Exploring the perception of Oncology Unit Nurses: Challenges and Barriers to Palliative Care Delivery in Government Hospitals of Addis Ababa, Ethiopia 2024

Exploring the perception of Oncology Unit Nurses: Challenges and Barriers to Palliative Care Delivery in Government Hospitals of Addis Ababa, Ethiopia 2024 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Exploring the perception of Oncology Unit Nurses: Challenges and Barriers to Palliative Care Delivery in Government Hospitals of Addis Ababa, Ethiopia 2024 Melke Bimrew, Mekdes Hailegebrael, Teketel Kifle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7321317/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Nurses spend the most time assisting patients and families with serious illnesses. Understanding their perceptions of challenges in palliative care is crucial for improving patient outcomes. Identifying these barriers allows healthcare organizations to implement targeted interventions and support, enhancing the palliative care environment. Objectives: to explore the Perception of Oncology Unit Nurses on the challenges and barriers to palliative care delivery in government hospitals of Addis Ababa, Ethiopia. Methods: A descriptive phenomenological approach was employed to explore the perceptions of oncology unit nurses regarding the challenges and barriers they face in providing palliative care in governmental hospitals. Participants were purposefully selected based on their years of experience in the oncology unit, resulting in a total of 14 nurses included until data saturation was reached. The data were analyzed using inductive thematic analysis, which involved identifying and examining patterns or themes within the data. Result : Data analysis revealed five key themes and thirteen subthemes detailing the challenges faced by oncology nurses in palliative care provision. These themes highlighted: insufficient holistic approaches, a deficit in continuing education, inadequate resources, and workplace stress and burnout, and communication barriers. These findings underscore the significant obstacles impacting the delivery of effective palliative care. Conclusion and recommendation: Oncology unit nurses encounter significant challenges, including resource limitations, high emotional demands, burnout risk, and communication barriers. To enhance palliative care delivery, comprehensive training and education are essential. Specifically, oncology nurses need improved skills in core palliative care principles, effective communication, emotional intelligence, and cultural competence. Biological sciences/Cancer Health sciences/Health care Health sciences/Oncology palliative care challenge barriers perception oncology nurses Ethiopia INTRODUCTION The World Health Organization defines palliative care as a holistic approach aimed at relieving suffering—physical, psychological, social, and spiritual—associated with life-threatening illnesses( 1 , 2 ). This care involves a multidisciplinary team, including physicians, nurses, social workers, spiritual leaders, pharmacists, counselors, and other specialists ( 3 ). Palliative care reduces suffering, enhances quality of life, and assists patients in meeting their requirements in the last stages of their lives( 4 ).Global Cancer Statistics (GLOBOCAN) reports that 51,865 Ethiopians lost their lives to cancer in 2020( 5 ). Late-stage presentations and delays in the diagnosis of life-threatening illnesses like cancer are widespread, and increase in NCDs is driving the demand for palliative care( 6 ). Globally, palliative care remains largely inaccessible, with only 14% of the 58 million patients in need receiving it each year ( 7 , 8 ). An estimated 9.7 million people require palliative care, especially in Africa( 9 , 10 ). Although there is little data available, the Ethiopian Federal Ministry of Health estimates that there are 50,000 cancer deaths and 120,500 cancer cases per year( 11 , 12 ). Providing palliative care is fraught with challenges( 13 ) Research indicates that financial assessments are crucial for the growth and sustainability of palliative care services( 13 ). A significant barrier to effective palliative care in Ethiopia stems from policymakers', medical professionals', and community members' lack of awareness regarding comprehensive services ( 14 , 15 ). Additional obstacles in Africa include delayed diagnoses, poverty, limited access to services, and a general lack of awareness ( 16 , 17 ). Among healthcare professionals, nurses play a pivotal role in assisting patients and families as they navigate the complexities of serious illness( 18 ). However, they often encounter difficulties in discussing end-of-life issues due to insufficient communication skills, even as families express a desire for greater openness during these emotionally charged conversations ( 19 ). Oncology nurses are essential in facilitating discussions about end-of-life concerns, but these conversations require time and often necessitate multiple sessions ( 20 ). A common barrier to delivering high-quality care is the lack of experience, education, and understanding of palliative care among health professionals ( 21 ). This gap can lead to increased stress, job dissatisfaction, and emotional burnout among nurses ( 22 ). Research from Turkey in 2023 highlighted various factors negatively impacting care, including the inability to relieve pain, inadequate clinic environments, and challenges in communication with patients and their families( 23 ). Similarly, a 2023 study in Ghana identified logistical and infrastructural deficiencies as major hurdles for integrating palliative care, revealing suboptimal conditions for practice and transportation issues for home visits( 24 ). Furthermore, a 2021 study indicated that administrative constraints significantly hinder cancer care for children, with nurses facing prolonged processes, poor collaboration, logistical challenges, work stress, and staff shortages, all contributing to job dissatisfaction ( 25 ). A 2023 study in Ethiopia emphasized the need for a dedicated budget to support sustainable integrated palliative care( 26 ). While some quantitative research has explored nurses' knowledge and attitudes towards palliative care, qualitative studies focusing specifically on oncology nurses' perspectives in Ethiopia are scarce( 27 ). This study addresses this gap by examining oncology nurses' views on palliative care, which can enhance care quality by identifying challenges, informing targeted training, and improving patient outcomes. The insights gained will promote better interdisciplinary collaboration and advocate for policy changes that address the holistic needs of patients and families. METHODS AND MATERIALS Study design and Setting The study employed a descriptive phenomenological approach, with data collection conducted by the principal investigator from May 20 to June 10, 2024. It took place in two government hospitals in Addis Ababa, selected for their extensive oncology experience: Tikur Anbessa Specialized Hospital (TASH) and St. Paul’s Hospital Millennium Medical College (SPHMMC). TASH, a referral teaching hospital with 800 beds, has offered advanced cancer treatments since 2004, serving over 4 million people. SPHMMC, established in 1968, has 700 beds and provides comprehensive cancer care, including chemotherapy and palliative services, with an oncology unit operational since 2018. Study population and sampling technique The study involved nurses from the palliative care unit who had at least six months of experience at the selected site, utilizing purposive sampling specifically maximum variance sampling based on the research question. Participants with severe illnesses or mental health issues were excluded from in-depth interviews, as these conditions could impact their ability to provide informed consent and participate effectively in the study. Data collection tool and procedure A semi-structured open-ended questionnaire was utilized as the primary data collection tool, developed from existing literature and expert insights. Key informant interviews targeted nurses working palliative care at SPHMMC and TASH, each with at least six months of experience in palliative cancer care. Verbal consent was obtained prior to each interview, ensuring participants understood the study's purpose, privacy policies, and data handling procedures. The sample size for the in-depth interviews (IDIs) was established based on the recommendations of Morse and Creswell for phenomenological studies, which suggest a range of 5 to 25 participants ( 28 ) ,achieved information saturation after interviewing 14 participants, but conducted two additional in-depth interviews to confirm the completeness of the findings. Interviews took place in private, comfortable settings, fostering open communication. The semi-structured format allowed for focused exploration while accommodating spontaneous insights, with audio recordings supplemented by field notes to capture context and non-verbal cues. Opening with the question, "Can you talk about your experiences dealing with palliative care in the oncology unit?" facilitated rich qualitative data, supported by follow-up questions to ensure clarity and depth. This method provided a comprehensive understanding of the nurses' interactions with patients and families in palliative care. Data Processing and analysis Data were analyzed using inductive thematic analysis as outlined by Virginia Braun and Victoria Clarke( 29 ), which involves identifying common themes and patterns within the data. The analysis followed six steps: ( 1 ) Familiarization, ( 2 ) Coding, ( 3 ) Generating themes, ( 4 ) Reviewing themes, ( 5 ) Defining and naming themes, and ( 6 ) Writing up the analysis. Audio recordings were transcribed verbatim into Word documents, ensuring accuracy. Each line was color-coded to aid coding, employing a line-by-line method to identify initial codes representing distinct concepts, actions, or sentiments. These initial codes were grouped into broader categories, leading to the development of overarching themes and sub-themes. This structured framework facilitated a deeper understanding of the data, enhancing the rigor and validity of the research. Additionally, preliminary testing was conducted to assess participants' understanding of the questions, improving the reliability of the main study. Data quality control To identify key themes and insights from the interviews, the investigator accurately reviewed audio recordings and field notes multiple times after each session, focusing on building rapport and understanding participants' contexts. The principal investigator and specialists translated and transcribed recordings using a standard verbatim approach to ensure data validity and rigor. Trustworthiness The study's trustworthiness was evaluated through credibility, dependability, transferability, and conformability. Credibility was established via prolonged engagement, peer debriefing, thick descriptions, and member checking, including feedback from four participants on initial findings. Dependability was ensured through an audit trail, process logs, and external reviews of the methodology. Transferability was supported by thick descriptions detailing the research setting and diverse participant experiences. Finally, conformability was maintained through comprehensive documentation of research decisions and peer debriefing with a qualitative expert, using direct quotes to ensure alignment with participants' voices. RESULT Socio demographic data of participants Fourteen key informants were interviewed separately with 7 participants (50%) identified as women. The average age of the respondents was 32.8 years. With regard to education, half of the participants (7or 50%) had a master's degree of them, 6 specialized in clinical oncology nursing, while 1specialised in adult health nursing. The average experience in the oncology unit is 6.5 years, from at least 4 to 17 years. The duration of the interview varied the longest being 60 minutes and the shortest 45 minutes. (Table 1 ). Table 1 Socio demographic data of participants exploring Perception of oncology unit nurses: challenges and barriers providing palliative care palliative care in government hospitals in Addis Ababa Ethiopia, 2024 Category No Sex Male 7 Female 7 Age 20-30years 5 31-40years 8 > 40years 1 Educational status BSC Degree 7 MSc Degree 7 Work experience in oncology unit 10years 1 Themes and Subthemes After multiple readings and coding of the transcriptions, five main themes were identified, each accompanied by several subthemes. These themes and subthemes are presented in Table 2 . Table 2 Themes and Subthemes Exploring Perception of oncology unit nurses: challenges and barriers providing palliative care in government hospitals in Addis Ababa Ethiopia, 2024 Themes Subthemes Lack of Holistic Approaches to Palliative Care Absence of Multi-Disciplinary Teams Lack of Family Involvement Lack Psychosocial Support for patient and family Gap in Continuous Education and Training in Palliative Care Inadequate Curriculum Integration of palliative care Inadequate On-the-Job Training Resource Scarcity in Palliative Care Medication Shortages Lack of isolated room and bed Patients Economic Constraints Healthcare Provider Burnout and Workplace Stressed Emotional Burnout Loss of Job Satisfaction Communication Barriers in Palliative Care Language Barriers Lack of Health Literacy Theme One: Lack of Holistic Approaches to Palliative Care Palliative care is a holistic approach to patient physical, emotional, social, spiritual and psychological needs, intended at improving the quality of life of patients and their families, not just at relieving symptoms of disease( 30 ). The main sub-theme identified involves the absence of a multidisciplinary team, the focus only on physical care, the absence of non-physical care, lack of involvement of families and the lack of psychosocial support for patients and their families. Absence of Multi-Disciplinary Teams Palliative care involves a range of professionals, including physicians, nurses, pharmacists, psychologists, physiotherapists, and social workers ( 3 ). However, in this study, findings indicate that not all of these disciplines were represented in the care services, as participants expressed concerns about the lack of comprehensive multidisciplinary involvement. “ Palliative Care is a comprehensive service…. This should include professional areas such as psychological counselors, social service professionals, religious leaders, charitable organizations, and all-centered services should be provided. But, in our setup no multi-disciplinary teams as there is only nurse and physician working together “ KII 014 Other participant also support this “ In our hospital palliative care service not incorporate all discipline …it includes physicians and nurses only but other discipline not Lack of Family Involvement Palliative care is focus on both patients and families and understands the interdependence of patients and their families, specifically in the event of severe illness and end of life( 18 ). Family involvement is vital to helping the physical, emotional and spiritual well-being of patients( 2 ). The key informant interviewed expressed that some families did not cooperate in patient treatment. When a patient is in pain, we counsel family members to give medication promptly to manage their discomfort. If the pain worsens, we suggest taking the patient to a healthcare facility for further investigation and assistance. Additionally, we inform families about the possible side effects of anti-pain like morphine, which can include constipation and respiratory issues. To address constipation, we recommend the use of laxatives. Unfortunately, some patients resort to selling family assets to afford treatment, which places significant conflict with their family member’s ones. KI 013 “ In palliative care, communication gaps between patients and caregivers often lead to challenges. Many patients suffer in pain without full knowledge of their condition, as families may withhold information to avoid distress. Providing education about the illness and treatment options can help shift perspectives and improve support. Additionally, some patients arrive from remote areas without family assistance, complicating their care. Financial barriers also hinder access to necessary medications, while caregivers struggle to balance work and home responsibilities, resulting in gaps in medication management and adherence” KI 014 Lack of Psychosocial Support for patient and family Psychosocial support is needed to meet the emotional, psychological, social, and spiritual desire of patients and their families facing life- treating illnesses( 31 ). By focusing on the whole person, it aims to increase quality of life, reduce distress, and help navigate the challenges associated with serious health conditions. “ The level of palliative care at our hospital focuses only on physical treatment and does not pay attention to social, spiritual and economic issues. “KI 010 Other participants added this idea, “Palliative care is comprehensive care. Pain relief, psychological care, social care includes spiritual care. It is to make patients free from pain. Cancer patients are the patients who need palliative care the most. In reality we were not give psychological support for our cancer patients which hinders their treatment progress.” KI 014 Theme Two: Gap in Continuous Education and Training in Palliative Care To ensure that healthcare providers deliver compassionate, high-quality management for patients with life-threatening diseases, sustainable education and training in palliative care are essential, addressing the physical, emotional, spiritual, and social needs of patients and their families to enhance their quality of life( 32 ). Continuous training is vital to stay update with the development of treatments. In addition to enable that health care providers maintain their competence in giving patient-centered compassionate care, continuous education and training in palliative care promote creativity and resilience in a demanding industry. Inadequate Curriculum Integration of palliative care The goal of incorporating palliative care into nursing education programs is to provide nurses the attitudes, abilities, and information needed to provide compassionate end-of-life care( 33 ). Numerous obstacles and difficulties prevent palliative care from being effectively incorporated into nursing courses. Participants expressed this idea “I have noticed professionals who do not know what palliative care is because it is not included in the education system .” KI OO4 “My continuous education and training made me understand what I have now .” KII 013 Lack of On-the-Job Training On-the-job training in palliative care is seen by nurses as crucial for bridging the gap between theoretical knowledge and the necessary practical skills for excellent end-of-life care. Participants said about training for nurses on palliative care, “Before, we used to make him take it only when he felt pain, and this does not reduce the suffering g of cancer patients, but it should be taken at the same time every day without stopping. I used to think of palliative care as a type of treatment given to dying patients. But now after training, change my thinking.” KI 008 Others key informants also added, “ Training should be prepared. I did not take palliative care training personally, but we were taught Fundamentals of Nursing palliative care. However, there is no training provided by the Ministry of Health. Besides, I am reading by searching the internet .” KI 011 Theme three: Resource Scarcity in Palliative Care Resource shortage is seen as a significant issue in palliative care that affects the consistency, quality, and accessibility of care for patients nearing the end of their lives. Limited resources have an impact on a number of factors, including support services, access to drugs, and workforce limitations. Medication shortages, lack of isolated rooms and beds, and patient economic constraints are concentrated on as subthemes. Medication Shortages The standard of treatment for patients with severe, terminal illnesses is immediately impacted by shortages of palliative care medications, making them a significant issue( 34 ). Effective symptom management, particularly pain management, is essential to palliative care in order to preserve patient comfort and dignity. Prescription medication shortages can impede this care, exacerbating patient discomfort and upsetting medical staff. “ We have a problem with the supply of medicine… If there is no medicine available, the suffering will increase if there is no medicine for the disease .” KI 008 “ There is a problem in the supply of medicines which is some day it is available on the other day it not available ” KII 004 Lack of isolated room and bed Participants stated there are problem of isolated room and bed for palliative patients for admission and giving care. Participants stated lack of isolated room and bed as follows “Bed and room shortages hinder equitable access to care for patients. When beds are occupied, those needing palliative care may be turned away, denying them essential treatment and negatively impacting their well-being. Increasing the number of available beds and preparing spaces would help resolve this issue.” KI 011 Other participant also expressed like this: “ The shortage of rooms and beds limits our ability to provide equitable, quality care. When beds are full, we cannot accept new patients, as we refuse to treat them while they are lying on chairs. Increasing the number of beds, along with separate rooms and facilities, would greatly improve the situation. ” KI 006 Patient Economic Constraints Financial constraints significantly hinder access to essential medications, therapies, and support for palliative care patients, adversely affecting outcomes, overall experiences for patients and families, and the quality of care, especially for those from low-income or disadvantaged backgrounds( 35 ). Participants stated the above idea: “ Those who can afford better services, go to a better private facility, get treatment for their discomfort, find a cure and go home, for example, if they have sleep problems, get treatment for their sleep problems, if they have pain, they can understand the way to get relief from pain and suffering with their money ….but those who cannot afford the anti-pain drugs go home with home without drugs ” KI 014 Other participant also expressed like this: “ I think it would solve the problem if health insurance coverage was accessible to all patients. When they are unable to continue the treatment due to lack of funds, they resort to prayer or holy water. And for this, the solution is to be a beneficiary of health insurance, which helps to overcome the problem in some way .” KI 003 Theme four: Healthcare Provider Burnout and Workplace Stress Palliative care providers frequently develop deep connections with patients and their families while navigating terminal illnesses, and this constant exposure to loss and grief can significantly impact their emotional well-being, resulting in burnout( 36 ). Key issues include emotional exhaustion and diminished job satisfaction, with some nurses reporting feelings of boredom and depression after prolonged care. “ A health professional especially working in palliative care experiences high tiredness. Such places are stressful in themselves. Other departments are treated and sent home, but here it is a place where anxious patients and caregivers are seen. ” KI OO1 Other participant also expressed like this: “Nurses become bored and depressed when they stay with palliative patients for long periods of time. The reason is that a high-level patient's stay is so short that when this happens repeatedly, boredom leads to despair. It causes stress on job satisfaction and makes him unhappy” KI 004 Lack of Job Satisfaction Palliative care practitioners face a combination of organizational and emotional challenges that impact job satisfaction; however, many derive personal and professional fulfillment from their work, and improving mental health resources, knowledge, and organizational support can enhance job satisfaction in this essential field( 37 ). Respondents shared the following insights: “When you know the stage of the disease by seeing the patient himself, this puts you under pressure. It makes you have two kinds of feelings, one makes you think that I will help as much as I can. And the other one feels that why don't I change the class if I don't suffer all this. So it puts pressure on job satisfaction in this way. You feel when you can help but can't do anything.” KI 010 “When you take the necessary care and see that the end is death, the psychological pressure makes you unhappy and makes you despair. On the contrary, when you see a patient being treated, it gives you emotional satisfaction. Sometimes it makes you hate your job and makes you think about quitting. When such palliative care causes mental stress.” KI 011 Theme Five: Communication Barriers in Palliative Care Effective communication is crucial in palliative care, particularly for end-of-life discussions, and overcoming communication barriers—through practical strategies, emotional intelligence, and cultural sensitivity—is essential for delivering proper care and support, especially in Ethiopia, where diverse languages complicate understanding and family involvement. Participants shared the following insights: “ Language is one of the communication barriers. We solve this language problem with a translator. Some patients have trouble understanding what we say. We will tell them again and again this time. We ask them what I said to know if they understood us. After that, if they tell us back what we said, we believe that they understood us ” KI 009. “ One of the challenges of communication is language. If people who know the language are assigned to provide information, the problem of language communication will be solved.” KI 007 Lack of Health literacy Health literacy in palliative care encompasses the ability of patients, families, and caregivers to understand medical information, engage in discussions, and make informed decisions about serious illness and end-of-life options, including palliative care and symptom management. Participants shared the following insights: “ Some patients have trouble understanding what we say. We will tell them again and again this time. We ask them what I said to know if they understood us. After that, if they tell us back what we said, we believe that they understood us.” KI OO9 “In palliative care, challenges often stem from a lack of health literacy among patients and their families. Many patients endure pain and suffering without understanding their condition, as families may withhold critical information out of fear that it will cause further distress. To address this issue, we can enhance health literacy through education and guidance. By providing clear information about the disease and treatment options, we can help shift attitudes and improve patient care. Additionally, some patients arrive from rural areas without family support, further complicating their understanding and management of their health.” KI O14 DISCUSSION This research focused on the perceptions of oncology nurses regarding the challenges and barriers to providing palliative care. The study highlights the need for integrated support for patients and families, emphasizing their physical, emotional, social, and spiritual needs as part of holistic healthcare. Participants stressed that while comprehensive care should address various aspects of patient well-being, the current emphasis remains on managing physical symptoms. This conclusion coincides with a study conducted in Ethiopia, which also found that existing care models give priority to pain management rather than comprehensive palliative care( 30 ). But this study result were in consistent with the fundamental concepts of palliative care and WHO definition of palliative care( 38 ). An ongoing education and training in palliative care is essential for nurses to provide compassionate and high-quality care to patients with life-threatening diseases. However, participants in this study indicated a lack of sufficient training and education. Improved training can increase nurses' knowledge and ultimately improve patient care. These findings align with studies carried out in Africa and Ethiopia, which show that the lack of appropriately trained health professionals poses significant challenges for effective palliative care( 39 , 40 ). Participants expressed a lack or limited part of the curriculum for nursing student education on palliative care, which is similar to the study carried out in Ethiopia, a lack of palliative care education in pre-and post-training as well as in the training programs for the various disciplines of health( 41 , 42 ). Limited resources in palliative care significantly affect the quality and availability of services for patients with terminal illnesses, necessitating competent multidisciplinary teams and substantial resources to effectively manage symptoms and provide emotional support( 43 ). This study found that there was a shortage of basic medicines such as morphine and chemotherapy drugs, which were often expensive and not covered by health insurance, and many patients ended their treatment. Nurses reported that they could not provide adequate hospice care due to the lack of funding from the government and medical facilities( 44 ). This causes patient live with pain and suffering. Workplace stress and burnout among healthcare providers significantly affect the quality of care of patients and the well-being of the providers. Participants stated that long-term work with palliative patients leads to emotional burnout and unemployment, which reflect the finding sofa similar study conducted in Singapore( 4 ). Effective communication in palliative care is crucial for building trust, supporting informed decision-making, and enhancing the overall care experience for patients and their families, as it allows healthcare providers to acknowledge and respect patients' preferences and concerns. However, communication barriers can hinder these interactions, with participants noting that language differences—particularly between Amharic speakers and patients who do not speak the language—often necessitate the use of translators. In Ethiopia's multilingual and multicultural context, these communication challenges can be further complicated by cultural differences, which sometimes lead nurses to withhold information to avoid causing offense to patients from diverse backgrounds( 4 ). Limitation of the study This study has inherent limitations, including potential researcher bias due to the subjective nature of qualitative inquiry and context-specific findings that may limit generalizability. Additionally, the exclusion of allied healthcare professionals' perspectives, and time constraints on participating nurses may have affected the data's richness and comprehensiveness, necessitating careful interpretation of the conclusions. Conclusion and recommendation Palliative care nursing is a demanding yet profoundly rewarding specialty that requires a strong foundation of clinical expertise and exceptional emotional resilience. To effectively address the inherent challenges, such as emotional burdens and resource limitations, comprehensive training programs should be established, focusing on advanced communication skills, cultural sensitivity, and emotional intelligence. Additionally, healthcare organizations must ensure adequate staffing levels, provide accessible mental health resources, and implement supportive policies to reduce burnout and enhance the quality of patient-centered care. Promoting open communication among patients, families, and the interdisciplinary care team is essential for creating a personalized and compassionate care experience. Declarations Ethical consideration All procedures in this study adhered to the ethical standards set forth in the Declaration of Helsinki. Ethical clearance was obtained from the St. Paul’s Hospital Millennium Medical College School of Nursing Research Ethics Institutional Review Board (IRB) with Ref no:pm23/1176. Participants were informed about the study's purpose, and their confidentiality and privacy were ensured through informed consent. An official letter was received from the Addis Ababa Health Bureau Research Directorate, along with letters of ethical clearance and cooperation for the participating hospitals. Confidentiality was maintained throughout data collection and storage by conducting interviews in private settings and not collecting personal identifiers. All audio files were anonymized during transcription, ensuring that only the research team had access to the stored data. Consent for Publication Not applicable Availability of data and materials Data will be available upon request from the corresponding author Competing interests The authors declare that they have no competing interests Funding All funding of this original research process cover by all authors Funding for Publication Not applicable: Authors’ contributions MH and MB contributed to the conception, design, methodology, analysis, and interpretation. TK was involved in the analysis, interpretation, and drafting of the manuscript. MH and MB were also actively engaged in the manuscript write-up. All authors have reviewed and approved the final submission of the manuscript. Authors’ detail: Melke Bimrew: MSc in Oncology Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia Mekdes Hailegebreal: Assistant professor in Pediatric and child health nursing, MSc in Pediatric and Child health nursing , St. Paul’s Hospital Millennium Medical college, Addis Ababa, Ethiopia Teketel Kifle : MSc in Oncology Nursing, Jimma University, Jimma, Ethiopia. Acknowledgment We would like to thank St. Paul’s Hospital Millennium Medical College for the support for the realization of this finding. Special thanks and appreciation to all those who agreed to participate in this study, mainly respondents, data collectors and supervisors. References Organization WH. Integrating palliative care and symptom relief into responses to humanitarian emergencies and crises: a WHO guide. Integrating palliative care and symptom relief into responses to humanitarian emergencies and crises: a WHO guide2018. 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Navigating Sample Size Estimation for Qualitative Research. Journal of Medical Evidence. 2024;5(2):133-9. Braun V, Clarke V. Thematic analysis. APA handbook of research methods in psychology, Vol 2: Research designs: Quantitative, qualitative, neuropsychological, and biological. Washington: American Psychological Association; 2012. p. 57-71. Mamo Y, Habte A, Abreha A, Ayers N, Abathun E, Reid E, et al. The evolution of hospice and palliative care in Ethiopia: From historic milestones to future directions. Ethiopian Journal of Health Development. 2020;34(4). Sanda MO. Psycho-Social Supports and Family Integration as Determinants of Palliative Care of Terminally-Ill Patients in University College Hospital, Ibadan Nigeria 2015. Rosa WE, de Campos AP, Abedini NC, Gray TF, Huijer HA-S, Bhadelia A, et al. Optimizing the global nursing workforce to ensure universal palliative care access and alleviate serious health-related suffering worldwide. Journal of pain and symptom management. 2022;63(2):e224-e36. Youssef H, Mansour M, Al-Zahrani S, Ayasreh I, Abd El-Karim R. Prioritizing palliative care: assess undergraduate nursing curriculum, knowledge and attitude among nurses caring end-of-life patients. European Journal of Academic Essays. 2015;2(2):90-101. Nauck F, Alt-Epping B. Crises in palliative care—a comprehensive approach. The lancet oncology. 2008;9(11):1086-91. Gardiner C, Brereton L, Frey R, Wilkinson-Meyers L, Gott M. Exploring the financial impact of caring for family members receiving palliative and end-of-life care: a systematic review of the literature. Palliative medicine. 2014;28(5):375-90. Tan F, Wu Y, Li N, Zhang C, Chen S, Huang L, et al. Job burnout and resilience among palliative care professionals in china: a qualitative study. BMC Palliat Care. 2025;24(1):2. Biagioli V, Prandi C, Nyatanga B, Fida R. The role of professional competency in influencing job satisfaction and organizational citizenship behavior among palliative care nurses. Journal of Hospice & Palliative Nursing. 2018;20(4):377-84. Organization WH. Integrating palliative care and symptom relief into responses to humanitarian emergencies and crises: a WHO guide. 2018. Abu-Odah H, Molassiotis A, Liu J. Challenges on the provision of palliative care for patients with cancer in low-and middle-income countries: a systematic review of reviews. BMC palliative care. 2020;19:1-16. Solomon K, Azmera YM, Kaba M. Perspective Chapter: Palliative Care Experiences in Ethiopia–Call for Comprehensive Care Approach. 2024. Negasa EH, Human SP, Roro AG. Challenges in Palliative Care Provision in Ethiopia: An Exploratory Qualitative Study. Journal of Pain Research. 2023:3405-15. LeBaron VT, Palat G, Sinha S, Chinta SK, Jamima BJB, Pilla UL, et al. Recommendations to support nurses and improve the delivery of oncology and palliative care in India. Indian journal of palliative care. 2017;23(2):188. Singer AE, Goebel JR, Kim YS, Dy SM, Ahluwalia SC, Clifford M, et al. Populations and interventions for palliative and end-of-life care: a systematic review. Journal of palliative medicine. 2016;19(9):995-1008. Zheng R, Guo Q, Chen Z, Ma L, McClement S. An exploration of the challenges for oncology nurses in providing hospice care in mainland China: A qualitative study. Asia-Pacific Journal of Oncology Nursing. 2021;8(2):139-46. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7321317","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":503001869,"identity":"4705a835-8695-4fa3-afda-9e364801a2d6","order_by":0,"name":"Melke Bimrew","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIie3PMWuDQBTA8TsCmYSuDeQrBOxyXUQ/SJZ3CGbK7uBgOEg+RD5D1swXDszyiKuQQJRA507FqfRpl0JR2y2Q+w/ykPfjcYzZbHfZSDFg2mlncD368pXuJ/wHKeOo+ZMOE8a+d3iJph16yWyzUm4ZX6azrcme5Tr3dxtDVxJv3kUEHhQAvjniFEVEzuEeJZEsWqZdpJBKy7VxBDo0ExGaCE9NN7lWRD4b8vRB5BSKvBogBVcg0/bKuADUPt0aICiVCxm9BcevNcQhiIKuQN9bjsZM6uQSCBzdXmrXD0S+qMr3xOskv5LtJvx1vSn4z7LNZrM9Rl/2VG9hZkgxmQAAAABJRU5ErkJggg==","orcid":"","institution":"St. Paul’s Hospital Millennium Medical College","correspondingAuthor":true,"prefix":"","firstName":"Melke","middleName":"","lastName":"Bimrew","suffix":""},{"id":503001870,"identity":"e10f55c0-a069-4ec5-adee-f701e58e8ab5","order_by":1,"name":"Mekdes Hailegebrael","email":"","orcid":"","institution":"St. Paul’s Hospital Millennium Medical College","correspondingAuthor":false,"prefix":"","firstName":"Mekdes","middleName":"","lastName":"Hailegebrael","suffix":""},{"id":503001871,"identity":"e678a0d0-9ec1-41b7-9532-81d60885191d","order_by":2,"name":"Teketel Kifle","email":"","orcid":"","institution":"Jimma University","correspondingAuthor":false,"prefix":"","firstName":"Teketel","middleName":"","lastName":"Kifle","suffix":""}],"badges":[],"createdAt":"2025-08-07 18:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7321317/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7321317/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95657030,"identity":"9400a884-2cd7-4f7c-8fa2-e968dcdba338","added_by":"auto","created_at":"2025-11-11 16:19:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1041174,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7321317/v1/f54c6ada-fc88-4f06-b6f8-efa53d26c1e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the perception of Oncology Unit Nurses: Challenges and Barriers to Palliative Care Delivery in Government Hospitals of Addis Ababa, Ethiopia 2024","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe World Health Organization defines palliative care as a holistic approach aimed at relieving suffering\u0026mdash;physical, psychological, social, and spiritual\u0026mdash;associated with life-threatening illnesses(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This care involves a multidisciplinary team, including physicians, nurses, social workers, spiritual leaders, pharmacists, counselors, and other specialists (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Palliative care reduces suffering, enhances quality of life, and assists patients in meeting their requirements in the last stages of their lives(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).Global Cancer Statistics (GLOBOCAN) reports that 51,865 Ethiopians lost their lives to cancer in 2020(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Late-stage presentations and delays in the diagnosis of life-threatening illnesses like cancer are widespread, and increase in NCDs is driving the demand for palliative care(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Globally, palliative care remains largely inaccessible, with only 14% of the 58\u0026nbsp;million patients in need receiving it each year (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). An estimated 9.7\u0026nbsp;million people require palliative care, especially in Africa(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Although there is little data available, the Ethiopian Federal Ministry of Health estimates that there are 50,000 cancer deaths and 120,500 cancer cases per year(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eProviding palliative care is fraught with challenges(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Research indicates that financial assessments are crucial for the growth and sustainability of palliative care services(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A significant barrier to effective palliative care in Ethiopia stems from policymakers', medical professionals', and community members' lack of awareness regarding comprehensive services (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Additional obstacles in Africa include delayed diagnoses, poverty, limited access to services, and a general lack of awareness (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Among healthcare professionals, nurses play a pivotal role in assisting patients and families as they navigate the complexities of serious illness(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, they often encounter difficulties in discussing end-of-life issues due to insufficient communication skills, even as families express a desire for greater openness during these emotionally charged conversations (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOncology nurses are essential in facilitating discussions about end-of-life concerns, but these conversations require time and often necessitate multiple sessions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). A common barrier to delivering high-quality care is the lack of experience, education, and understanding of palliative care among health professionals (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). This gap can lead to increased stress, job dissatisfaction, and emotional burnout among nurses (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Research from Turkey in 2023 highlighted various factors negatively impacting care, including the inability to relieve pain, inadequate clinic environments, and challenges in communication with patients and their families(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Similarly, a 2023 study in Ghana identified logistical and infrastructural deficiencies as major hurdles for integrating palliative care, revealing suboptimal conditions for practice and transportation issues for home visits(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Furthermore, a 2021 study indicated that administrative constraints significantly hinder cancer care for children, with nurses facing prolonged processes, poor collaboration, logistical challenges, work stress, and staff shortages, all contributing to job dissatisfaction (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA 2023 study in Ethiopia emphasized the need for a dedicated budget to support sustainable integrated palliative care(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). While some quantitative research has explored nurses' knowledge and attitudes towards palliative care, qualitative studies focusing specifically on oncology nurses' perspectives in Ethiopia are scarce(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This study addresses this gap by examining oncology nurses' views on palliative care, which can enhance care quality by identifying challenges, informing targeted training, and improving patient outcomes. The insights gained will promote better interdisciplinary collaboration and advocate for policy changes that address the holistic needs of patients and families.\u003c/p\u003e"},{"header":"METHODS AND MATERIALS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and Setting\u003c/h2\u003e\u003cp\u003eThe study employed a descriptive phenomenological approach, with data collection conducted by the principal investigator from May 20 to June 10, 2024. It took place in two government hospitals in Addis Ababa, selected for their extensive oncology experience: Tikur Anbessa Specialized Hospital (TASH) and St. Paul\u0026rsquo;s Hospital Millennium Medical College (SPHMMC). TASH, a referral teaching hospital with 800 beds, has offered advanced cancer treatments since 2004, serving over 4\u0026nbsp;million people. SPHMMC, established in 1968, has 700 beds and provides comprehensive cancer care, including chemotherapy and palliative services, with an oncology unit operational since 2018.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy population and sampling technique\u003c/h3\u003e\n\u003cp\u003eThe study involved nurses from the palliative care unit who had at least six months of experience at the selected site, utilizing purposive sampling specifically maximum variance sampling based on the research question. Participants with severe illnesses or mental health issues were excluded from in-depth interviews, as these conditions could impact their ability to provide informed consent and participate effectively in the study.\u003c/p\u003e\n\u003ch3\u003eData collection tool and procedure\u003c/h3\u003e\n\u003cp\u003eA semi-structured open-ended questionnaire was utilized as the primary data collection tool, developed from existing literature and expert insights. Key informant interviews targeted nurses working palliative care at SPHMMC and TASH, each with at least six months of experience in palliative cancer care. Verbal consent was obtained prior to each interview, ensuring participants understood the study's purpose, privacy policies, and data handling procedures. The sample size for the in-depth interviews (IDIs) was established based on the recommendations of Morse and Creswell for phenomenological studies, which suggest a range of 5 to 25 participants (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) ,achieved information saturation after interviewing 14 participants, but conducted two additional in-depth interviews to confirm the completeness of the findings. Interviews took place in private, comfortable settings, fostering open communication. The semi-structured format allowed for focused exploration while accommodating spontaneous insights, with audio recordings supplemented by field notes to capture context and non-verbal cues. Opening with the question, \"Can you talk about your experiences dealing with palliative care in the oncology unit?\" facilitated rich qualitative data, supported by follow-up questions to ensure clarity and depth. This method provided a comprehensive understanding of the nurses' interactions with patients and families in palliative care.\u003c/p\u003e\n\u003ch3\u003eData Processing and analysis\u003c/h3\u003e\n\u003cp\u003eData were analyzed using inductive thematic analysis as outlined by Virginia Braun and Victoria Clarke(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), which involves identifying common themes and patterns within the data. The analysis followed six steps: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Familiarization, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Coding, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Generating themes, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Reviewing themes, (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Defining and naming themes, and (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Writing up the analysis. Audio recordings were transcribed verbatim into Word documents, ensuring accuracy. Each line was color-coded to aid coding, employing a line-by-line method to identify initial codes representing distinct concepts, actions, or sentiments. These initial codes were grouped into broader categories, leading to the development of overarching themes and sub-themes. This structured framework facilitated a deeper understanding of the data, enhancing the rigor and validity of the research. Additionally, preliminary testing was conducted to assess participants' understanding of the questions, improving the reliability of the main study.\u003c/p\u003e\n\u003ch3\u003eData quality control\u003c/h3\u003e\n\u003cp\u003e To identify key themes and insights from the interviews, the investigator accurately reviewed audio recordings and field notes multiple times after each session, focusing on building rapport and understanding participants' contexts. The principal investigator and specialists translated and transcribed recordings using a standard verbatim approach to ensure data validity and rigor.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eTrustworthiness\u003c/h2\u003e\u003cp\u003eThe study's trustworthiness was evaluated through credibility, dependability, transferability, and conformability. Credibility was established via prolonged engagement, peer debriefing, thick descriptions, and member checking, including feedback from four participants on initial findings. Dependability was ensured through an audit trail, process logs, and external reviews of the methodology. Transferability was supported by thick descriptions detailing the research setting and diverse participant experiences. Finally, conformability was maintained through comprehensive documentation of research decisions and peer debriefing with a qualitative expert, using direct quotes to ensure alignment with participants' voices.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULT","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eSocio demographic data of participants\u003c/h2\u003e\u003cp\u003eFourteen key informants were interviewed separately with 7 participants (50%) identified as women. The average age of the respondents was 32.8 years. With regard to education, half of the participants (7or 50%) had a master's degree of them, 6 specialized in clinical oncology nursing, while 1specialised in adult health nursing. The average experience in the oncology unit is 6.5 years, from at least 4 to 17 years. The duration of the interview varied the longest being 60 minutes and the shortest 45 minutes. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eSocio demographic data of participants exploring Perception of oncology unit nurses: challenges and barriers providing palliative care palliative care in government hospitals in Addis Ababa Ethiopia, 2024\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20-30years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31-40years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;40years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEducational status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBSC Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMSc Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eWork experience in oncology unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;5years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5-10years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eThemes and Subthemes\u003c/h2\u003e\u003cp\u003eAfter multiple readings and coding of the transcriptions, five main themes were identified, each accompanied by several subthemes. These themes and subthemes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and Subthemes Exploring Perception of oncology unit nurses: challenges and barriers providing palliative care in government hospitals in Addis Ababa Ethiopia, 2024\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubthemes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eLack of Holistic Approaches to Palliative Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsence of Multi-Disciplinary Teams\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of Family Involvement\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack Psychosocial Support for patient and family\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGap in Continuous Education and Training in Palliative Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInadequate Curriculum Integration of palliative care\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInadequate On-the-Job Training\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eResource Scarcity in Palliative Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedication Shortages\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of isolated room and bed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients Economic Constraints\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHealthcare Provider Burnout and Workplace Stressed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmotional Burnout\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLoss of Job Satisfaction\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCommunication Barriers in Palliative Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLanguage Barriers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of Health Literacy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eTheme One: Lack of Holistic Approaches to Palliative Care\u003c/h2\u003e\u003cp\u003ePalliative care is a holistic approach to patient physical, emotional, social, spiritual and psychological needs, intended at improving the quality of life of patients and their families, not just at relieving symptoms of disease(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The main sub-theme identified involves the absence of a multidisciplinary team, the focus only on physical care, the absence of non-physical care, lack of involvement of families and the lack of psychosocial support for patients and their families.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAbsence of Multi-Disciplinary Teams\u003c/h2\u003e\u003cp\u003ePalliative care involves a range of professionals, including physicians, nurses, pharmacists, psychologists, physiotherapists, and social workers (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, in this study, findings indicate that not all of these disciplines were represented in the care services, as participants expressed concerns about the lack of comprehensive multidisciplinary involvement.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003ePalliative Care is a comprehensive service\u0026hellip;. This should include professional areas such as psychological counselors, social service professionals, religious leaders, charitable organizations, and all-centered services should be provided. But, in our setup no multi-disciplinary teams as there is only nurse and physician working together \u0026ldquo; KII 014\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eOther participant also support this\u003c/h2\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIn our hospital palliative care service not incorporate all discipline \u0026hellip;it includes physicians and nurses only but other discipline not\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eLack of Family Involvement\u003c/h2\u003e\u003cp\u003ePalliative care is focus on both patients and families and understands the interdependence of patients and their families, specifically in the event of severe illness and end of life(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Family involvement is vital to helping the physical, emotional and spiritual well-being of patients(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The key informant interviewed expressed that some families did not cooperate in patient treatment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhen a patient is in pain, we counsel family members to give medication promptly to manage their discomfort. If the pain worsens, we suggest taking the patient to a healthcare facility for further investigation and assistance. Additionally, we inform families about the possible side effects of anti-pain like morphine, which can include constipation and respiratory issues. To address constipation, we recommend the use of laxatives. Unfortunately, some patients resort to selling family assets to afford treatment, which places significant conflict with their family member\u0026rsquo;s ones.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eKI 013\u003c/h2\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIn palliative care, communication gaps between patients and caregivers often lead to challenges. Many patients suffer in pain without full knowledge of their condition, as families may withhold information to avoid distress. Providing education about the illness and treatment options can help shift perspectives and improve support. Additionally, some patients arrive from remote areas without family assistance, complicating their care. Financial barriers also hinder access to necessary medications, while caregivers struggle to balance work and home responsibilities, resulting in gaps in medication management and adherence\u0026rdquo;\u003c/em\u003e KI 014\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLack of Psychosocial Support for patient and family\u003c/h2\u003e\u003cp\u003ePsychosocial support is needed to meet the emotional, psychological, social, and spiritual desire of patients and their families facing life- treating illnesses(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). By focusing on the whole person, it aims to increase quality of life, reduce distress, and help navigate the challenges associated with serious health conditions.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe level of palliative care at our hospital focuses only on physical treatment and does not pay attention to social, spiritual and economic issues.\u003c/em\u003e \u0026ldquo;KI 010\u003c/p\u003e\u003cp\u003eOther participants added this idea,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Palliative care is comprehensive care. Pain relief, psychological care, social care includes spiritual care. It is to make patients free from pain. Cancer patients are the patients who need palliative care the most. In reality we were not give psychological support for our cancer patients which hinders their treatment progress.\u0026rdquo;\u003c/em\u003e KI 014\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eTheme Two: Gap in Continuous Education and Training in Palliative Care\u003c/h2\u003e\u003cp\u003eTo ensure that healthcare providers deliver compassionate, high-quality management for patients with life-threatening diseases, sustainable education and training in palliative care are essential, addressing the physical, emotional, spiritual, and social needs of patients and their families to enhance their quality of life(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Continuous training is vital to stay update with the development of treatments. In addition to enable that health care providers maintain their competence in giving patient-centered compassionate care, continuous education and training in palliative care promote creativity and resilience in a demanding industry.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eInadequate Curriculum Integration of palliative care\u003c/h2\u003e\u003cp\u003eThe goal of incorporating palliative care into nursing education programs is to provide nurses the attitudes, abilities, and information needed to provide compassionate end-of-life care(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Numerous obstacles and difficulties prevent palliative care from being effectively incorporated into nursing courses.\u003c/p\u003e\u003cp\u003eParticipants expressed this idea\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have noticed professionals who do not know what palliative care is because it is not included in the education system\u003c/em\u003e.\u0026rdquo; KI OO4\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My continuous education and training made me understand what I have now\u003c/em\u003e.\u0026rdquo; KII 013\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eLack of On-the-Job Training\u003c/h2\u003e\u003cp\u003eOn-the-job training in palliative care is seen by nurses as crucial for bridging the gap between theoretical knowledge and the necessary practical skills for excellent end-of-life care. Participants said about training for nurses on palliative care,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Before, we used to make him take it only when he felt pain, and this does not reduce the suffering g of cancer patients, but it should be taken at the same time every day without stopping. I used to think of palliative care as a type of treatment given to dying patients. But now after training, change my thinking.\u0026rdquo;\u003c/em\u003e KI 008\u003c/p\u003e\u003cp\u003eOthers key informants also added,\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eTraining should be prepared. I did not take palliative care training personally, but we were taught Fundamentals of Nursing palliative care. However, there is no training provided by the Ministry of Health. Besides, I am reading by searching the internet\u003c/em\u003e.\u0026rdquo; KI 011\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eTheme three: Resource Scarcity in Palliative Care\u003c/h2\u003e\u003cp\u003eResource shortage is seen as a significant issue in palliative care that affects the consistency, quality, and accessibility of care for patients nearing the end of their lives. Limited resources have an impact on a number of factors, including support services, access to drugs, and workforce limitations. Medication shortages, lack of isolated rooms and beds, and patient economic constraints are concentrated on as subthemes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eMedication Shortages\u003c/h2\u003e\u003cp\u003eThe standard of treatment for patients with severe, terminal illnesses is immediately impacted by shortages of palliative care medications, making them a significant issue(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Effective symptom management, particularly pain management, is essential to palliative care in order to preserve patient comfort and dignity. Prescription medication shortages can impede this care, exacerbating patient discomfort and upsetting medical staff.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWe have a problem with the supply of medicine\u0026hellip; If there is no medicine available, the suffering will increase if there is no medicine for the disease\u003c/em\u003e.\u0026rdquo; KI 008\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThere is a problem in the supply of medicines which is some day it is available on the other day it not available\u003c/em\u003e\u0026rdquo; KII 004\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eLack of isolated room and bed\u003c/h2\u003e\u003cp\u003eParticipants stated there are problem of isolated room and bed for palliative patients for admission and giving care. Participants stated lack of isolated room and bed as follows\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Bed and room shortages hinder equitable access to care for patients. When beds are occupied, those needing palliative care may be turned away, denying them essential treatment and negatively impacting their well-being. Increasing the number of available beds and preparing spaces would help resolve this issue.\u0026rdquo;\u003c/em\u003e KI 011\u003c/p\u003e\u003cp\u003eOther participant also expressed like this:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe shortage of rooms and beds limits our ability to provide equitable, quality care. When beds are full, we cannot accept new patients, as we refuse to treat them while they are lying on chairs. Increasing the number of beds, along with separate rooms and facilities, would greatly improve the situation. \u0026rdquo;\u003c/em\u003e KI 006\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003ePatient Economic Constraints\u003c/h2\u003e\u003cp\u003eFinancial constraints significantly hinder access to essential medications, therapies, and support for palliative care patients, adversely affecting outcomes, overall experiences for patients and families, and the quality of care, especially for those from low-income or disadvantaged backgrounds(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParticipants stated the above idea:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThose who can afford better services, go to a better private facility, get treatment for their discomfort, find a cure and go home, for example, if they have sleep problems, get treatment for their sleep problems, if they have pain, they can understand the way to get relief from pain and suffering with their money \u0026hellip;.but those who cannot afford the anti-pain drugs go home with home without drugs\u003c/em\u003e\u0026rdquo; KI 014\u003c/p\u003e\u003cp\u003eOther participant also expressed like this:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI think it would solve the problem if health insurance coverage was accessible to all patients. When they are unable to continue the treatment due to lack of funds, they resort to prayer or holy water. And for this, the solution is to be a beneficiary of health insurance, which helps to overcome the problem in some way\u003c/em\u003e.\u0026rdquo; KI 003\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eTheme four: Healthcare Provider Burnout and Workplace Stress\u003c/h2\u003e\u003cp\u003ePalliative care providers frequently develop deep connections with patients and their families while navigating terminal illnesses, and this constant exposure to loss and grief can significantly impact their emotional well-being, resulting in burnout(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Key issues include emotional exhaustion and diminished job satisfaction, with some nurses reporting feelings of boredom and depression after prolonged care.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eA health professional especially working in palliative care experiences high tiredness. Such places are stressful in themselves. Other departments are treated and sent home, but here it is a place where anxious patients and caregivers are seen.\u003c/em\u003e\u0026rdquo; KI OO1\u003c/p\u003e\u003cp\u003eOther participant also expressed like this:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Nurses become bored and depressed when they stay with palliative patients for long periods of time. The reason is that a high-level patient's stay is so short that when this happens repeatedly, boredom leads to despair. It causes stress on job satisfaction and makes him unhappy\u0026rdquo;\u003c/em\u003e KI 004\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eLack of Job Satisfaction\u003c/h2\u003e\u003cp\u003ePalliative care practitioners face a combination of organizational and emotional challenges that impact job satisfaction; however, many derive personal and professional fulfillment from their work, and improving mental health resources, knowledge, and organizational support can enhance job satisfaction in this essential field(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Respondents shared the following insights:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When you know the stage of the disease by seeing the patient himself, this puts you under pressure. It makes you have two kinds of feelings, one makes you think that I will help as much as I can. And the other one feels that why don't I change the class if I don't suffer all this. So it puts pressure on job satisfaction in this way. You feel when you can help but can't do anything.\u0026rdquo;\u003c/em\u003e KI 010\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When you take the necessary care and see that the end is death, the psychological pressure makes you unhappy and makes you despair. On the contrary, when you see a patient being treated, it gives you emotional satisfaction. Sometimes it makes you hate your job and makes you think about quitting. When such palliative care causes mental stress.\u0026rdquo;\u003c/em\u003e KI 011\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eTheme Five: Communication Barriers in Palliative Care\u003c/h2\u003e\u003cp\u003eEffective communication is crucial in palliative care, particularly for end-of-life discussions, and overcoming communication barriers\u0026mdash;through practical strategies, emotional intelligence, and cultural sensitivity\u0026mdash;is essential for delivering proper care and support, especially in Ethiopia, where diverse languages complicate understanding and family involvement.\u003c/p\u003e\u003cp\u003eParticipants shared the following insights:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eLanguage is one of the communication barriers. We solve this language problem with a translator. Some patients have trouble understanding what we say. We will tell them again and again this time. We ask them what I said to know if they understood us. After that, if they tell us back what we said, we believe that they understood us\u003c/em\u003e\u0026rdquo; KI 009.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eOne of the challenges of communication is language. If people who know the language are assigned to provide information, the problem of language communication will be solved.\u0026rdquo;\u003c/em\u003e KI 007\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eLack of Health literacy\u003c/h2\u003e\u003cp\u003eHealth literacy in palliative care encompasses the ability of patients, families, and caregivers to understand medical information, engage in discussions, and make informed decisions about serious illness and end-of-life options, including palliative care and symptom management.\u003c/p\u003e\u003cp\u003eParticipants shared the following insights:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSome patients have trouble understanding what we say. We will tell them again and again this time. We ask them what I said to know if they understood us. After that, if they tell us back what we said, we believe that they understood us.\u0026rdquo;\u003c/em\u003e KI OO9\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In palliative care, challenges often stem from a lack of health literacy among patients and their families. Many patients endure pain and suffering without understanding their condition, as families may withhold critical information out of fear that it will cause further distress. To address this issue, we can enhance health literacy through education and guidance. By providing clear information about the disease and treatment options, we can help shift attitudes and improve patient care. Additionally, some patients arrive from rural areas without family support, further complicating their understanding and management of their health.\u0026rdquo;\u003c/em\u003e KI O14\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis research focused on the perceptions of oncology nurses regarding the challenges and barriers to providing palliative care. The study highlights the need for integrated support for patients and families, emphasizing their physical, emotional, social, and spiritual needs as part of holistic healthcare. Participants stressed that while comprehensive care should address various aspects of patient well-being, the current emphasis remains on managing physical symptoms.\u003c/p\u003e\u003cp\u003eThis conclusion coincides with a study conducted in Ethiopia, which also found that existing care models give priority to pain management rather than comprehensive palliative care(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). But this study result were in consistent with the fundamental concepts of palliative care and WHO definition of palliative care(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAn ongoing education and training in palliative care is essential for nurses to provide compassionate and high-quality care to patients with life-threatening diseases. However, participants in this study indicated a lack of sufficient training and education. Improved training can increase nurses' knowledge and ultimately improve patient care. These findings align with studies carried out in Africa and Ethiopia, which show that the lack of appropriately trained health professionals poses significant challenges for effective palliative care(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Participants expressed a lack or limited part of the curriculum for nursing student education on palliative care, which is similar to the study carried out in Ethiopia, a lack of palliative care education in pre-and post-training as well as in the training programs for the various disciplines of health(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLimited resources in palliative care significantly affect the quality and availability of services for patients with terminal illnesses, necessitating competent multidisciplinary teams and substantial resources to effectively manage symptoms and provide emotional support(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). This study found that there was a shortage of basic medicines such as morphine and chemotherapy drugs, which were often expensive and not covered by health insurance, and many patients ended their treatment. Nurses reported that they could not provide adequate hospice care due to the lack of funding from the government and medical facilities(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). This causes patient live with pain and suffering.\u003c/p\u003e\u003cp\u003eWorkplace stress and burnout among healthcare providers significantly affect the quality of care of patients and the well-being of the providers. Participants stated that long-term work with palliative patients leads to emotional burnout and unemployment, which reflect the finding sofa similar study conducted in Singapore(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEffective communication in palliative care is crucial for building trust, supporting informed decision-making, and enhancing the overall care experience for patients and their families, as it allows healthcare providers to acknowledge and respect patients' preferences and concerns. However, communication barriers can hinder these interactions, with participants noting that language differences—particularly between Amharic speakers and patients who do not speak the language—often necessitate the use of translators. In Ethiopia's multilingual and multicultural context, these communication challenges can be further complicated by cultural differences, which sometimes lead nurses to withhold information to avoid causing offense to patients from diverse backgrounds(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eLimitation of the study\u003c/h3\u003e\n\u003cp\u003eThis study has inherent limitations, including potential researcher bias due to the subjective nature of qualitative inquiry and context-specific findings that may limit generalizability. Additionally, the exclusion of allied healthcare professionals' perspectives, and time constraints on participating nurses may have affected the data's richness and comprehensiveness, necessitating careful interpretation of the conclusions.\u003c/p\u003e"},{"header":"Conclusion and recommendation ","content":"\u003cp\u003ePalliative care nursing is a demanding yet profoundly rewarding specialty that requires a strong foundation of clinical expertise and exceptional emotional resilience. To effectively address the inherent challenges, such as emotional burdens and resource limitations, comprehensive training programs should be established, focusing on advanced communication skills, cultural sensitivity, and emotional intelligence. Additionally, healthcare organizations must ensure adequate staffing levels, provide accessible mental health resources, and implement supportive policies to reduce burnout and enhance the quality of patient-centered care. Promoting open communication among patients, families, and the interdisciplinary care team is essential for creating a personalized and compassionate care experience.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical consideration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures in this study adhered to the ethical standards set forth in the Declaration of Helsinki.\u0026nbsp;Ethical clearance was obtained from the St. Paul\u0026rsquo;s Hospital Millennium Medical College School of Nursing Research Ethics Institutional Review Board (IRB) with Ref no:pm23/1176. Participants were informed about the study\u0026apos;s purpose, and their confidentiality and privacy were ensured through informed consent. An official letter was received from the Addis Ababa Health Bureau Research Directorate, along with letters of ethical clearance and cooperation for the participating hospitals. Confidentiality was maintained throughout data collection and storage by conducting interviews in private settings and not collecting personal identifiers. All audio files were anonymized during transcription, ensuring that only the research team had access to the stored data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be available upon request from the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll funding of this original research process cover by all authors\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding for Publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMH and MB contributed to the conception, design, methodology, analysis, and interpretation. TK was involved in the analysis, interpretation, and drafting of the manuscript. MH and MB were also actively engaged in the manuscript write-up. All authors have reviewed and approved the final submission of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; detail:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMelke Bimrew:\u0026nbsp;\u003c/strong\u003eMSc in Oncology Nursing, St. Paul\u0026rsquo;s Hospital Millennium Medical College, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMekdes Hailegebreal:\u0026nbsp;\u003c/strong\u003eAssistant professor in Pediatric and child health nursing, MSc in Pediatric and Child health nursing , St. Paul\u0026rsquo;s Hospital Millennium Medical college, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeketel Kifle\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eMSc in Oncology Nursing, Jimma University, Jimma, Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank St. Paul\u0026rsquo;s Hospital Millennium Medical College for the support for the realization of this finding. Special thanks and appreciation to all those who agreed to participate in this study, mainly respondents, data collectors and supervisors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOrganization WH. Integrating palliative care and symptom relief into responses to humanitarian emergencies and crises: a WHO guide. Integrating palliative care and symptom relief into responses to humanitarian emergencies and crises: a WHO guide2018.\u003c/li\u003e\n\u003cli\u003eAppiah EO, Menlah A, Xu J, Susana AA, Agyekum BS, Garti I, et al. Exploring the challenges and roles of nurses in delivering palliative care for cancer patients and co-morbidities in Ghana. BMC palliative care. 2023;22(1):121.\u003c/li\u003e\n\u003cli\u003eConnor SR, Gwyther E. The worldwide hospice palliative care alliance. Journal of pain and symptom management. 2018;55(2):S112-S6.\u003c/li\u003e\n\u003cli\u003eChuah PF, Lim ML, Choo SL, Woo GY, To HK, Lau KY, et al. 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CARES: AACN\u0026apos;s new competencies and recommendations for educating undergraduate nursing students to improve palliative care. Journal of Professional Nursing. 2016;32(5):327-33.\u003c/li\u003e\n\u003cli\u003eBoyd D, Merkh K, Rutledge DN, Randall V, editors. Nurses\u0026apos; perceptions and experiences with end-of-life communication and care. Oncology nursing forum; 2011.\u003c/li\u003e\n\u003cli\u003eBushinski RL, Cummings KM. Practices of effective end-of-life communication between nurses and patients/families in two care settings. Creative nursing. 2007;13(3):9-12.\u003c/li\u003e\n\u003cli\u003eSoikkeli‐Jalonen A, Stolt M, Hupli M, Lemetti T, Kennedy C, Kydd A, et al. Instruments for assessing nurses\u0026rsquo; palliative care knowledge and skills in specialised care setting: An integrative review. Journal of clinical nursing. 2020;29(5-6):736-57.\u003c/li\u003e\n\u003cli\u003eBanerjee SC, Manna R, Coyle N, Shen MJ, Pehrson C, Zaider T, et al. Oncology nurses\u0026apos; communication challenges with patients and families: a qualitative study. Nurse education in practice. 2016;16(1):193-201.\u003c/li\u003e\n\u003cli\u003eSarıkahya SD, Gelin D, \u0026Ouml;zbay S\u0026Ccedil;, Kanbay Y. Experiences and Practices of Nurses Providing Palliative and End-of-Life Care to Oncology Patients: A Phenomenological Study. Florence Nightingale Journal of Nursing. 2023;31(Suppl 1):22.\u003c/li\u003e\n\u003cli\u003eOkyere J, Kissah-Korsah K. Barriers to the integration of palliative care in Ghana: evidence from a tertiary health facility. Palliative Care and Social Practice. 2023;17:26323524231179980.\u003c/li\u003e\n\u003cli\u003eNukpezah RN, Khoshnavay Fomani F, Hasanpour M, Nasrabadi AN. A qualitative study of Ghanaian pediatric oncology nurses\u0026rsquo; care practice challenges. BMC nursing. 2021;20:1-10.\u003c/li\u003e\n\u003cli\u003eAmare N, Gintamo B, Tukeni KN, Gebremichael EH, Abera EG. The prevalence of cancer patients requiring palliative care and its associated factors at St. Paul Hospital, Addis Ababa, Ethiopia: a Cross-Sectional Study. Risk Management and Healthcare Policy. 2023:1203-14.\u003c/li\u003e\n\u003cli\u003eAregay A, O\u0026rsquo;Connor M, Stow J, Ayers N, Lee S. Perceived policy-related barriers to palliative care implementation: a qualitative descriptive study. Palliative Care and Social Practice. 2023;17:26323524231198542.\u003c/li\u003e\n\u003cli\u003eSharma SK, Mudgal SK, Gaur R, Chaturvedi J, Rulaniya S, Sharma P. Navigating Sample Size Estimation for Qualitative Research. Journal of Medical Evidence. 2024;5(2):133-9.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic analysis. APA handbook of research methods in psychology, Vol 2: Research designs: Quantitative, qualitative, neuropsychological, and biological. Washington: American Psychological Association; 2012. p. 57-71.\u003c/li\u003e\n\u003cli\u003eMamo Y, Habte A, Abreha A, Ayers N, Abathun E, Reid E, et al. The evolution of hospice and palliative care in Ethiopia: From historic milestones to future directions. Ethiopian Journal of Health Development. 2020;34(4).\u003c/li\u003e\n\u003cli\u003eSanda MO. Psycho-Social Supports and Family Integration as Determinants of Palliative Care of Terminally-Ill Patients in University College Hospital, Ibadan Nigeria 2015.\u003c/li\u003e\n\u003cli\u003eRosa WE, de Campos AP, Abedini NC, Gray TF, Huijer HA-S, Bhadelia A, et al. Optimizing the global nursing workforce to ensure universal palliative care access and alleviate serious health-related suffering worldwide. Journal of pain and symptom management. 2022;63(2):e224-e36.\u003c/li\u003e\n\u003cli\u003eYoussef H, Mansour M, Al-Zahrani S, Ayasreh I, Abd El-Karim R. Prioritizing palliative care: assess undergraduate nursing curriculum, knowledge and attitude among nurses caring end-of-life patients. European Journal of Academic Essays. 2015;2(2):90-101.\u003c/li\u003e\n\u003cli\u003eNauck F, Alt-Epping B. Crises in palliative care\u0026mdash;a comprehensive approach. The lancet oncology. 2008;9(11):1086-91.\u003c/li\u003e\n\u003cli\u003eGardiner C, Brereton L, Frey R, Wilkinson-Meyers L, Gott M. Exploring the financial impact of caring for family members receiving palliative and end-of-life care: a systematic review of the literature. Palliative medicine. 2014;28(5):375-90.\u003c/li\u003e\n\u003cli\u003eTan F, Wu Y, Li N, Zhang C, Chen S, Huang L, et al. Job burnout and resilience among palliative care professionals in china: a qualitative study. BMC Palliat Care. 2025;24(1):2.\u003c/li\u003e\n\u003cli\u003eBiagioli V, Prandi C, Nyatanga B, Fida R. The role of professional competency in influencing job satisfaction and organizational citizenship behavior among palliative care nurses. Journal of Hospice \u0026amp; Palliative Nursing. 2018;20(4):377-84.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Integrating palliative care and symptom relief into responses to humanitarian emergencies and crises: a WHO guide. 2018.\u003c/li\u003e\n\u003cli\u003eAbu-Odah H, Molassiotis A, Liu J. Challenges on the provision of palliative care for patients with cancer in low-and middle-income countries: a systematic review of reviews. BMC palliative care. 2020;19:1-16.\u003c/li\u003e\n\u003cli\u003eSolomon K, Azmera YM, Kaba M. Perspective Chapter: Palliative Care Experiences in Ethiopia\u0026ndash;Call for Comprehensive Care Approach. 2024.\u003c/li\u003e\n\u003cli\u003eNegasa EH, Human SP, Roro AG. Challenges in Palliative Care Provision in Ethiopia: An Exploratory Qualitative Study. Journal of Pain Research. 2023:3405-15.\u003c/li\u003e\n\u003cli\u003eLeBaron VT, Palat G, Sinha S, Chinta SK, Jamima BJB, Pilla UL, et al. Recommendations to support nurses and improve the delivery of oncology and palliative care in India. Indian journal of palliative care. 2017;23(2):188.\u003c/li\u003e\n\u003cli\u003eSinger AE, Goebel JR, Kim YS, Dy SM, Ahluwalia SC, Clifford M, et al. Populations and interventions for palliative and end-of-life care: a systematic review. Journal of palliative medicine. 2016;19(9):995-1008.\u003c/li\u003e\n\u003cli\u003eZheng R, Guo Q, Chen Z, Ma L, McClement S. An exploration of the challenges for oncology nurses in providing hospice care in mainland China: A qualitative study. Asia-Pacific Journal of Oncology Nursing. 2021;8(2):139-46.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"palliative care, challenge, barriers, perception, oncology nurses, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-7321317/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7321317/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Nurses spend the most time assisting patients and families with serious illnesses. Understanding their perceptions of challenges in palliative care is crucial for improving patient outcomes. Identifying these barriers allows healthcare organizations to implement targeted interventions and support, enhancing the palliative care environment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e to explore the Perception of Oncology Unit Nurses on the challenges and barriers to palliative care delivery in government hospitals of Addis Ababa, Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA descriptive phenomenological approach was employed to explore the perceptions of oncology unit nurses regarding the challenges and barriers they face in providing palliative care in governmental hospitals. Participants were purposefully selected based on their years of experience in the oncology unit, resulting in a total of 14 nurses included until data saturation was reached. The data were analyzed using inductive thematic analysis, which involved identifying and examining patterns or themes within the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult\u003c/strong\u003e: Data analysis revealed five key themes and thirteen subthemes detailing the challenges faced by oncology nurses in palliative care provision. These themes highlighted: insufficient holistic approaches, a deficit in continuing education, inadequate resources, and workplace stress and burnout, and communication barriers. These findings underscore the significant obstacles impacting the delivery of effective palliative care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion and recommendation: \u003c/strong\u003eOncology unit nurses encounter significant challenges, including resource limitations, high emotional demands, burnout risk, and communication barriers. To enhance palliative care delivery, comprehensive training and education are essential. Specifically, oncology nurses need improved skills in core palliative care principles, effective communication, emotional intelligence, and cultural competence.\u003c/p\u003e","manuscriptTitle":"Exploring the perception of Oncology Unit Nurses: Challenges and Barriers to Palliative Care Delivery in Government Hospitals of Addis Ababa, Ethiopia 2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-25 17:42:31","doi":"10.21203/rs.3.rs-7321317/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"873793cc-5a02-4dfd-a401-13f2b23a184a","owner":[],"postedDate":"August 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":53433457,"name":"Biological sciences/Cancer"},{"id":53433458,"name":"Health sciences/Health care"},{"id":53433459,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2025-11-11T04:53:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-25 17:42:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7321317","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7321317","identity":"rs-7321317","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}