4.2. Problem Impacting on the Quality of Nursing Care
The main reason why patients should be admitted at the hospital is that they should be provided with quality care by healthcare professionals to recover well. However, there are challenges that impact quality of care. The following sub-themes will be discussed; adherence to treatment, delay in diagnosis, lack of equipment and working resources, and lack of enough skills and in-service training.

4.2.1. Adherence to Treatment
Patients default on treatment for different reasons, such as no longer feeling sick, lack of knowledge, personal or cultural beliefs, lack of access to healthcare facilities, lack of motivation, and poor relationship with healthcare workers. Non-adherence is one element that impacts negatively on the quality of nursing care. Below are the comments made by the participants. 
Nurse (N4) indicated that: “The major problem that we have is that (emotional) our hospital is a rural-based and most patients are from the poor backgrounds; so, they always default their treatment for various reasons, such; continue to receive TB grant, bad side effects of medication, social problems and long distances to the clinics where they should collect their medications; lack of money to buy food since TB drugs make them eat more.”
Nurse (N2) added that: “There is a high TB prevalence in surrounding rural areas. Some of them default because they go to traditional healers and the healers tell them that they have been bewitched; they are not really sick. When those patients come back to the hospital their condition will be bad and most of them do not survive a week. Some patients continue to smoke and drink alcohol and worsen their conditions as they fail to adhere to their treatment.”
The findings of this study revealed that patients continued to default treatment for different reasons, such as experiencing side effects, alcohol abuse, cultural and religious beliefs, and lack of access to healthcare facilities. Some default because they wanted to continue receiving the TB grant. The findings of this study concur with those of a study that was done by Herrero et al. [17], which listed the barriers contributing to poor TB treatment compliance, such as communication difficulties, low literacy level, inadequate knowledge and low awareness of TB disease, patients’ attitudes and beliefs in treatment efficacy, depression and other psychiatric illness, alcohol and substance abuse, unstable living conditions, negative health provider attitudes, stigma and discrimination, overcrowding, and access to medicine.

4.2.2. Delays in Diagnosis
Tuberculosis control can be effectively achieved if individuals with the disease receive adequate and timely treatment. Early diagnosis and prompt effective therapy form the key elements of the tuberculosis control programme. Delay in diagnosis results in increased infectivity in the community.
Nurse (N3) said: “Most of the patient are critically ill. Most of them report to the hospital when their conditions have deteriorated. They first go to traditional healers for help.”
Nurse (N1) indicated that: “Even when patients are diagnosed with TB they will still go to traditional healers for help because they do not believe they are ill; rather they believe that they have been bewitched. Some of them won’t even disclose their status to their family members because of fear of being stigmatized. Many people in deep rural areas lack understanding.”
According to the findings of the present study delays in diagnosis were due to the following factors: fear of stigma, patients’ dissatisfaction with service from private healthcare providers, lack of knowledge, patients’ beliefs, and patients choosing to consult traditional healers rather than healthcare facilities. The findings of this study concur with the study conducted by Mbuthia et al. [18], many people in Africa visit traditional healers prior or concurrently with formal healthcare services. Delays in TB diagnosis is common in many regions worldwide, due to patient related factors, such as stigma, lack of information, dissatisfaction with TB service, inaccessibility of treatment, or provider-related factors such as diagnosis delay, knowledge and skills of healthcare workers, and inadequate infrastructure.

4.2.3. Lack of Equipment and Working Resources
Improving the productivity and performance of health workers to ensure that health interventions are efficiently delivered is important in the healthcare setting. Human resources for health, consisting of clinical and non-clinical staff, are the most important assets of health systems. The performance of a health organization depends on the knowledge, skills, and motivation of individuals. It is important for employers to provide suitable working resources to ensure that the performances of employees meet the desired standards. 
Nurse (N5) said: “we do not have essential equipment in the TB wards: UV lights, fans and air-conditioner are not working properly hmmm. I do not think they have ever been serviced since they were installed. Airflow in the wards is very poor because the wards are too small.”
Another (Nurse 4) added: “There is a poor supply of N95 masks (sad) and it puts us in danger of contracting infection. But we are surviving by the grace of God. We are told that the hospital doesn’t have enough money to buy masks.”
According to the findings of this study, there is a shortage of equipment and working resources were impacting the quality of health in the TB wards. Participants appeared to be scared and were discouraged by the poor supply of resources in the wards. There was poor supply of N95 respiratory masks, UV lights were not regularly serviced, and there were no fans and air conditioners in the wards. The wards had small windows. There was also poor hygiene practice since there was a poor supply of detergents and hand washing soap. A study done by Mosadeghrad [19] concludes that inadequate or non-available facilities, equipment, and resources, especially basic resources to provide services such as water, steam, and electricity, hindered the provision of quality healthcare, proper conduct of tests, therapies, investigations, and surgery. Another study done by Reilly [20], concluded that patients are almost twice as likely to die in some hospitals because they lack the proper equipment and resources.

4.2.4. Lack of Sufficient Skills and In-Service Training
Healthcare delivery can be highly labor-intensive and frustrating if the healthcare worker is not well trained. The quality, efficiency, and equity of services are dependent on the availability of skilled and competent health professionals. It is essential that health workers are appropriately trained to deliver the required services according to set standards. 
Nurse (N5) indicated that: “our biggest challenge in the wards, is that we only have one nurse who is knowledgeable about TB. She is the only specialist in the wards; the rest of us know TB a bit because we read about it and from the experience that we have as nurses, even though some of us have attended workshops but I do not recall having to go for training. TB patients undergo different stages and it is important for us to understand them. Hmm some of the behaviors that we see in the wards shock us and we do not understand why patients could behave like they are insane.”
A study by ten Hoeve et al. [21], found that one of the independent functions of a nurse is education. According to a study that was done by WHO [1], healthcare professionals need to seek up-to-date scientific knowledge from national, and international, academic and research institutions, including professional associations. The findings of this study revealed that there was a lack of skills and in-service training in the wards. This finding concurs with those of a study conducted by Yang et al. [22], which indicated various barriers contributing to poor TB treatment, such as communication difficulties, low literacy level, inadequate knowledge, and low awareness of TB disease.