Overall, 40 semi-structured interviews (between 12 and 55 min) were held with medical house officers at two Nigerian tertiary institutions, resulting in roughly 17 h of raw audio-recorded interview data. The sociodemographic characteristics of the participants are summarised in Table 1.

Table 1 Sociodemographic characteristics of participants

Qualitative content analysis resulted in a comprehensive code system (Fig. 1; Additional file 2). The codes were analysed to answer the research questions. Through code-based analysis of the final code system, variables which potentially influence NQPs’ perceived self-efficacy and preparedness in practising PC were identified. Potential variables were found at different levels. Some variables were seen as ‘frame conditions’, influencing the participants’ perceived self-efficacy and preparedness in practising PC on a systemic level. Other variables, however, were identified on a personal level and labelled as ‘individual variables’.

Fig. 1

The final code system: Main codes and corresponding subcodes

After code-based analysis, the main codes of the final code system were systematised according to their core content and findings. Variables influencing NQPs’ perceived self-efficacy and preparedness in practising PC, which were seen on a systemic level, were mostly identified under the code PC in Nigeria. It was therefore grouped as ‘frame conditions’ for PC in Nigeria. Variables identified on a personal level were mostly found under the codes Professional Development, Education and Experiences in PC, Personal Understanding of PC and Attitudes and Role Concept. Therefore, these codes were grouped together as ‘individual variables’. Finally, the codes highlighting key components of NQPs’ PC practice (Breaking Bad News, Prognosis and Diagnosing Dying, Involving the Family, and Pain and Symptom Management) were grouped together and labelled ‘PC Practice’.

Code-based analysis showed that overarching influences on NQPs perceived self-efficacy and preparedness in practising PC were socio-economic considerations of a resource-limited setting and cultural and religious aspects characteristic of Nigeria. These influences recurred frequently and abundantly throughout all interviews and at both the study sites. They were found, both on a systemic and personal level and can be seen as a clear thread running through all interviews and almost all codes.

The systemisation of the main codes of the final code system is shown in Fig. 2. The arrows should visualize how the frame conditions for PC in Nigeria are influencing variables found on the personal level, while all variables identified influence NQPs’ perceived self-efficacy and preparedness in practising PC. Socio-cultural and socio-economic influences were seen at all levels. Example quotations are presented in Additional file 3.

Fig. 2

Systemisation of the main codes: Frame conditions for PC in Nigeria and variables on the individual level influence NQPs’ perceived self-efficacy and preparedness in practising PC. Socio-cultural and socio-economic influences are relevant at all levels

Frame conditions for PC in Nigeria

The code PC in Nigeria highlights the frame conditions for PC practice in Nigeria as perceived by NQPs. The code provides a framework for everything discussed in the interviews. It depicts PC in Nigeria at a systemic level. Text segments coded under this code describe features of the Nigerian healthcare system as well as the socio-cultural and socio-economic characteristics of Nigeria in relation to PC. This code codes text segments discussing challenges for PC in Nigeria, as identified by participants as well as the interviewees’ hopes for the future of PC in Nigeria. The challenges and frame conditions for PC in Nigeria discussed here can be seen as variables on a systemic level, influencing NQPs’ perceived self-efficacy and preparedness in practising PC.

The subcodes identified under this code provide an overview of the relevant challenges for PC in Nigeria (Fig. 1). Among them were existing PC structures, which were described as “still not solid” (S1I, 77) by several participants. In this context, it was indicated that the integration of different specialties working together was not yet optimal.

“It would be a whole lot easier if the PC team is doing all this together with the managing team. So, it would not be an independent, as if different teams is managing independently. If it was a collective effort, managing team along with the PC team.” – S2I, 88

Inadequate collaborative care may affect participants perceived self-efficacy and preparedness in practising PC.

“I also know that in this hospital there is a special PC team. Special PC clinic, where the nurses, the doctors there are trained in that, uhm, subspecialty. But usually, uhm, because of the way things are not well (delineated?) here, we still find ourselves treating such patients on the wards, yes.” – G1I, 24

“During surgery, you know, see patients with uh, obstructive jaundice, advanced obstructive jaundice, you just know that the eventuality is death. But, you don’t know when and you have to prepare the patient. Patients with colorectal-CA, you know, on the ward and uhm so. The/ it’s just a mixed uhm, feeling that you have to find those patients on the ward and not there at the palliative, uhm, care.” – G1I, 30

However, participants’ descriptions of existing PC structures in Nigeria varied. Just looking at the participants at UCH, Ibadan, many knew about the PC unit of their institution and its working structures. In comparison, interviewees at UNTH, Ituku-Ozalla, referenced the PC unit of their institution far less, with some admitting that they were not aware of such a unit.

“Like you said, that there is already a department here, uh-hu, and I’m not even aware of it. That means it’s so small and non-functional.” – G2E, 116

One participant argued with a culturally conditioned, clear curative focus of medical practice as a reason for the lack of well-developed PC structures in Nigeria.

“Well, PC is very, uh, how do I put it? It's not so well established. But I, I feel it’s because of our country is more or less like ’pro-life’. So every unit has that, uh, the, should I say, the orientation of doing everything they can, to extend what time the patient has. So, people don’t really, should I say, give up on patients on this side. We do everything we can, even when we know that, there (is?) very little that can be done. So, instead of people referring to someone to PC, they will rather just do everything they have to do, to ensure the patient lives.” – S2I, 18

The observation that in Nigeria, there was not enough consideration given to PC, both by healthcare workers and by society, was reported repeatedly. However, in stark contrast to the “pro-life” argument, another explanation for not considering PC, was saying that “the value of life is not that much in this part of the world” (S3I, 26). Poverty and lack of resources were argued to be reasons for that. Furthermore, PC was discussed as “not brining money”, so “people don’t go into it” (P1I, 136) as an explanation for the lack of consideration that healthcare workers are giving to this subspecialty of medicine.

A resource-limited setting was quickly identified as a major challenge for PC in Nigeria. The participants' answers showed how it influenced their perceived self-efficacy and preparedness in practising PC.

“The challenge we have, the facilities, the materials needed to handle those things. So, uh, most times, we discover that’s, uh, it’s difficult, getting those things.” – P2E, 96

“Because the truth is, there are a lot of things here, there is a lot of mental wear and tear involved in practising. Especially here, you understand, with the standard of living and the standard of, you know.” – M1I, 83

Additionally, the resource-limited setting may cause a conflict of values in NQPs, as they know the right thing to do, but impeded access to healthcare means makes it almost impossible to do so.

“Life is valued here but despite that, there is no resources to save it sometimes. So, I’ve seen, where a very young child, who have long life to live, who be in her early 20, 21, 22, due to some trauma, had acute kidney injury, needs just one or two dialysis, the relations could not afford, she had to die, you understand.” – S3I, 82

“So now, you know what you should do in that situation, but you can't do them. Probably the patient needs a better analgesic and they can't afford them. […] So, you see the patient in pain. They call you, ‘doctor what can I do?’. The drugs they can afford, is not really handling their pain as much and you are limited. So, over here we know what we can do but we are constrained with what patients can afford. And sometimes some of the services may not be available. Readily available. So, that's the limitations we have. So, if this were handled, it's easier for us to, the patient is in pain, you know what to do, you can do that right away.” – S2I, 36

Drug availability and affordability are important issues that are associated with resource limitations. The limited availability and affordability of drugs and other necessary services in PC may directly affect NQPs’ perceived self-efficacy and preparedness in practising PC.

“Sometimes, sometimes, we may not have the right drugs. Or even the right drugs, the patients may not afford it. That is a fact. The patient may not afford it. The ones that can relieve the symptoms, the patient may not afford it. That’s the challenges we have here. So, what we do is, we work with what is available.” – M2E, 55

A lack of health insurance was repeatedly raised. This leads to patients’ dependency on private donors and relatives who may not have the appropriate knowledge and awareness of the benefits of PC.

“Some families don’t have money to feed, so what is to waste that money on that PC for that patient that is dying in two weeks’ time. Just keep the money and pay for your children’s school fees.” – P6E, 116

“Most people don’t really care about it, uhm, because of financial constraints. When you know that/ it’s, in fact, they see it as/ they see it like a waste. When you know that the patient will finally die, so what’s the essence of spending money on medicines and all that, when you know that those things will not finally get the person back to good health. So, it’s better you spend your money on something that will yield you better profit. You have hope of regaining your, uh, expenditure, your expenses. So, that’s the major problem we have here in Nigeria over PC.” – P7E, 18

The reported observation of PC being perceived as a “waste” by relatives may negatively affect NQPs perceived self-efficacy and preparedness in practising PC. Additionally, the problem of late presentation by patients came up frequently, influencing participants perceived self-efficacy and preparedness.

“People say, ‘okay, maybe because of mismanagement of the doctors that’s why the patient die.’ No. Patient coming dead. Go to our emergency, patient comes in dead, patient comes in bad. So, there is really nothing you can do.” – P1I, 114

Another recurring theme in many interviews at both study sites was a low educational background among many patients which participants equated with a low level of health literacy and a lack of awareness of PC benefits. The late presentation of cancer patients in the advanced stages of the disease, even though most likely of multifactorial genesis, can be linked to low health literacy among many patients and their families. With regard to the greater topic of communication in PC, the educational background of patients emerged repeatedly and was discussed as a variable influencing NQPs’ perceived self-efficacy in practising PC.

“The enlightened ones will always try to find out. They will like to understand the details […] So, but if you deal with, uhm, the ones that are not so enlightened, most times they are not really interested. […] And most unfortunately, most of our patients are not enlightened. And even when you’re trying to tell them, they’re not really keen in taking what you’re saying. They are not really keen. Their emphasis is usually on money, money, money, money, money.” – M2E, 67

Other relevant identified frame conditions for NQPs’ perceived self-efficacy and preparedness in practising PC included, a hierarchical system within Nigerian healthcare institutions, in which NQPs found themselves at the lower end, which was associated with limited perceived competence and responsibility. Furthermore, the lack of human resources was identified as a frame condition possibly influencing NQPs’ perceived self-efficacy and preparedness in practising PC. Other challenges associated with PC in Nigeria included a general increase in the incidences of malignancies.

The overwhelming majority of respondents opined that more training on PC for medical professionals was needed. They stated, however, that “experiences should be favoured” (S5I, 144) over classroom teaching and that it was ultimately the government’s responsibility to fund PC in Nigeria adequately. They opined that, nonetheless, the present Nigerian PC specialists should complement the government and take responsibility for expanding their area of specialty. The participants’ answers regarding their hopes for the future of PC in Nigeria are summarised in Table 2.

Table 2 The participants’ Hopes for the future of PC in Nigeria

Regarding support systems for physicians who experience emotionally challenging patient care, participants stated that the most common source of support was an informal one that was expected from senior colleagues. There were no formal structures for personal support for healthcare professionals at either study site, although the need for such support was recognised by many participants.

In summary, variables to NQPs’ perceived self-efficacy and preparedness in practising PC which were identified on a systemic level as frame conditions for PC in Nigeria, were dominated by the frameworks of a resource-poor healthcare system and the challenges of an emerging economy. These, along with poor health literacy, lack of awareness regarding PC and cultural influences lead to a lack of consideration given to PC and insufficient organisational structures. These factors may reduce NQPs’ perceived self-efficacy and preparedness in practising PC. More training opportunities, especially active learning opportunities, intensified governmental funding, and increased awareness of the benefits of PC among the Nigerian public were areas for potential improvements that participants pointed to.

Individual variables

Variables affecting NQPs’ perceived self-efficacy and preparedness in practising PC examined as variables on the personal level were factors such as the university visited, months of work experience, current postings, and potential extracurricular work experiences. Furthermore, they included experienced PC training and clinical or personal exposure to PC. This group of variables also included the participants’ personal understanding of PC, their role concepts as medical doctors, and their personal attitudes towards death, dying and end-of-life care. Additionally, NQPs’ personal coping strategies with morally and emotionally distressing patient care were analysed for a potential impact on their perceived self-efficacy and preparedness in practising PC.

We examined Professional Development as well as prior Education and Experiences in PC as some of the variables on the personal level relevant for NQPs’ perceived self-efficacy and preparedness in practising PC. In this context, extracurricular work experiences were mentioned by some respondents as a variable, directly linked to an increase in “confidence in discussing with patients” (S6E, 48).

While most participants reported that they had some sort of PC training and/or exposure to PC in university, even if not formal or extensive, the extent of this exposure and the evaluation of its impact on their clinical practice differed significantly among the interviewees.

“Well, definitely. Because as a medical student, I don’t think I was ready for the idea that, uhm, part of the training would be accepting that there is nothing you can do for some patients. So, during those courses, during that orientation, you know, during that short rotation through […] that unit/ during that short rotation through that unit, I have to say that it gave me some exposure. You know, and it helped me accept, you know, that you/ to be a good doctor, you need a level of, uh, equanimity, I think is the word. Whereby, uhm, you just have to know when there is nothing you can do for a patient and then instead just do everything you can to make the patient happy.” – M1I, 26

“Uh, it wasn’t elaborate, uh, it wasn’t, uh, extensive. It was […] like sketchy skeletal lesson. So, […] for me as a person, I didn’t gain so much out of the lecture. […] No, it didn’t prepare me well. If I have opportunity to learn more, I will learn.” – G3E, 34-36

“No, I’m not fully prepared to care for dying patients. No, I’m not.” – S5E. 48.

Some remembered multiple specific PC lectures and practical PC exposure, while others stated that they did not have any formal training and were only exposed to PC in the context of clinical electives as students or only after they started working as medical doctors. For NQPs at UCH Ibadan, a mandatory orientational visit to the PC centre of their institution at the beginning of their clinical housemanship was identified as important and for some, the only source of PC knowledge and exposure. Interviewees of the UNTH cohort did not describe a similar mandatory orientational visit to their institutions’ PC unit.

“And then I also remember that, uhm, well, like I said, we didn’t have a proper rotation. Even when we were starting medical internship, we had to do some orientation, where we had to go to the PC unit and ask what they do. We had to see the place. And we were taught how to send consults to them. So basically, I think we were given an idea of what it is, an idea of why patients need PC and a very good idea, I think it’s the most important part, when to call PC team. If you, yourself, cannot implement PC, at the very least, you should know when to call them. Yes.” – M1I, 24

When discussing the perceived benefits of university PC exposure, the focus was repeatedly placed on communication and psycho-social issues in PC. The participants lamented a lack of preparation concerning these key aspects of PC.

“Uh, I would say yes and I would say no. Even, I’m not trying to be political, but the thing is uh, we could do more. I thought just, uh, that lecture and some other experiences here and there, are not really enough, uh, in terms of the psychological preparedness. It’s not entirely about being able to control the pain. Some people might not have the physical pain, but emotional pain and all. I don’t think we have been adequately prepared for that. How you break news to people, how you talk with those, who you know are going to pass on, in a short time. So, I don’t think its optimal, but it’s something. But it’s not, it’s not enough.” – P2I, 20

Looking at participants’ Personal Understanding of PC as a potential variable to NQPs’ perceived self-efficacy and preparedness in practising PC, overall, a solid understanding of basic PC principles was documented, as key components of PC were mentioned by most participants and severe misconceptions were rare. However, misconceptions like equating PC with hospice care (G2aI, 40) or with strictly “terminal care” (e.g., M1E, 14) came up at both study sites and may be an indicator of insufficient PC education.

Additionally, participants’ Attitudes and Role Concepts were analysed as a variable on the personal level, potentially influencing the interviewees’ perceived self-efficacy and preparedness in practising PC. Attitudes and role concepts reported included the idea of a “privilege” being a medical doctor (e.g., M1I, 87). The concept, summarised by the subcode: ‘Being a doctor is a big responsibility. Compose yourself’, was widespread, possibly influencing participants’ PC practice. Some participants described themselves as “a bridge between God and man, to save humanity” (G3E, 130), as others pointed out that in their work as medical doctors, they “have a responsibility to God” – “God judges” (M2E, 89). Furthermore, ideas of “a service to humanity” (G5I, 96) and making peoples’ “lives better” (M2E, 89) were repeatedly brought up. In this context, participants explained how they were geared towards valuing life and preventing death. The concept, summarised by the subcode: ‘Saving lives – Don’t give up on a patient’, as the defining role of a medical doctor, was mentioned frequently. This is in accordance with the “pro-life” attitude previously mentioned and may lead physicians to not consider PC treatment options, as outlined above.

Care for the terminally ill was described as “emotionally tasking” (P4I, 122) by several participants. They said that terminally ill patients “are not like other patients” (G3I, 42) and that medical training should focus on peculiar challenges regarding caring for them.

“And then you’d know how well to handle patients with those illnesses. Because okay, with our job, there is a lot of tension, a lot of stress, sometimes you tend to maybe, uhm, (clicks tongue)/ for patients that are terminally ill, you have to be a little more, you have to be a little more empathic and things like that. So, I think, education and that would (help?). Because they are not like other patients, who have illnesses that you just treat and they can get discharged like that.” – G3I , 42

Equally, participants’ religious sentiments were seen as an important variable influencing their perceived self-efficacy and preparedness in practising PC, as beliefs in God, miracles and godly interventions were extensively discussed and documented throughout all interviews. Although mixing personal religious beliefs with medical practice was seen as inappropriate according to medical ethics by some, others explained that “there is a higher being in charge of healing and health” (P3I, 89). Many interviewees offered their personal religious views, stating that they are personally religious, oftentimes saying they are Christians, believing in God, miracles, and godly interventions. These observations were made at both study sites, and no significant differences were observed between the study sites.

In summary, participants’ professional development, their experienced education and prior exposure to PC, as well as their personal attitudes and role concepts, were identified as variables to NQPs’ perceived self-efficacy and preparedness in practising PC on a personal level. Prior education and experiences in PC may be seen as relevant variables for NQPs’ perceived preparedness and self-efficacy in practising PC. However, the evaluation of the received university PC exposure varied considerably among interviewees. This is in accordance with the varying degrees and extents of PC exposure reported by interviewees. This may be an indicator of missing nationwide standardised undergraduate PC education.

The participants’ attitudes and role concepts were dominated by religio-spiritual sentiments shaping their views on PC practice, as well as by perceived societal pressure in their roles as physicians. Equally, a tendency towards a curative approach towards medical practice and the notion of “saving lives” as the core objective of a medical doctor were documented abundantly.

PC practice

To highlight key components of PC practice in Nigeria and to assess NQPs’ perceived self-efficacy and preparedness in practising PC, codes which concentrated on the actual PC practice of the interviewed NQPs were defined and analysed.

The topics of communication and Breaking Bad News were central within the semi-structured interviews. The code codes text segments which are discussing participants’ perceived self-efficacy and preparedness in breaking bad news, as well as potential variables directly influencing them. Interview segments discussing the core PC topics, Prognosis and Diagnosing Dying were summarised under a separate code. It highlights individual and societal attitudes and perspectives towards the topics of prognosis, imminent death, and dying in a PC context. Involving the family is a key aspect of PC. It was therefore of interest to research how this aspect of PC is perceived and practiced by NQPs and what cultural, societal, or economic variables influence the involvement of patients’ families in Nigeria. Finally, Pain and Symptom Management was defined as a code summarising text segments discussing the interviewees’ perceived self-efficacy and preparedness in practising this aspect of PC.

Breaking bad news

Many respondents reported learning how to break bad news through practical experiences rather than through classroom lectures. Additionally, they described “passive learning” (S1I, 39) by observing senior colleagues. Accounts of personal experiences in breaking bad news varied. Some described their experiences as “not pleasant” (M2E, 63). They expressed their inability to break bad news to cancer patients. In contrast, others described feeling “not scared” (G5I, 30) or “confident” (e.g., S6E, 46). Interview segments in which participants indicated that they had either no confidence, low confidence, or just moderate confidence in breaking bad news were summarised with the subcode: ‘A hard story to tell – I am not too confident’. This was coded in most interviews, indicating that many participants did not feel very confident in communicating bad news. The notion, “I don’t even want to do it” (P5I, 42), was often stated. One interviewee described it as “emotionally disturbing” (S1I, 28).

“But a patient who comes for the first time, maybe in clinic, they tell you to clerk, just even as a student. And they are making diagnosis of stage four cancer. The patient is saying, ‘I hope I be fine, what can you say?’ Though you are not the doctor, but you know already, the prognosis is poor. In school then, I would not even talk to (him?) again. I’ll just stop my and go. Like, there was a time I was, in school then, and I saw a teacher of mine in secondary school, who came for a cancer clinic and I (stopped?) the clinic, till the man stopped come. I couldn’t face it.” – S4I, 44

Reasons for the reduced confidence mentioned were empathy for patients in these situations, fear of disappointing the patients’ hopes, and fear of emotional overreaction by patients or relatives. Fear of false prognosis of death in a superstitious society was reported repeatedly. Additionally, there is the hierarchical system within Nigerian healthcare institutions, where breaking bad news is socially expected to be done by elders. The resource-limited setting directly influencing participants’ perceived confidence in communicating bad news was frequently mentioned.

“Well, you know, everybody that comes to hospital wants you to tell him that he will get better. That’s the most important thing. And then, […] especially in advanced metastasis that you wanna tell your patients that, see the drugs/ the main drugs that main treat this case is not there and it/ that there/ that even if it’s there that it’s going/ you’re not gonna get better. It’s a very hard question to answer and it’s even a very hard story to tell. And nobody wants to hear that. Even your patient. And then, this somebody you’ve been managing with all confident, that’s why he came to you, to get better and you come to tell him that you can’t get better. The worst patient will wanna hear, that doctor cannot help him.” – M1E, 35

Furthermore, breaking bad news to less-educated or enlightened patients was reported to be harder for some.

“Of course, I’m not confident, because, nobody wants to be breaking the bad news to the patient. So, most times, we look for a very, near perfect way to say it. But the confidence is not always there. Most especially if the patient is not enlightened. So, it becomes a little bit more difficult.” – P5E, 42

On the flipside, a positive connection between perceived self-efficacy and preparedness in breaking bad news and respondents’ PC knowledge and clinical experience, was repeatedly emphasised.

“But my experience now has made me more confident. I am now able to/ I am more psychologically prepared. I now have the empathy and let me say the strength, and the know-how of passing this information, without necessarily making them depressed.” – S4I, 44

Being able to break bad news the assumed right way was identified as a variable that positively influenced the participants’ perceived self-efficacy and preparedness. It was argued that knowing how to break bad news and having guidelines to follow could increase the physician’s confidence and therefore the quality of care given, “so that, irrespective of your personality or your type of person, you are able to communicate appropriately” (S4I, 70). Involving a third party when breaking the news, as well as connecting to patients’ religious sentiments as a way of comforting them through bad news, was described as increasing perceived confidence in young physicians. Equally, participants’ personal beliefs in God’s intervention and miracles positively influenced their perceived self-efficacy and preparedness in breaking bad news.

The subcode: ‘What raises confidence?’ (Table 3) summarises variables, which positively influenced participants' perceived self-confidence in communicating bad news.

Table 3 Breaking Bad News – What raises confidence?

When examining the use of the word death, participants frequently opined that this word was avoided to make patients feel as comfortable as possible. They explained that the word death could deteriorate a patient’s condition, and the news should therefore be passed in a subtler manner. In this context, it was explained that proverbs and euphemisms are culturally prevalent and preferably used in lieu of more direct communication. For example, the Yoruba language has many proverbs and euphemisms for the word death and therefore the word was hardly used in communication with patients. It was repeatedly described that generally, Nigerians are “not so free with death” (M3E, 56), and culturally, negativity is avoided. Some indicated that they themselves were afraid of the word.

“But I use, uh, euphemisms or proverbs. In this part of the world they like proverbs a lot. So, if you put it in proverbs, it's easier for them to understand. They can easily link it to a context or circumstance which they can, have a vision. So, with the whole medical jargons which they may not get, putting (it?) in a proverb or in their native language in a way they understand, it's easy for them to even get a hint of what you are trying to say without having to say it.” – S2I, 42

Prognosis and diagnosing dying

Several conflicting ideas relevant to the participants’ perceptions of Prognosis and diagnosing dying were identified. The participants discussed widespread and strong religious beliefs in God’s supreme power, God’s intervention, and miracles. These beliefs lead to general optimism and sometimes unrealistic expectations among terminally ill patients and physicians. Furthermore, a culture of avoiding negative predictions rooted in superstition and a “pro-life” (S2I, 18) attitude was observed among patients and medical professionals alike, directly influencing NQPs’ perceived self-efficacy and preparedness in practising PC. Throughout the interviews, a conflict of values was seen between the medical practitioners’ personal role concepts of saving lives, associated with societal pressure perceived in their role as medical doctors, a cultural climate of avoiding negativity, and medical knowledge of the incurability of certain disease conditions. It was pointed out by NQPs how more experience and training are needed to meet this challenge.

“Uhm, dying, yes, is a natural thing, most of the time. But still when it comes, it’s very scary, even for doctors. Uhm, you have to deal with a lot of, uhm, emotional and psychological, uhm , issues. And particularly with the relations. Uhm, the patient that suffers the illness, sometimes, many times, some of them, they are hopeful that they will get better. When they see a doctor, they’re like, ‘oh, doctor save me, doctor save me’, and you know that, I can’t save this person, this person is like going to die. Uh so, this/ and then the patient has (placed?) so much premium on you. So, you are caught in-between your professional experience and knowledge and how to translate it to the patient. Especially in this part of the world, where a lot of, I don’t know how to put it, spiritual/ you know, people believe, until it happens, that is when we believe that somebody is actually going to die. You cannot predict death. Although then, you know, professionally, you can. But your patient will not accept it from you. So, it takes a lot of, I think experience and training. At my level, the confidence is still not there. No. Not such much, no.” – P7I, 30

Involving the family

The high value of the family within Nigerian society warrants relatives to be involved in patient care. The fact that relatives are the ones financing the patients’ therapy and consequently have the right to be informed about and involved in the patients’ management and decision-making processes was emphasised. The importance of the patients’ families as an active part of the care team was underlined, as the relatives were seen as the ones “doing the running” (G4I, 76). All of these led to an overall high perceived self-efficacy and preparedness in involving the family among the interviewed NQPs. It was pointed out that without proper communication, relatives may withdraw their financial support and active participation. Participants explained that, especially in chronic illness and other situations where the outcome is either unclear or unpleasant and prolonged therapy is expected, good communication with relatives is needed to guarantee their support throughout the process. Questions on confidentiality and patient autonomy were discussed in this context. Family involvement was linked to increased compliance, understanding, and acceptance by patients. This may lead to a higher perceived self-efficacy among NQPs. Talking to relatives first, instead of directly to patients, was described as making it easier for NQPs to break bad news. A low level of education among patients and the need to identify better-educated relatives were emphasised.

“I think I’m more confident talking to the relatives than the patients. Because most of our patients are not the very educated kind and they’re usually very poor. They are not very literate. So I, when I talk to the relatives, I’m more confident.” - P5I, 42

The discussion on the limitations of family involvement included the workload and time restrictions of NQPs. Additionally, the economic constraints of a resource-poor setting associated with a lack of awareness and sensitisation to PC benefits among many patients and relatives was stated as one of the challenges of involving the family.

“The sensitisation in the first place is really not, personally to me, is not adequate. It’s not adequate. Because a lot of times when it gets to that point, most times, patients’ relatives just disappear. They neglect, because, they feel, ‘what’s left, this person is eventually going to die’, you know, and all that. Maybe because the sensitisation is not, is really not adequate. […] You know but, one of the habits in Nigeria, uh, is the fact that, why waste money when we know that eventually this is the outcome. Let’s try as much as possible to invest your resources, you know, in, you know, people that we can save, you know, and all that. But that shouldn’t be.” – M2I, 82

Pain and symptom management

Most participants felt confident in managing pain and symptoms. Sources of confidence and increased perceived self-efficacy and preparedness included previous clinical experience, medical training, supervision by senior colleagues, a procedural approach of grading pain, and a stepwise, systematic approach in pain management, as well as direct positive results. In addition, personal experiences of suffering pain as a motivating factor in readiness to offer pain control were described. Additionally, participants’ role concepts as physicians reportedly increased their perceived preparedness in offering pain and symptom management, since reducing discomfort in patients was mentioned as one of the key objectives of a medical doctor. However, limitations in their perceived self-efficacy and preparedness in applying pain control measures were discussed by the participants, and their self-confidence was expressed especially if limited to a basic level of pain management. Several participants indicated that fear of potential side effects and drug abuse may reduce their perceived self-efficacy and preparedness in applying pain and symptom management in patients. While the lack of experience, especially in the use of opioids, was lamented, it was also pointed out that a lack of resources and limited affordability and availability of drugs, facilities and other healthcare means reduced confidence. This is directly related to the frame conditions of resource-limited settings, as discussed above.

Discussing Pain and symptom management in Nigeria more generally, the term “pele-pele anaesthesia” (P2I, 62) was mentioned. This word ‘pele’ derives from the Yoruba language which translates to ‘sorry’, meaning as much as just using words instead of effective pharmaceutics. In that context, the cultural perception of pain in Nigeria was touched upon, and a general scepticism towards Western medication was reported.

“Let me not say part of our culture, but (clicks tongue) we see things that when things are painful that’s when things are serious. And then uh, the ease or will I say the reaction to it, is more, more slower than that of the westerns. Because I think for/ even (now?), our own people, if you give somebody a lot of analgesic drugs to take, tablets, he will say, ‘all these drugs doctor, what will I use all this drugs/’, well, (is it?) better (he?) to carry his painful leg and be walking around than taking the medication. But, (well, you know?), a white person cannot do that, just because he has a small pain, he will take a lot of analgesics. So, (clicks tongue), the way/ our own perspective about drugs, per se, is far different than that of the other people. But I think it’s because, (clicks tongue), people don’t wanna feel the fact that there’re coming to hospital. As in, they feel hospital is the kind of place where you’ll come; you will see a lot of things that doesn’t improve your condition. So, anything associated with it, people run away from it. I think that’s it.” – M1E, 85

In summary, when looking at the areas breaking bad news, prognosis and diagnosing dying a limited perceived self-efficacy and preparedness were documented among many NQPs at both study sites, leaving room for improvement. The major influences were socio-cultural factors as outlined above. Interviewees emphasised the potential positive impacts of PC training, experiences, and institutional guidelines to follow.

In comparison, in the areas involving family and pain and symptom management, participants reported a higher level of perceived self-efficacy and preparedness. However, socio-cultural and socio-economic influences have also been documented. Challenges of a resource-limited setting and socio-cultural characteristics of their environment influenced interviewees’ perspectives, potentially reducing their perceived self-efficacy and preparedness.