The study had twenty (20) participants consisting of eleven (11) nurses and nine (9).midwives. The participants were nurses and midwives who had rendered nursing care to women with advanced cervical cancer for more than one year.

The data analysis yielded two (2) themes and eight (8) sub-themes. Table 1 presents the synthesis of the themes and sub-themes gleaned from the data (Table 1).

Table 1 Synthesis of themes and sub-themesChallenges with care

In this study, three key sub-themes emerged. They were; Inadequate Resources (inadequate human resources and inadequate material resources), Leadership/Managerial challenges (unappreciative, unsupportive and favouritism) and Workload (type of patient, demands of care, patient’s preferences, patient’s family neglect and delays).

The findings revealed that most nurses faced difficulties and frequently turned to alternative sources for help.

Inadequate resources

Like every institution, the health sector needs resources to operate efficiently, whether they are human, material, or environmental. Participants in this study admitted that they have many resource-related difficulties. This sub-theme gave rise to the following two minor sub-subthemes: Inadequate human resources and inadequate material resources.

Inadequate human resource

One of the ongoing issues in nursing care is inadequate staff to work on the ward. Eleven (11) out of the sixteen (16) nurses and midwives attending to patients with advanced-stage cervical cancer brought this issue to light in the following ways;

“You come to work and you are just like 4 and you are taking care of 25 patients or 30 patients, it is the workload, is too much so we have issues with that…”. (CNM06)

“As for the challenges, there are many of them. As a result, our staffing levels are always inadequate. Looking at our nurse-patient ratio is woefully inadequate”.(CNM13).

“we are not enough as nurses and midwives to care for the numerous patients who come to this unit, its not easy” (CNM 15).

“Here, the work is too much and the staff are very few” (CNM 11).

Also, some participants expressed that the issue with the human resource is not that they are understaffed but there are shortages occasionally due to staff gender.

“Given that nursing is a profession where women predominate, most of the time, we get nurses going on maternity leave, some are pregnant and all that which adds up to the staff shortage” (CNM16).

“Some of our colleagues are on maternity and annual leave, so we are few at post and this puts pressure, unnecessary pressure on us and no one cares” (CNM 03).

“Our staff in this unit are few because some are on leave and is like the leave is not coordinated at all” (CNM 09).

Again, other participants expressed that the staff shortage they have is due to the stressful nature of their work which causes some staff to experience burnout and others to report sick, causing them to bring excuse duties which worsens the issue of staff shortage:

“Also, the stress here is unbearable, so we have most of our staff bring in excuse duties, reporting sick and all that so for staffing I will say is inadequate. For the personnel element, that is what I can say”. (CNM15)

“my colleague that I was working with is now on sick leave and this has left me with pressure ” (CNM 04).

However, there was one respondent who had the opinion that, staffing is better now compared to the past;

“With staffing, it is better, now it’s better. They posted some nurses here so it is better. At first, it was bad; you would come and you would be assigned to 12 patients. Am telling you. And when you come if it’s in the morning some would go for x-rays, go here…hmm…and the whole day”. (CNM01)

“Even though the staff are many now, so are the patients and this puts pressure on the staff” (CNM 14).

Inadequate material resources

When there is a lack of resources, it proves as an impediment that will lead to compromising the quality of care given to patients by nurses and midwives. These challenges were not only limited to human resource issues, but logistics to facilitate health care delivery were also lacking. There were the experiences by fourteen (14) nurses and midwives as stated below;

“I like this, where you have gotten to because it is a big challenge. A challenge that I don’t expect to see from a very big hospital like [Mention the name of a Facility] but sometimes you come to work and the things to work with is a problem, things like…. logistics like syringes, BP apparatus, cannulas, giving sets. I don’t get it. I mean, the biggest referral centre in the whole Ghana and even a referral centre in West Africa, why, must such a hospital go through some of these challenges”. (CNM03)

Other participants affirmed that to meet patient’s care needs, they had to improvise with what they have due to inadequate material resources.

“Again, the logistics we use in working are frequently unavailable or insufficient, so we are constantly instructed to either improvise or to do our best with the few things we do have. At times it is so bad that we go around looking for items from other wards which I think a facility like ours should not be having”(CNM16).

“You come to work with no logistics or materials to work with and this is a main challenge” (CNM 11).

“The bosses don’t care about us and they don’t provide the things we need to work, unfortunately most of the patients are poor and cannot buytthe things too” (CNM 07).

Worth to note that participants borrowed from other wards to meet the health needs of patients;

“I will say in terms of logistics too is not enough, sometimes common gloves we have to borrow from other wards which is a big challenge because the work is already tiring”. (CNM 09)

“Sometimes we go to the nearby wards/units to borrow things for work” (CNM 11).

Participants stated that the majority of patients receiving treatment are oxygen dependent, and that causes frequent oxygen shortages in the ward, which slows down work activities related to managing these patients. They cited the lack of oxygen as a major obstacle;

“Oxygen is a big problem, most of our patients have breathing issues and depend on oxygen, but at times you will see nurses carrying oxygen cylinders from other wards just to save lives”. (CNM11)

“I remember sometimes on the ward three people are on oxygen and then another person needs oxygen you have to be monitoring the SPO2 too. So, let’s say this person’s SPO2 is a bit okay. Then we swap to save lives” (CNM12).

Some participants also discussed how the lack of material resources has an impact on the level of care they provide, which is emotionally draining;

“Again there are days when consumables to work with are not available, you try your best as a nurse manager, you go to all the things that you can go to and yet still you don’t have the consumables to work with, it makes you emotional, it makes you sad because you just ask yourself why they cannot get you the consumables you need to work with because at the end of the day infection prevention measures must be used and if you are not providing us with the basic requirements like gloves. Hmmm, it disturbs me a lot. You realize that the staffs are not happy everybody looks angered, they are not happy at all and some would be sad but this is where we find ourselves. So, they all come to you as the ward in charge and you also look sad and angry at the same time because they expect that you provide them with the items and where you are supposed to get the items too you are not getting”. (CNM08)

Similarly, some participants expressed that the beds on the ward are in deplorable states making caregiving very difficult. Below is what they had to say:

“Again, for now, a major challenge for me on the ward is also the state of the ward especially the state of our beds in the ward are in a deplorable state and anytime we draw the attention of the superiors they say is in the pipeline like trying to get new ones not knowing when it would come in., we have patient falling, patient complaining, we have some of the beds even not for patients to be lying on, that is what we have as at now”. (CNM16)

Lack of a conducive environment

The quantity of hours spent at work by nurses and midwives is relatively high. The attitude of personnel toward work is influenced by the environment, which is perceived by the participants as unhealthy or unconducive.

Some participants complained of torn window nets which give way to mosquitoes leading to patients and staff getting malaria:

“…the ward environment itself brings so much stress. For example, in my unit, all the nets are torn, and the nets cover the window. And at night the patient and staff have to battle with mosquitoes…. yes! and almost every week one is struck down with malaria…this is a lot of stress to us because at the end of it would affect my staff’s strength…. So, the ward environment is a big problem for me”. (CNM08)

Some participants lamented that there was too much heat on the ward making them uncomfortable whilst at work:

“…the environment is not encouraging because there is a lot of heat in the ward, so sometimes when you are working you would be sweating and you won’t feel comfortable to even work”. (CNM02)

Poor ventilation the ward is very hot sometimes by the time you finish working then your entire uniform is soaked in sweat. The washrooms too are not neat”. (CNM07)

Similarly, some respondents also revealed that the signs and symptoms of cervical cancer at the advanced stages bring about some unpleasant odour which affects caregiving.

“And sometimes because of the cancer patient has some scent, so sometimes the ward will be smelling like faeces, discharges and so many things, so the ward is not encouraging, scent. So sometimes because of the scent around a patient, when you are working on a patient you are in a hurry to leave because of the smell which is not encouraging and the ventilation is very poor”. (CNM02)

Again, some respondents termed their working environment as discouraging due to the absence of a medium of entertainment such as television and radio as a source of diversional therapy both for patients and staff:

“…sometimes before we take up, we are already tired and the environment too is very discouraging. If you look at the ward there is no tv. Sometimes the patient might feel exhausted at the same time experiencing pain. If there was a television here it could take their mind off the pain. Hmmm, we are stressed. Am not saying we should come and play music at work but something to at least make the patients happy and expand their lives. No television to entertain us,”. (CNM07)

Again, some participants expressed that, the unkempt nature of the washrooms on the ward made the environment unconducive which was a challenge to them:

“Sometimes the washrooms because of the bleeding all the time. The place is not well kept some of them don’t keep the place neat and then all the time you have to be getting people and some the orderly’s coming they’re angry. somebody will remove the pad puts in the WC”. (CNM12)

Leadership/Managerial challenges

Nurses and midwives in this study expressed that, some superiors don’t appreciate their efforts and jump to conclusions whenever patients and relatives report them which is a challenge for them;

“Yeah, my challenge with the superiors is that, as I said earlier, some of the superiors don’t appreciate what we do and even when the patients’ relatives report the nurses to them, instead of them listening to our side of the story, they won’t and they would just attack you like that. They always say the patient is right”. (CNM02)

Some participants expressed that they are misunderstood by their superiors;

“Our superiors too tend to misunderstand us anytime a problem comes up, they don’t listen to our part of the story, they just jump to conclusion, which at times is very painful”. (CNM10)

Similarly, some participants also lamented the fact that some in-charges when on duty are found ‘table nursing’ instead of supporting them which increases their workload;

“Hmm! Some of the in-charges when you come with them, do table nursing, they would be sitting by the table writing. At times too not writing but they would be ordering you around. There are instances that the in charge has to see the patient but they would be sitting down, then sharing patients but they wouldn’t know what is going on in the wards. That too is a problem. The table nursing is a problem”. (CNM01)

Again, some participants complained of delayed information by superiors when colleagues report to work sick or seek for excuse duty leading to staff shortages with increased stress and workload;

“Also, with my matron for instance, when a colleague reports to her that he or she is sick, instead of her informing us the nurses on duty that may be your colleague asked for permission she won’t and when we come and we share the work we leave her portion there until later when you call that particular nurse before she will tell you that am sorry am not well, I reported to matron so am not coming to work”. (CNM16)

Additionally, some participants had the opinion some superiors had their favourite staff which affected relationships with some of them;

“There is also favouritism, especially in my ward. My matron likes some people more than others because some people will not even bring excuse duty but they will be granted permission. Someone can just stay home and call that my father is sick and so she wants to take care of him and will be granted permission”. (CNM19)

Some nurses and midwives also expressed that, looking at the stressful nature of their work, patient’s family support would be helpful, but they are being stopped by superiors when the opportunity presents itself;

“…And so, if the patient’s relatives are ready to come and assist the nurses and the superiors will come and say that it’s not their job, it’s the job of the nurses to do and other things. It means they don’t have us at heart, they don’t have us at heart do you understand yeah? So then again it leaves us with a lot of conditions”. (CNM20)

Moreso, some respondents had the view that if superiors could have listening ears for them and confidentiality it would have been helpful;

“Hmm! I think one, for me if we had open leaders or leaders who are willing to listen to us when we have problems, they always say that if you have a problem you can come to us but you talk to a senior issue about your problems and the next minute more than 3 or 4 people are aware of it. So, whenever you have a problem, you rather prefer to keep it to yourself”. (CNM08)

However, few of the participants feel superiors are trying their best in terms of support;

“Hmmm…. Our matron is our greatest support, she understands how the work is so she is always behind us, she is always defending us. So, I think…. Hmmm”. (CNM05)

Workload and burnout

Some participants revealed that the magnitude of the workload is too much causing staff to report sick and request for excuse duties which further increases the workload of the few available staff;

“Okay, personally when staff comes with complaints, and, you are with them, I feel it puts pressure on other staff. So, if people keep on bringing up excuses because they are stressed, then all the workload will be on a few people who are not complaining. So, let’s say you come to work, you’re supposed to be three. And now it’s only two people coming or one person coming”. (CNM12)

Similarly, some participants expressed that their workload is intensified due to the type of patients they care for, who are most critically ill and bedridden;

“The number of patients coming in! and the level of help we have to give them. Most of them at the terminal stage, become bedridden, and they come in with DVT that they won’t be able to walk by themselves. You have to carry them or wheel them to the washroom or if they are going to take scans or x-rays, they can’t walk by themselves so you have to put them in a wheelchair if the patient is heavy or not heavy you have to. That makes the work…that part of it makes the work very stressful. Okay so, physically it is very stressful, especially when the patient becomes immobile like the patient is bedridden and all that. Yeah, it’s a bit stressful to handle such a patient”. (CNM05)

Additionally, the study discovered lifting as a major stressor of nurses and midwives managing patients with advanced-stage of cervical cancer because most of their patients are bedridden;

“The major stressors are the lifting. Because the patient cannot do anything for themselves. Some are bedridden so you have to lift them. Even when you are changing their diapers and soiled linen you have to raise them so sometimes you have to employ correct body mechanics and even with that the bending still exits. So sometimes you get home with waist pains, you will be tired having pain all over your body”. (CNM14)

Moreso, the study revealed that the demand for care is intensified as a patient’s condition advances;

“Like I said they come in when the condition is deteriorating and so most of them are bedridden, have respiratory problems and all that. So basically, we do everything for them which adds to our workload. You get home so tired to the extent that you don’t have the energy to do anything else. Sometimes, I don’t even eat nor bath, I just sit on my sofa and am gone”. (CNM11)

Also, some participants also revealed that patient preferences are contributing factors to participant’s stress and workload;

“Even some of the patients if you bathe them in bed will not agree, you have to take them to the bathroom and you have to stay with them even if they have to empty their bowels because if you leave them, they might fall and die. Recently an incident like that happened by the time the nurse got there she was dead”. (CNM07)

Again, some participants expressed that, sometimes their competency is questioned by patients when the condition advances which becomes unbearable for them;

“For example, when they get to the terminal stages, rejected by family and all that. At times you go to administer a drug to a patient and they even doubt your competence. They feel you want to help end their lives because they are stressing you”. (CNM09)

Similarly, participants lamented that, when patients get to the advanced stages of cervical cancer, they even doubt the medications served:

“Sometimes, especially those who have been rejected by their family often feel that the nurses want to kill them when they are been served with their medications”. (CNM07)

“I once had an encounter with a patient who when it got to the end stages asked me to take the drug first while I was serving medication because he didn’t trust the nurses anymore. They also become addicted to some of the pain medications and once we don’t keep the drugs and the drugs are with them, sometimes by the time you go to them they have already taken the drug, when you complain they become angry”. (CNM11)

Additionally, participants revealed that their workload and stress are heightened when patient’s family members abandon them leaving nurses and midwives to perform the roles of relatives;

“Some of them too their relative will come and damp them here and then will not even buy the prescribed drug for them which at times we have to contribute and do so. We have discharged patients; some have been here for three months now while they’ve been discharged”. (CNM01)

To add to, participants revealed that not only does the patient’s family neglect increase their workload but it also burdens them financially;

“Some of the relatives are not helping at all, they bring the patients here and you don’t see them again, so you have to do everything for the patients. Is like the relatives are waiting for the patient to die so that they come for the body. At times we have to organize and buy certain things for the patient, it is very heartbreaking. (CNM13)

However, some participants revealed that is not just about the workload in caregiving but some external factors adding up to their stress;

“As for [mentioned a name of a facility] stress, can you? you get home very tired. Even now am pregnant, I get to work and am assigned to about four patients to care for them, and I have to do everything for them so I get home very tired. Sometimes, when you get home, you can’t bathe by the time you realize, the next day has come”. (CNM07)

Participants of this study revealed that most of their patients only seek care when the condition has advanced making caregiving problematic;

“And they mostly come when it’s stage three B’s, stage four. I mean, the stages where cancer has gotten to and there is nothing much the doctors can do or the health team can do to make sure this patient comes out of that situation. And that makes it more stressful. So, the psychological, should I say trauma, or should I say stress, or imbalance, so we go through all of that”. (CNM03)

The majority of participants expressed that they are exposed to frequent deaths of their patients because most of them seek care when the condition has advanced. They expressed this in the following ways;

“Here the deaths are a lot compared to maternity, most of the cases that are being bought here are in advanced stages so the deaths are a lot. Most of the patients wait until the cancer metastasis to either their liver or kidneys…before they are brought to the hospital. (CNM16)

Participants revealed that the reasons why patients report to the hospital in advanced stages are because most of the patients seek spiritual help and delay in churches;

Some when you interview them will tell you that they were in the church for a while and seeing the condition was getting worse, they were asked to go to the hospital and were referred here at the [Mention the name of a Facility] teaching hospital. So, by the time they get here, the condition has become worse. They would have deteriorated and then nothing could be done about it. So, if we don’t take care …. then they go off”. (CNM01)

However, it was revealed that the delay in seeking care by cervical cancer patients is due to inadequate information on cervical cancer

“Cervical Cancer patients come in the wards most times err as you’re seeing terminally ill because they don’t have prior information about their condition at the time they come, they are almost at their terminal stage”. (CNM12)

Support

This sub-theme seeks to answer the question “what are the available support systems for nurses and midwives in cervical cancer care?”. From this sub-theme, the following headings were discussed; support from colleagues, patient family support, participant’s family support and institutional support. All participants expressed their views on this.

Some participants revealed that support from colleagues serves as a source of support that helps them bounce back from stressful events;

“What helps us is that, when we come to work, we entertain ourselves because we know that no matter what we have to do the work, so the staff-to-staff relationship helps” (CNM07).

“Is the teamwork here that also keeps us going. So at least we have each other’s support”. (CNM13)

Patient’s family support

Participants revealed that patient’s family support is inadequate, in that most relatives dump the patients on the ward without visiting making caregiving difficult;

“Like I said when you come for night duty, you’re the only person taking care of a bed-ridden patient you understand, and like I was saying if we get assistance from the patient’s relatives, especially the bed-ridden ones, it will make our work less difficult. But here is the case whereby the patient’s relatives are ready to come and assist us and then our superiors will come and tell them that they don’t need like they shouldn’t come and assist us and we are the ones supposed to do like literally everything”. (CNM06)

Participant’s family support

It was revealed from this study that the major support system for participants is their families, which they mentioned; parents, spouses, children and cousins:

Some expressed they get their support from extended families such as cousins:

“You can’t do that alone. Hmmm, me like this I have a cousin who helps me with the kids, other than that it won’t be easy at all. But those without helpers, if they come in the morning and you see their faces…hmmm…. but me at least I have someone who helps me. When I get home and am tired, she helps does whatever that is supposed to be done and if only your husband understands there is no problem. At least you have your 3 days off…yeah so if only they would understand, there would be no problem”. (CNM01)

Some revealed their mothers as their support system:

“Yes, I have my mother’s support. She is with the kids now and is here. That is the greatest support I have. For my colleagues, we are co-working together. The environment is conducive though it is tedious because we support one another it becomes less stressful and conducive to work”. (CNM05)

Similarly, some participants expressed how relieved they become seeing their children after a day’s work:

“Yes, I would say my support is from my family, because no matter how sad I am no matter how angry I may be when I get home, once the children see it, I mean they know me so well, in fact, the whole family they know me very well so once they see my facial expression, they know that something is wrong so they would surely ask about it then I won’t look down, so I think for now they are my support system. They are my strength, the times I come home distressed and tired, they are my strength because of their words of encouragement, my children would say, mommy, don’t worry everything would be fine”. (CNM08)

The majority of respondents had support from their spouses which is so encouraging;

“My husband has been of great support to me, he understands my work and I think that contributes a lot because at times you get home late and even for you to cook is a problem…”. (CNM13)

However, some participants revealed that the nature of their job is on a verge of breaking their homes;

“It is not easy because right now I come for the afternoon shift when I close by the time, I get home late, I am tired and want to sleep and when I cook my husband doesn’t even eat because is late and on my off days too, I have a lot of things to do. I don’t have time for the family at all because am always tired. No time for communication. And the food is the problem. What the family would eat. So, marriage and work are not easy. And because these patients are dependent, you get home so tired”. (CNM07)

Institutional support

To implement health promotion, illness prevention, and health protection activities effectively, institutional support entails making sure that there are efficient organizational structures and mechanisms in place. Most healthcare personnel lack specific training in oncology.

Some participants lamented that there are no support systems for them in any way;

“As for the facility, there are no support systems, I don’t know if they are now doing something about it but there’s no support system…”. (CNM01)

“Hahaha, we don’t get any motivation from the hospital nor the superiors at the end of you will just work they won’t even appreciate you” (CNM02).

Other participants had the opinion that management compounds their stress rather than supporting them;

“At first this challenge was hitting me, but with time, the unfortunate aspect of it is our management too are not helping, you come to work and they will even compound your stress for you. Why didn’t you do this? Why didn’t you do that? And your whole mind will… If you don’t take care, you go crazy. Because already you’ve gone through… Let me say you came for the night, you’ve gone through a whole lot during the night, and in the morning your superior will come and be compounding the stress for you” (CNM03).

Again, some described the support received from the facility as woefully inadequate;

“The motivation is not the best. Yeah, so if we say that we are looking at the motivation am not sure we would come to work. And even now the salary is not even anything to write home about. And…. so those things would rather pull down the energy you are coming to work with”. (CNM05)

Worth noting, participants lamented that they pay for seeking health care in the facility they work in, even though their illness resulted from their nature of work;

“…When you’re sick too, they don’t do anything about it, usually when it started or it’s something that happened on the ward, the hospital doesn’t do anything about it. You take care of yourself”. (CNM06)

Moreso, participants expressed that if not for the strict rule on transfer in their facility, they would have left;

“But this is a situation where the condition of service is poor. You work with no motivation. Sometimes you could realize that if people work here to find another job elsewhere, they will leave. We are working in a health facility with no insurance knowing that you could contract an infection from a needle pick. By doing so they leave you to go home and cater for yourself expecting you to resume work thereafter. Don’t you think if such a person finds a better job in a better environment she will stay, the facility would have been empty if not for their strict rules on transfer”? (CNM10) .

“I wish I can leave and go to another department, I am tired of this ward” (CNM 04).

“sometimes you feel you are BURNT with the work and you want a change of environment but that too is difficult, I wish I can leave this unit” (CNM 10).