Statistics show that in Kenya there is one nurse for every 4000 people as compared to one doctor for every 18,000 people. This alone is the main reason behind the push for nurses to prescribe oral morphine. Nurses spend so much time with patients and are often in a better position to know how patients are really coping with highly toxic, technically life-prolonging treatments. The argument is also that patients will often put on a brave face when doctors are around and then ask the nurse to tell the doctor many things they feel they can’t because of limited interaction.
“Nurses dispense comfort, compassion, caring without even a prescription. Hence they need to be allowed to prescribe oral morphine to ease the pain of patients,” said Edna Kimaiyo, the registrar of the Nursing Council of Kenya.
Those in favour of nurses prescribing oral morphine say that they are important in making decisions about when life-prolonging treatments should end and in supporting patients and families in the process of accepting that they are dying. They also believe that nurses respect not only the choices made by patients, but also their nurse colleagues. The meeting also heard of a suggestion that nurses should be trained on oral morphine use so they can be in the position to issue prescriptions. The idea is to borrow from Uganda that already has a system in place to train nurses on oral morphine prescription.
The chairperson of the Nursing Council of Kenya said, “we need to ensure we do all we can to give patients and families can get access to palliative care. It is also important that nurses identify patients who need palliative care early.”
“We need to start these discussions now. We may not reach conclusions today but we have started on a fine road. Nurses run hospitals in this country. We need to understand the role of nurses in palliative care,” said KEHPCA Executive Director Dr. Zipporah Ali. Kenyan laws only allow registered medical practitioners, veterinary doctors and dentists to prescribe oral morphine. A patient will therefore have to wait for a doctor’s prescription to have their severe pain relieved.
The Ministry of Health in Kenya has imported 47kg of morphine a majority of which unfortunately is still at the Kenya Medical Supplies Agency (KEMSA) depot in Nairobi. The largest teaching and referral hospital in Kenya, Kenyatta National Hospital, uses approximately 1kg of morphine annually. This shows that more can and still needs to be done to improve pain treatment countrywide.
“A lot of things are changing and that’s good for the relief of pain among patients,” added Dr. Ali.
Borrowing from neighbouring Uganda who have been at the forefront of advancing palliative care on the African continent, Rose Kiwanuka, the Country Director of the Palliative Care Association of Uganda – PCAU, encouraged her Kenyan counterparts that it is possible to put nurses at the centre of pain treatment and palliative care. Like in Kenya, nurses make the biggest group of health care workers in the Ugandan health care system. The nurse to patient ratio is at 1:1800 in urban areas and 1:2800 in rural areas. The doctor to patient ratio is at 1:28,000 in urban areas with the figures worse in the rural areas. Aware of this, PCAU has implemented palliative care initiatives such as home care, road side clinic and community day care to reach more patients.
Ø Palliative care is available in 90 districts of Uganda
Ø Over 250 nurses have qualified as prescribers
Ø 13 regional referral hospitals are practicum sites for palliative care
Ø Morphine consumption has increased from 1kg to 35kgs annually
Ø There exists a statute that allows nurses to prescribe that was gazetted in 2004
Ø Nurses are specializing in palliative care
Ø Palliative care position is in the nurses scheme of work
“Doctors are few in the system so it is the nurses who do the bulk of the work. They need to be accepted and supported. Palliative care needs that acceptance for patients in pain,” said Rose Kiwanuka, the Country Director of the Palliative Care Association of Uganda – PCAU.
Dr. Amandua Jacinto, the Commissioner for Clinical Services at the Ministry of Health in Uganda spoke of the need to develop capable, motivated and supported health workers as it is essential for overcoming bottlenecks to achieve global and national health goals. He added that health service providers are the link between knowledge and health action: they treat, heal and care for people, ease pain and suffering, prevent and mitigate risk.
Dr. Amandua also spoke of statistics that show that countries with less than 2.5 health professionals per 1000 population have a critical shortage. There is a global shortage of health workers in 57 countries worldwide and that 36 out of those 57 countries are in Sub-Saharan Africa. Africa has the largest relative need of health workers: 140% increase to meet threshold. Palliative care needs are big and growing and there are too few health workers in Africa especially in rural areas with doctors even less available in rural Africa. Some of his recommendations for the improvement of treatment of pain include:-
Ø Recognizing that national obligations cannot be achieved with the current workforce.
Ø Increasing nurse prescribers and practitioners in many specialties.
Ø Updating of most narcotic regulations and laws in African countries to improve access and ensure control.
Ø Integration of all stakeholders in health, security and foreign affairs sectors.
Ø Regional and continental approach to nurse prescription.
Ø Harmonize laws and regulations.
Ø Recognition and licensing of specialist nurse practitioners.
Ø Scale up medicines availability for palliative care.
“If we do not allow nurses to prescribe opioids, we will lag behind in the treatment of pain and patients in pain,” said Dr. Amandua Jacinto, the Commissioner for Clinical Services at the Ministry of Health in Uganda.
The conversation continues through the leadership of the Nursing Council of Kenya with the aim of improving access to pain relief.