitudes. All of the following have been reported in previous studies (Al Khalaileh & AlQadire, 2012; Breuer et al., 2011; Saini & Bhatnagar, 2016). As Wild and Mitchell (2000) suggest, good pain outcomes occur in nursing units where nurses have positive attitudes. However, a number of misconceptions and negative attitudes limit positive patient outcomes. Evidence that nurses fear administration of opioids has been found in other studies (Kaki et al., 2009; Yava et al., 2013) despite the availability of clinical guidelines on management of side effects. Lack of access to pain management guidelines and palliative care training may explain why most nurses in the private unit fear administering morphine. In developed countries such as the United States, high levels of opioid consumption and prescription drug abuse have created barriers such as providers fearing overprescribing or lawsuits related to opioids. These barriers affect optimum pain control,
Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006
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especially for cancer patients (Foxwell, Uritsky, & Meghani, 2019). On the other hand, it has been suggested that opioid availability is a barrier to cancer pain management in developing countries (Saini & Bhatnagar, 2016). This conjecture is not supported by the findings in this study. Opioid availability is no longer an issue of concern for this hospital; rather, consistency in dispensing on the private unit and physician reluctance to prescribe were reported barriers. Regardless of morphine availability, nurses need additional evidence-based education to alleviate their negative beliefs regarding opioids. Education should take into consideration the existing barriers in different subcultures that prevent providers from using opioids. Previous studies have shown that lack of collaboration with physicians has negative consequences for pain management (Egan & Cornally, 2013). Findings in the present study reveal a lack of collaboration among the healthcare professionals in the private unit; these are congruent to findings previously reported in the literature (DeSilva & Rolls, 2011; McCarthy & Riley, 2012). The institution should put mechanisms in place to ensure teamwork and collaboration. Burnout has a negative effect on the quality of care provided to patients (Lee & Akhtar, 2011). Factors such as workload, lack of debriefing sessions, and lack of career progression within this institution may contribute to burnout and nurses leaving their jobs. Our findings are similar to those of a recent review which suggested that there is a negative relationship among nursing retention, stress, and burnout among oncology nurses (Toh, Ang, & Devi, 2012). Although the nursing shortage is a global problem, subSaharan Africa is worst hit. Findings in this study suggest that improvements in working conditions may improve nurse retention, quality of pain management, and welfare among nurses in this institution. Lack of specialization also needs consideration; a culture in which specialization is not valued may explain findings of this study. Kenya's government institutions did not offer any oncology nursing training programs during the study period. Currently, one private hospital with a hospice program is offering 4-week clinical placements for community college students. Lack of training in the universities where physicians and BSN nurses are trained is a concern. This finding bears some resemblance to findings by Harding et al. (2014) and Selman et al. (2013) highlighting the lack of specialists as a barrier to cancer pain management in developing countries. Specialization and availability of specialists can improve pain management practices and alleviate some of the barriers that currently exist (Kwon, 2014; LeBaron, Bohnenkamp, & Reed, 2011). The study has implications for nursing practice in developing countries. The failure to take into consideration the role of nursing subculture in cancer pain management, even with the availability of evidence-based cancer pain management guidelines and pain medication, is a possible explanation as to why barriers to cancer pain management continue to exist. Finally, the study has implications beyond pain management. Evaluating different subcultures in nursing provides a useful mechanism for examining different aspects of nursing practice. Such examination can enhance understanding of how practices in different nursing units within the same facility are formed and maintained. Limitations One researcher conducted, transcribed, and analyzed interviews. This could be considered a limitation; however, the researcher used representative quotations from the transcribed text, and also sought guidance from experts in pain management and qualitative research during the research process.
Conclusion This study took place in one government hospital in Kenya, and thus may be most relevant to similar care settings. Barriers reported by nurses in this study can apply generally to developing countries, and are not unique to public hospitals or to Kenya. For example, concerns regarding lack of specialization in oncology nursing are likely to be pertinent for most nurses in developing countries, irrespective of specific practice setting. The current study focused specifically on identifying barriers to cancer pain management in the two units, and asserts that cancer pain management practices can be improved when nurses in a subculture share the same beliefs, knowledge, skills, and attitudes towards pain management. This can be achieved through consistency in training and availability of pain management policies. For instance, an individual nurse armed with new knowledge regarding cancer pain management is less likely to consistently apply this knowledge in practice if it is inconsistent with the nursing subculture predominant on the specific unit. For practices to be changed, tailored interventions are needed for specific units, taking into consideration the nurses’ subculture in each unit.
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Please cite this article as: Onsongo, L. N., Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.08.006