Background Nurses are critical in the achievement of universal health coverage. However, nurses remain largely ignored and underutilised in the Indian health system. The aim of this study was to identify the various issues that influenced the role of nurses in the public healthcare system of Kerala, a state in southern India with a population of over 35 million, and very high quality of life indicators comparable to that of high-income nations.

Methods We undertook a qualitative study within a selected district health service system in the state of Kerala, using in-depth interviews with 30 participants, which included clinical nurses, nurse educators, nurse administrators, leaders and activists, and medical doctors. The interviews were transcribed and analysed using a thematic analysis approach with ATLAS.ti software.

Results Various systems-specific and profession-specific issues were identified in the study that influenced the role of nurses in government-run institutions of Kerala. Most issues were attributable to human resource shortages, including that of allied health professionals. This leads to increased workload, reduced work satisfaction, and missed opportunities for career advancement. Nurses are often expected to carry out administrative and clerical tasks in the absence of adequate administrative staff. Thus, there is an evident case of underutilisation of nurses in these institutions where they spend more time doing non-nursing activities than nursing care. There are also circumstances where nurses are forced to perform advanced procedures that do not fall under their roles as per government rules. These tasks fail to figure into appraisal systems, remaining unappreciated, an ‘open secret’, and often putting them under legal risk. The government sector also fails to tap the potential of nurses with advanced degrees or training, with no earmarked positions for them, unlike those available for doctors. The discourse on development of independent nurse practitioners is also met with much resistance from the medical fraternity. The need for support from the medical fraternity was identified as a necessity by the study participants. This study highlighted that development of the nursing profession in India is deeply intertwined and influenced by gender and power relations within health services.

Conclusion Investing in nurses is a vital step toward achieving universal health coverage. Having strong policies aimed at protecting and empowering nurses, translation of these policies to scalable interventions, timely recruitment and provision of in-service career advancement opportunities are a few ways through which the government can invest and facilitate the growth of the nursing profession in India.