Table 1 Perceptions that MLPs are not being supported

Job descriptions

"We as nurses, we know what to do as we have learnt from school. But, eh, the job description given by the hospital, we are not given." (FGD, ENM1)

"...it's up to the CHAM institutions to adopt or adapt them...to fit them according to their working environment." (KI, HRO1)

"You can't say no, because as I was saying there is a critical shortage of staff" (FGD, CO1)

Management and supervision

"...it's not like something which is constant or regularly done. It's erratic. I think it is a problem. It matters. Because if you could have something constant you know for sure that at one point I will have this. But then you are not sure, so all the time you are working it's like, 'I don't know what will happen next,' so you are in constant fear sort of or you are not stable." (FGD, RNM1)

"Even if the anaesthetists can say, 'we don't have this drug for anaesthesia.' You complain to the Administrator, they will tell you we don't have money. But it's an essential thing, which a medical personnel would know, that this is essential." (FGD, CO6)

"If one is given appraisal so one is being encouraged for her contribution. So most of the time no, there's no appraisal." (FGD, CO6)

"...appraisal would be a very important issue, because it would be motivating you to work even more." (FGD, NMT3)

"But here, somebody does well, no difference. Does bad, no difference." (FGD, CO5)

Training and career progression

"...if you join that facility as a nurse you work the rest of your life at that grade." (KI, HRO1)

"Look at me, working at the same position for 11 years." (FGD, NMT1)

"So a policy that a clinical officer remains a clinical officer, there's no motivation, there's no what." (FGD, CO7)

"I don't want to die a clinical officer. I am still young. I would like to increase my knowledge, my skills and to be a somebody." (FGD, CO4)

"...as a medical assistant at least I have hope of becoming a clinical officer in the future. But what happens to me if I become a clinical officer?" (FGD, MA1)

"Money is not a good motivator, it's not the perfect motivator. People still need to have the job satisfaction in terms of their career path." (KI, Admin1)

"...then people would get motivated. They would feel like they are real professionals in their field, rather than just having a diploma..." (KI, Admin2)

Incentives and retention factors

"The problem you see, when it comes to remuneration package, it's discriminatory, let's be honest. Doctors are favoured...100% of the time it is COs, MAs, who are running the hospitals in Malawi...It's very unfair." (KI, HRO1)

"If you've worked for it you need to have something to show...the pay, the package, is too little for the work that we do." (FGD, CO6)

"The allowances we are given for taking calls, it's horrible, it's almost a joke. And it's a flat figure, it's fixed, but we do more hours, sometimes get so exhausted. In the past at some point they tried to make the allowance according to the hours that you put in. But then they have seen that the figures which were coming out..." (FGD, CO1)

"Here the biggest problem is of salaries, because comparing our salaries to untrained persons, to untrained personnel, there's not much difference." (FGD, ENM3)

"But here though I think accommodation is good, but we don't have enough houses. That's why they are failing to employ more staff, because of shortage of houses." (FGD, RNM3)

"Once they have employed you, it's over." (FGD, NMT5)

Resource constraints

"You still want to manage each and every day that patients are seen, but you are few of you, therefore you strain yourself." (FGD, CO4)

"Our problem is lack of...many inadequate equipment and materials to use... due to maybe the financial stand of institutions...they will still insist that you still use those things. You are always improvising." (FGD, NMT3)

"The next is you lose a patient because you cannot access the blood." (FGD, CO5)

"The nurses are shortage...Providing there is somebody attending the patients, but the quality of the nursing itself is not...it's not good as we were trained." (FGD, NMT5)

"A lot of things are against us. It's a difficult situation working here." (FGD, CO1)

"All these problems which I meet I should not encounter." (FGD, NMT4)

Motivation

"We sacrifice ourselves to be working, even during all the hours, even beyond our levels, only to make sure that we want to assist those who want to be assisted." (FGD, CO3)

"...we get afraid of being sacked. So we are trying to do our work best." (FGD, NMT2)

Status with other health care providers

"...with the advent of College of Medicine and the coming in of our own doctors that we train, it's like the medical assistant and the clinical officer, they have sort of been like relegated to the background." (FGD, CO1)

"Students (registered nurses) are sometimes rude at you, because they see you like someone with low grade. And they think after graduating they will be above you, so when you are instructing them at times they are rude to you, because they already know that you are under them. They can't respect you...in spite of you having that big experience." (FGD, NMT1)

"I suspect if you look for the signals that we have, I think you can think maybe they don't appreciate our services the way they treat us some of the times... They (medical officers) feel like they can do without us." (FGD, CO8)