Pain Management Nursing 21 (2020) 283e289

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Pain Management Nursing

journal homepage: www.painmanagementnursing.org

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: Background: Up to 80% of cancer patients in Kenya suffer from untreated moderate to severe pain.
Received 29 March 2019 Aim: This study explored barriers to cancer pain management among nurses caring for oncology patients
Received in revised form in Kenya. This was part of a larger study whose primary objective was to understand the role of nursing
5 August 2019
subculture on cancer pain management.
Accepted 27 August 2019
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 man-
agement 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 man-
agement 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 mil-
lions 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: Onsongo.lister@ku.ac.ke.
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 con-
sumption 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.
284 L.N. Onsongo / Pain Management Nursing 21 (2020) 283e289
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 recog-
nized. 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 un-
derstand the role of nursing subculture on cancer pain manage-
ment. 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 in-
terviews were audio recorded (with permission) and lasted
approximately 45 minutes. Questions were open-ended and eli-
cited challenges related to pain management. For example, ques-
tions 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 incor-
poration or use of the pain management guidelines in your prac-
tice?” 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 observa-
tions 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 prin-
ciples 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 classi-
fying 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 par-
ticipants’ quotes to establish descriptive validity, keeping a reflec-
tive 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 Institu-
tional 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.
 L.N. Onsongo / Pain Management Nursing 21 (2020) 283e289 285

Table 1 Table 2
Participants Demographics Barriers to Cancer Pain Management in Oncology and Private Units (N ¼ 25)

Variable n (%) % Theme OU n (%) PU n (%)

25 100 Organizational related barriers

Accessibility to pain management guidelines 1 (4) 8 (32)
Sex
Restrictive dispensing procedures for opioids 0 3 (12)
Male 6 24
Inconsistency in training 3 (12) 10 (40)
Female 19 76
Staffing & workload 7 (28) 4 (16)
Age
Unavailability of supplies 0 2 (8)
21-30 4 16
Lack of specialized unit 0 12 (48)
31-40 8 32
Cognitive barriers
41-50 6 24
Pain is difficult to manage 3 (12) 3 (12)
51> 7 28
Fear of opioid-related side effects 4 (16) 8 (32)
Work status
Nurse burnout 3 (12) 8 (32)
Permanent 22 88
Professional related barriers
Locum 3 12
Lack of formal recognition as specialists 11 (44) 0
Unit
Physicians as a barrier 0 8 (32)
Oncology 12 48
Lack of professional collaboration 0 4 (16)
Private 13 52
Patient/family related barriers
Education
Delayed treatment 2 (8) 5 (20)
Certificate (ERN)* 6 24
Patient/family factors 0 5 (20)
Diploma (RN) 9 36
Baccalaureate (BScN) 9 36 OU ¼ oncology unit; PU ¼ private unit.
Higher Diploma 1 4
*
All worked in the oncology 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 medica-
tion 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 unreason-
able 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. Further-
more, 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
286 L.N. Onsongo / Pain Management Nursing 21 (2020) 283e289
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 pa-
tients 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 holi-
days 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 time-
consuming 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 invol-
untarily; 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
 L.N. Onsongo / Pain Management Nursing 21 (2020) 283e289
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 medi-
cine; 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 physi-
cians because they believe they will be perceived as assistants
rather than equals. As a result of this refusal, there is a communi-
cation 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 hos-
pital 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, accom-
modation, 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
287
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 in-
terviews, 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 dis-
ease, 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 man-
agement 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,
288 L.N. Onsongo / Pain Management Nursing 21 (2020) 283e289
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 find-
ings 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, sub-
Saharan Africa is worst hit. Findings in this study suggest that im-
provements 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) high-
lighting the lack of specialists as a barrier to cancer pain man-
agement in developing countries. Specialization and availability
of specialists can improve pain management practices and alle-
viate some of the barriers that currently exist (Kwon, 2014;
LeBaron, Bohnenkamp, & Reed, 2011). The study has implica-
tions 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 manage-
ment 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 fa-
cility are formed and maintained.
Limitations
One researcher conducted, transcribed, and analyzed in-
terviews. 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 be-
liefs, knowledge, skills, and attitudes towards pain management.
This can be achieved through consistency in training and avail-
ability of pain management policies. For instance, an individual
nurse armed with new knowledge regarding cancer pain manage-
ment 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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