| Interpersonal challenges | Hierarchical nurse–doctor relationship | “We contribute but for the head of the doctors here unless he asks me. If he doesn’t ask me I won’t contribute because I don’t want it to be as if I’m dictating to him” (Interview number 2, statement number 1) |
| “If something happens between the nurse and the doctor and is reported to the administration in some cases the doctor goes scot-free and the nurse will have an issue because doctors are the heads of the hospital which I think is not right” (Interview number 8, statement number 5) |
| “We had a pregnant woman with a fever. The laboratory results came in the evening and she had severe septicaemia. That night I called the doctor but he didn’t come, I sent for him three times. He came in the morning and we started management but she died” (Interview number 4, statement number 1) |
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| Ineffective multidisciplinary team | “Hardly do you see all of us discussing the patient’s problem. The doctors discuss what to do, the nurses also discuss what to do but we don’t normally come together and discuss” (Interview number 5, statement number 4) |
| “The rapport has not been created. I can’t mention the name of anybody working at the social welfare or the laboratory …. I don’t know anybody there personally. It would have made things easier” (Interview number 2, statement number 3) |
| “Sometimes you advocate for your patient and your colleagues wonder; why is this person is so much into this patient? They assume you think you know too much and you would seem annoying to them” (Interview number 7, statement number 6) |
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| Institutional challenges | Time constraints | “The time we have on the ward is so tight that we are not able to educate patients or advocate for them. Mostly it doesn’t happen” (Interview number 7, statement number 3) |
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| Difficult rules and regulations | “This time the hospital is not giving anything free to patients who don’t have money. At first, those who didn’t have money were given emergency drugs for 24 hours so that relatives would come and pay and buy the rest of the drugs. When you go to the pharmacy now its cash and carry” (Interview number 3, statement number 5) |
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| Lack of support | “Advocacy is a broad thing but our tuition and our curriculum do not help much. They need to enlighten us much about how to go about issues, how to talk, how to explain your stand. If it is well incorporated in our curriculum I think it can help” (Interview number 1, statement number 5) |
| “We don’t go for workshops so if there is a programme to sharpen our skills or knowledge on patient advocacy nobody would tell you. We cannot even renew our professional licenses” (Interview number 6, statement number 5) |
| “They are not giving study leave. When the person is ready to go to school then they will say no you need to work” (Interview number 11, statement number 4) |
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| Ineffective administration | “We have a patient who has been referred but has not settled the bill. We called the social welfare and they said they had to contact the administrators but at the end of the day we have to decide because the patient’s condition is deteriorating” (Interview number 10, statement number 4) |
