Environmental limitations.

Limited accommodation/space. Inadequate space was common to both hospital settings. Resuscitation and high dependency units were congested, and ward bed numbers were frequently insufficient. In both countries, caregivers also slept on the wards, usually under or in between the beds. Limited space compromised privacy and ability to perform clinical examination and procedures and administer treatments; for example, intravenous fluids were administered to patients lying on the floor. HCWs discharged patients early to create space for the critically ill, with patients and caregivers expressing concern that discharge was premature and occurred before sufficient recovery.

“We ask the clinicians to at least find the patients that are better and recovering well so that they are discharged and given drugs to continue treatment at home just to create space for the new ones.” Female Nurse–Malawi

“They discharge us early so that new patients can get a chance to have a bed. If a patient stays here for 10 days, there will be a lot of patients sleeping along the corridors and the HCWs won’t manage.” Female Patient–Uganda

Strained WASH amenities. All groups were concerned about the hospital WASH facilities and practices. Participants reported incorrect disposal and sorting of wastes and sharps despite the availability of appropriate containers. Infrequent emptying of waste bins led to overflow. HCWs blamed patients and caregivers for improper use of toilets and bathrooms, including soiling and inappropriate disposal of pads, papers and food stuffs in the toilets. Cleaners reported a lack of cleaning materials (heavy duty gloves and chemicals) which limited their effectiveness. Sanitation in the hospitals was further compromised by limited and non-functional toilets and wash basins.

“Right now, only one bathroom is being used; the other two have blockage for three weeks now. Sometimes you just go to the toilet room and use it as a bathroom.” Female Patient–Malawi

“My husband stopped me from going to the toilets. It seems he went there and found that they were dirty. So he would give me a bucket so that I ease myself there, and he kept taking it to the toilet to pour it.” Female Patient–Uganda

Patient welfare/inadequate provision for basic needs.

Meals. The hospital in Malawi provided complimentary patient meals. Morning porridge was considered nutritious by all groups; the other meals were viewed as nutritionally substandard, comprising nsima (maize staple food) and cabbage. Patients in Uganda depended on food delivered from their homes.

“The food that is provided is not that good. The way the cabbage is prepared, it is like it was just boiled with water and salt. This is hard for people coming from far, their relatives cannot bring them food.” Female Caregiver–Malawi

“They should at least give us porridge. If you have come from very far, people at home may not have the money to buy you food or even come to see you. They ask you to buy drugs and you remain with no money to buy food.” Female Caregiver–Uganda

Quality of services.

Insufficient staff. HCWs reported that they were overstretched and at risk of burnout, which resulted in critically ill patients being neither identified nor monitored frequently enough.

“We were told 1 nurse to 5–6 patients. But because we are very few its 1 nurse to 15–20 patients per day. You cannot carry out the orders (duties) or maybe you might carry out all the orders [duties] but at the end you can’t have enough time to rest and refresh to go back and start helping the patients again.” Male Nurse–Malawi

Staff shortages (doctors and nurses) compromised the time spent by clinicians with patients and the facility’s capacity to attend to multiple emergencies and resulted in delays in care. Increased workloads were exacerbated by absenteeism amongst HCWs and also resulted from organizational issues (for example, hospitals dealing with patients who could be cared for in primary care facilities). HCWs wished to provide quality care to all patients, and patients expressed appreciation for those HCWs who took the time to attend to their needs.

“Patients who are getting worse are seen frequently but identifying them in the first place is the problem. But if they are identified, they are usually followed up by both clinicians and nurses.” Female Doctor–Malawi

“One clinician has to review 40 patients in the ward and each review will take ten or more minutes… by the time he reaches the last patient, the time for administering the medicine is gone.” Female Nurse–Uganda

Shortage of medical equipment, testing and medication. All groups noted shortages in consumables (e.g., reagents, syringes, etc.) and non-functioning equipment (e.g., laboratory analysers, x-ray, ultrasound machines) which limited the quality of care that could be delivered. Scarcity of patient monitoring equipment (e.g., thermometers, sphygmomanometers, pulse oximeters) due to breakage and theft necessitated frequent borrowing and negotiation between wards; HCWs also highlighted the limited availability of oxygen.

“We don’t have enough [oxygen] concentrators, there’s only one working at the moment. So you can imagine if ten out of 60 patients are having respiratory problems…death will probably occur.” Male Nurse–Malawi

“…there is a patient who is very sick, needs blood gases immediately and I have to walk in the night to [another unit] and convince someone that they should share me either the syringe or the bottle of the blood gas, then I have to call their clinician on call there and convince them that their nurses should let me use their machine.” Female Doctor–Malawi

Staff referred carers to costly external private centres to purchase medical goods (e.g., catheter bags, intravenous cannulas). In Uganda, stock outs of pharmaceuticals were a common occurrence and resulted in delayed care.

“These days we have not been doing investigations like LFTs [liver function tests] and CBC [complete blood count] because our machines are down…patients have no money to go to a private laboratory to be investigated. There are others who die before they are investigated.” Female Nurse–Uganda

“I have also noted that antibiotics for organisms that are easily treated like Streptococcus pneumoniae, typhoid, are readily available. But there are instances that you get blood culture results…it’s a multi drug resistance organism…we don’t have those drugs so it becomes a challenge to the attending physician, it’s a poor patient who cannot buy.” Male Doctor–Malawi

“There is a woman who died on the ward. They told them to go and buy drugs and they failed to get the money. They waited for their relative at home to send the money and they failed. So, she died yesterday.” Female Patient–Uganda

Interpersonal relationships between HCWs, patients and caregivers.

All groups recounted cases of unprofessional behaviour which strained interpersonal relationships and delayed treatment. Some patients and caregivers felt that HCWs were lazy, rude and non-responsive. The relationship between HCWs working in different departments could be strained, which affected handovers and created gaps in continuity of care. HCWs explained that their perceived slow approach to work was a result of the heavy workload and the unavailability of equipment and drugs. Some felt demotivated by lack of training opportunities and remuneration compounded by inequity when others received monetary top-ups.

“Last week there was a patient who needed hourly nebulizer. Some of the nurses were doing [providing the hourly nebulizer] but some were not…They would say they forgot and yet the handover notes were clearly written.” Female nurse–Malawi

“You can clearly see the issue of attitude. We lack commitment. Someone imagines her colleagues sleeping and she or he is here suffering and nobody is supervising them. In the end, she sleeps, she refuses to open when called [open the door when patients need them]. Others just absent themselves.” Male Doctor–Uganda

Limited communication from HCWs.

Patients reported variable experience of communication, meaning that some did not understand their diagnosis and management:

“They never explained anything to me. I just overheard them when they were doing the scanning that my kidneys are swollen. I asked what the problem was and they told me that my doctor would be the one to explain it to me. The doctor did not explain anything; he just wrote the medication I needed.” Female patient–Malawi

“The nurses did a good job but this doctor was extraordinary. He would come and greet you all the time, he asks how you are, how are you feeling? What about this time? He would spend a lot of time on me.” Male Patient–Uganda

Some patients and caregivers wished doctors could further follow-up all their patients after referral to other departments to maintain continuity.

Role of caregivers.

Caregivers assumed multiple roles that included explaining their patient’s condition to doctors; bathing and feeding patients and sourcing food, drugs and other resources. Caregivers were frequently family members. Although minor conflicts emerged with HCWs who felt that caregiver presence occasionally compromised patient care, HCWs generally observed that patients without caregivers were disadvantaged in terms of nursing care and outcomes.

“Another day, we were told to go out of the ward for them to mop. My patient was in pain, then she told them to call me so that I should go get drugs for her. The one who was mopping refused to open the door for me while my patient was in pain.” Female Caregiver–Malawi

“There was a woman who was abandoned here…In such a situation when we are also few especially during evening hours, you find that you are torn apart and the workload is too much.” Female nurse–Uganda

Perceived disparities in care provision.

Disparities in care delivery were sometimes perceived as partiality (e.g., being related to a nurse or a clinician or having a better socio-economic background or status). HCWs noted that their increased attention on critically unwell patients could be misinterpreted as favouritism.

“…we have ward rounds between 9am and 12noon, the patients that you may start with, you may have adequate time to talk to. You may also have students to teach. When the time is approaching 12 noon, it becomes difficult to see the patients adequately so we may rush things.” Male Doctor–Malawi

“You have to give some money to be able to beat the line. While we were there, they had withdrawn our request forms and taken them to the x-ray room. They covered them because they did not want to work without money. You would see someone who has just come is being called and helped.” Female Caregiver–Uganda

Delays in triaging, treating, stabilizing and monitoring patients.

In both Uganda and Malawi, patients and caregivers described long queues during the hospital admission process. In Malawi, patients and caregivers questioned whether the reasons for long delays during triage were related to heavy workload or HCWs’ work ethic.

“…they take a long time to check on a patient…they must check patients as soon as they arrive to see if there’s need for urgency.” Female Caregiver–Malawi

“We arrived at the reception at 9:00 am and I stayed in the line for 3 hours, yet I was very sick. Those giving numbers are slower than the time you spend when the doctor is seeing you in OPD (Out-patient department).” Female Patient–Uganda

Other patients described positive experiences of being rapidly attended, contrary to their expectations and consistent with good triage processes:

“At first, when we reached and found a line, I said … “Oh God”, I used to hear people talk about [hospital name], that one can die while on the queue. But that is not what I found. I went straight and when I reached the ward, doctors came and worked on me immediately.” Male Patient–Uganda

While HCWs identified systems issues such as multiple parallel emergencies and protracted hand-overs between departments, patients and caregivers pointed to staff shortage and long lunch breaks. Additionally, laboratory delay and suboptimal prioritisation of blood testing and reporting frustrated all groups.

“A patient sent to the lab, they stay there the whole day and they come back and tell you ‘I have not been worked on’. The lines are always long; they don’t prioritize very sick patients on ward.” Female Nurse–Uganda

“Samples are coming from different departments, but the staff could be helping us by preparing the samples marked ‘emergency’, faster.” Male Nurse–Malawi

Delays were also compounded by the inherent limitations of some tests for sepsis.

“After 5 o’clock, people are not happy to do a blood culture, that’s what I think. Unfortunately, blood cultures even if you take them correctly, they will not always show you what bacteria it is…if you are lucky, it will come back in 72 hours, probably by this time you already realized that the antibiotic you gave them is not working.” Female Doctor–Malawi

All groups reported experiencing misplaced or lost blood samples as a contribution to delayed treatment. In some cases, HCWs said they failed to remember where they placed the samples, and caregivers in both Malawi and Uganda explained that HCWs did not mark the collection bottles properly or that laboratory reports were misplaced or lost; subsequent need for repeat blood testing was received with resistance by both patients and caregivers.

“They have taken blood from him 5 times. It looks like the patient is donating blood, because they come without telling us the reason why they are taking blood samples, what they want to test, and they don’t even give us report of the outcome…” Male Caregiver–Malawi*

(*For context, rumours of malevolent “blood suckers” who attack individuals at night are commonplace in Malawi)

“I got angry and asked him, ‘why are you saying that I should go and test more blood?’. He said that they lost the previous lab report. I thought that every time we bring a copy, you put it in the file. I told them, ‘If you keep telling me to go out and repeat tests, it shows that I’m equally responsible for the custody of my patient’s files’, which is wrong.” Female Caregiver–Uganda

Non-compliance with patient triaging, treatment and monitoring procedures.

Lack of expertise, supervision, and guidelines. HCWs reported that procedures for quality management of patients admitted with sepsis in accordance with existing guidance were not carried out due to lack of knowledge regarding sepsis management or lack of documentation.

“Sometimes people don’t do all the vital signs; they may do the blood pressure, but without checking the temperature. So that’s the first challenge, one identifying that this patient has got sepsis using the set standards. Secondly, knowing what to do at the right time.” Male Doctor–Malawi

Patients and caregivers expressed limited confidence in trainees, questioning interns and some HCWs for failure to perform certain clinical procedures. They preferred to be attended to by senior doctors. HCWs in Uganda suggested that guidelines for sepsis would help address this issue:

“At the policy level, I may say that we do not have algorithms for managing patients with sepsis in this hospital…… algorithms give you step by step way of how the patients should be managed until when they are discharged.” Male Doctor–Uganda

High workload affecting patient monitoring. Patients reported missed doses of prescribed medications due to HCWs’ lack of time or oversight ascribed to staff shortages. Clinicians agreed that these omissions were detrimental to care:

“The doctor may prescribe, ok this patient give them a bolus of IV fluids and maybe continue with 3 litres over 24 hours. He will come there the following day and find that the patient only received that 1 litre that was put in [the emergency department]; the reason is maybe there is no one to continue with monitoring.” Male Doctor–Malawi

“Much they are seen and prescriptions are made on a daily basis, timing of administering the medicine is the biggest problem. If the patient is not receiving what you have written, then it is really nothing there.” Male Doctor–Uganda

In some cases, although the patients were seen and prescription were made on a daily basis, timing of administering the medicine was the biggest problem:

“There was one doctor who was working on day duty. I told them that the drip is finished and told me that I go and tell another doctor to come and change the drip. But all the people I went to said they were very busy.” Female Caregiver–Uganda

HCWs acknowledged gaps in patient monitoring. They tried to monitor very sick patients at least twice a day. Caregivers also felt responsibility for timely management of their patients and prompted nurses.

“Caregivers come to us to complain about IV fluids…If the drugs are missed they always tell you that, doctor prescribed this drug yesterday, received an injection, but today has not received any injection, we ask the nurses or the doctors they say the medication is not available, it is out of stock so it means that day is missed.” Male Doctor–Malawi

HCWs understood these problems contributed to delays in care and tried to mitigate against them. For example, to help detect deterioration sooner, very sick patients slept closer to the nurses’ station for ease of monitoring, which was positively perceived by caregivers.

“Those that have severe infections like septicaemia, severe malaria, cardiac failure and others are reviewed twice daily depending on the situation really. They even have special beds, if you look this side of female ward and even male ward, those patients sleep on beds closer to the nursing station.” Male Doctor–Uganda