TABLE 4.

Nurse interview quotes.

Theme	Quote
Caregiver stress	‘It is a challenge [not having morphine], actually a very big one. You get there and you have nothing with which to help the pain. Sometimes the person needs help, and when you fail to deliver that help, it is as if you have done nothing. They may even wonder why you bothered to visit.’ (Nurse 5)
	‘As a PC [palliative care] professional you can only be satisfied when you feel you are doing the right thing, although you are not curing you are doing the right thing. But if you are not doing the right thing [giving oral morphine] you feel as if you are mismanaging the patient.’ (Nurse 3)
Unrelieved pain	‘For this case, it was very difficult to control her pain using tramadol and ibuprofen. There was not much improvement. It became necessary for me to go to KCMC [regional hospital] where we were able to get oral morphine. She was so happy to get that medication! She continued with it … but near the end she was unable to get it again, as we were unable to refill the medication. So we used tramadol and others as we had done before. It did not give her relief like when she had the morphine. The challenge was, if only in our institutions morphine would be available, in order that for patients like her with strong pain they might get some relief…Truly, I felt very badly; terrible. I kept thinking that there was medicine just there at KCMC. But the restrictions of the pharmacy, that they cannot just give it to anybody, it really hurt me. If only this woman had lived somewhere like Arusha, being near a place like Selian, where oral morphine is available without severe restriction.’ (Nurse 6)
	‘... a patient who was 70 years old or so, who had been found to have cancer of the prostate ... We worked with him with the pain. We started Diclopar [diclofenac plus paracetamol] four times daily and tramadol 50 mg four times daily. It did not help much ... Still the pain continued ... We had to increase pain medications, the tramadol to 100 mg four times daily. But 3 days later we found the pain to still be so much. More medications were added... amitriptyline and diazepam at night. From then pain reduced slightly but not a great deal. He continued until he was called by God... These patients are here. They do not respond satisfactorily to our pain medications and are not satisfied with our care.’ (Nurse 5)
	37 y.o. female with advanced ovarian cancer taking tramadol orally. ‘She reported to us with very advanced disease and very advanced pain; it was too late to really help her ... But all along her pain was not responding ... When she recognised what was going on, she didn't want to see us ... We had to gradually convince them that our services would help; it took time. Then when we did the pain did not improve. It began as overwhelming and was helped only slightly by our medications. Eventually she was unable to swallow and she died... That last time when she could not swallow tramadol, perhaps morphine in the mouth might have been absorbed and she could have had the chance of relief.’ (Nurse 4)