Table 1.

Staff themes

Theme	Illustrative quotations
Emotion	‘’To work with children is wonderful… you can play and pull your face. It is so satisfying” ‘’ I have an instinct for this” ‘’ We get emotional because we care”, ‘’ I have an emotional connection”. ‘’I am passionate..” “I lost it…” ‘’I get so angry..” ‘’I have to say this thing (malnutrition) kills.. It is heart wrenching”, ‘’It makes me so sad”
Logistics	‘’It takes hours waiting for files .. It is ridiculous .. They are so tired when they get to us.” ‘’Unnecessary referrals from PHC” ‘’ Patients know what to tell us..(referred from ED to clinic).. “’I am not stupid, I will come back after 4”’
(a) waiting
(b) triage	‘’Triage is done by students with no insight.” ‘’Get rid of triaging and go back to ‘first come first served’
(c) space	‘’The new POPD is very nice” ‘’ We need a sound proof room for counselling.” ‘’Mothers sleep on the floor”. ‘’Move to the ground floor so that we can have a play area outside”
(d) clinical protocols	‘’The 10 steps has helped such a lot”, ‘’ we do in-service every day”
Patient factors	‘’There are changing caregivers all the time with lack of responsibility”. ‘’It seems the children blame themselves especially where the mothers passed away..this sometimes leads to overdose” ‘’They really don't know..80 % don't know babies can eat protein” ‘’Rooibos (tea). It comes from the grannies ..They see it as medicine” ‘’Mothers are hungry for information . They want to do the right thing and be better parents” ‘’Parents are passive” ‘’The mothers hide this (that they have given muti/traditional medicine)” ‘’Some of the grants go for alcohol” ‘’Some lie…” ‘’Sometimes she cannot read so she misses the appointment” ‘’Their hair is done, they are wearing nice clothes. You don't see suffering on the side of mothers..how did it come to this?” ‘’It is their culture..The ‘raad’ ‘’(traditional medicine)
Attitude	‘’I feel so bad when I have that heart and others don't” ‘’Certain patients are easier targets” ‘’I have seen mothers in tears who don't want to talk....she was told she isn't a good mother” ‘’Patients feel judged” ‘’The dietician confronted the nurses..They were so mean to the mother after that” ‘’Guilt and blame is projected by us” ‘’Sister is sometimes impatient..I tell them it is not the patient’s fault” ‘’We should move away from the blame and listen to the reasons why certain things happen” ‘’I don't shout at them..I try and compose myself” ‘’Our nurses are respectful” ‘’I will never greet you from a distance” ‘Some mothers need to be "shouted" ‘’Some people in the ward create a good culture..It makes a difference” ‘’The staff at ward.X …are very warm, very kind, very welcoming. That kind of atmosphere.. There is a culture”
communication	‘’The mother gets some relief where someone is listening” ‘’If you remain calm and explain they become receptive and say they will try. If you attack them they shut off..they don't even look at you when you come in the room” ‘’Encourage them by showing them increases in weight” ‘’It was said by the nurses that the mother was in tears because she didn't have an ID and no one had asked” ‘’I try to find out the reasons” ‘’Sometimes the mother was alone, there was no food, the father had left and she tried to get money..when they tell you their story their challenges…” ‘’After the news was broken that was the difficult moment” ‘’I had to learn the language, this really made a difference” ‘’I play with the baby if I cannot open the door to the parents..that is my door” ‘’I sometimes tease the mothers who sleep on the floor just to get the spirits up” ‘’The new doctors don't understand the struggle and say..just come back next week without thinking, then they get angry when the mother doesn't come back” ‘’Most of them..It is the wrong message the media is giving” ‘’I try and give a lecture. Some are thankful and others resistant” ‘’I explain that (related to traditional medicines) anything that goes into the mouth or rectum is dangerous and it is all about dosage. Pour Harmanns (folk medicine) into water and wash, don't drink, to protect against spirits” ‘’We were discussing a child and they (the doctors) started laughing. The mother started crying because she thought we were laughing at her child. The interns don't always realise the parents are listening” ‘’It is difficult to carry the message across”
Team	‘’It's important that the social worker sees them-she gets the true background and the mother gets some relief” ‘’There is great team work” ‘’Lots of support and interest from my manager” ‘’The safety net (of the clinic nurses) is not so strong. There is a lack of clinical sharpness/attention to detail” ‘’Feedback from team members is not always good” ‘’With each and every visit they must go to the counsellor and social worker.” ‘’When you call a doctor 4–5 times and he doesn’t pick up…those who get into trouble are the nurses” ‘’The staff is like minded. The dietician, doctors and nurses-children are important for them” ‘’The front clerks and I sometimes fight” ‘’We are working in a team and if the chain breaks…”
Continuity	‘’The paediatricians are very focussed and there is some continuity” ‘’Some of them have been there for years and years” ‘’She (HIV positive young woman) has a baby who is negative. I have known her for 10 years” ‘’They know the children and recognise the story is going on. This affects the way they are managed. I have already treated this child. This is the third time … this is now serious”