Seizing the opportunity of the moment;nurse education in Cameroon: a grounded theory research study

Abstract

Background

Cameroon became a republic in 1960 but tensions have continued over the last half century; such tensions, and some of the opportunities afforded, have shaped policy decisions around issues including nursing education.

Aims

The aim of this paper is to present a constructivist grounded theory of the evolution of nurse education in Cameroon based on interviews and available historical records.

Methods

Two data sources were used to develop the theory. Semi-structured interviews were carried out by the researcher with a purposive sample of 10 informants. Informants involved in the historical and current development of nurse education policy and practice were interviewed. Historical records were also located and examined, to understand the differing philosophical and pragmatic basis for decision-making in relation to nurse education in Cameroon.

Results

The emergent grounded theory is entitled ‘Seizing the opportunity of the moment’. This theory outlines the evolution of nurse education in Cameroon since the country gained independence. It explores the centrality of timeliness and context on the evolution of nurse education policy.

Conclusions

Conclusions are drawn that identify the current context in Cameroon as a critical moment for harmonisation of policy and practice for nurse education.

Keywords

Cameroon constructivist grounded theory grounded theory higher education nurse education

Introduction

The origin of nurse education in post-colonial countries is complex; often bound to the emerging political context of the country. In Cameroon, the dearth of reliable evidence has made informed debate regarding the evolution of nurse education problematic.

To understand this lack of available evidence, it is important, first, to appreciate the traumas that Cameroon has undergone in becoming a republic. Such upheavals do not support the systematic recording of historical records or the creation of accessible archives for interrogation by researchers. Consequently, trying to construct a picture of the evolution of nurse education in Cameroon must rely on diverse sources of information which may, or may not, be consistent.

Cameroon

Cameroon is a country in west central Africa of some 183,568 square miles. It has a population of 23.3 million people (UNDP-HDR, 2018) representing around 200 linguistic groups, including the colonial legacy of French and English.

Cameroon has a complex colonial history. Kamerun was colonised by Germany from 1884; in 1916, with the defeat of Germany in World War I, the country was ‘given’ by the League of Nations to France and the United Kingdom. In 1961, the Federal Republic of Cameroon was formed under President Ahidjo. This new republic incorporated much of the existing Cameroun with some small northern areas electing to become part of Nigeria.

Cameroon is ranked 153rd on the United Nation’s Human Development Index, and nearly half of the population are described as living in multidimensional poverty. Despite this, Cameroon has a 75% literacy rate (UNDP-HDR, 2018). In 2014, Cameroon’s total expenditure on healthcare was 4.1% of GDP (WHO, 2018). The government does not fund a national healthcare system, though some basic services are provided. Of the total expenditure, public health measures represent around 0.9% GDP (UNDP-HDR, 2018).

Since the establishment of the Republic of Cameroon in 1960, the country has continued to experience political and social tensions, but against this backdrop a contemporary nursing service has developed. Operating within this inconstant context exposed the researcher to diverse and often contradictory positions and ideas about nurse education. In this study the researcher (MNM) sought to create a grounded theory of nurse education in Cameroon. This grounded theory would build from the views of stakeholders with influence over the development of nurse education, alongside whatever archival material that could be located, to offer some degree of triangulation.

Study aim

The aim of this study was to generate a grounded theory of nurse education in Cameroon since 1960 (i.e. post-independence).

In order to achieve this aim, nurse education policy decisions emanating from the three Ministries that exercise control over policy were identified, deconstructed and analysed. The grounded theory enabled the present national nurse education model to be understood alongside competing ideological positions.

Methods

Study design

The grounded theory design in this study was selected because it is an emergent method, defined as ‘… inductive, indeterminate and open-ended’ (Charmaz 2008:155). Phenomenology – studying the structure of various types of experience including perception and social activity (Smith, 2018) – was considered and rejected in favour of grounded theory, which has an explanatory power; this was valuable in illuminating the development of nurse education in Cameroon. Charmaz offers a constructivist approach to grounded theory.

‘Research participants’ implicit meanings, experiential views –and researchers’ finished grounded theories – are constructions of reality.’ (Charmaz 2006:10).

Constructivist grounded theory retains the characteristics of grounded theory: concurrent data collection and analysis; constructing analytic codes from data; constant comparative method; theorising at each stage; memo writing and theoretical sampling (Glaser and Strauss, 1967). However, it applies these within a ‘constructivist paradigm’ that repudiates the ‘notion of objectivity’ (Annells, 1997). It emphasises the role of the researcher and study subjects in co-creating reality. This ‘discovered’ reality emerges from the interactive process between researcher, participants and study context (Charmaz, 2000). Constructivist grounded theory also permits the researcher to be positioned within data, revealing ‘… the author of a construction of experience and meaning …’ (Mills et al. 2006:32). The researcher (MNM) was integrally part of nurse education in Cameroon and, therefore, already a component of the emerging theory.

The positioning of the researcher in this study is important. Strauss and Corbin (1990:44) discuss the grounded theory concept of theoretical sensitivity; this includes the researcher’s insight and their level of awareness of nuances and complexities of that which is under investigation. The researcher, as a nurse educator in Cameroon, had such insights that would enable him to understand some of the complexities. However, it was equally important to ensure that such insights did not prejudice the data collection or analysis.

Data collection and analysis

This grounded theory study comprised two data sets; face-to-face interviews with informants selected because of their experiential knowledge of nurse education in Cameroon, and archival material regarding nurse education policy. These data sets were integrated into a single data set from which findings and a grounded theory emerged.

Data collection: interviews

Purposive sampling was used initially. Participants were selected based on their role in nurse education in Cameroon. Nurses who had been involved in nurse education for many years as instructors and/or education administrators (at school level and within the ministries) were invited to take part in the study. No database existed in Cameroon to identify such nurses; consequently, potential participants were identified through professional association meetings and references from informal professional networks.

All interviews took place within Cameroon and were carried out in English by the researcher (MNM). There were 10 primary semi-structured interviews, which were digitally recorded and lasted 40–60 min.

After the initial interviews, theoretical sampling was used to attain greater depth in relation to the emerging theory. Charmaz describes this as sampling for ‘theory construction and not for representativeness’ (Charmaz 2006:6). A further three follow-up interviews were carried out with participants (one new, but this was covered in the initial ethical clearance) who were able to offer specific insights into the emerging theory. For example, participants with mastery of the francophone system were sought to elaborate on the emerging ‘francophone perspective’ of nurse education.

Data collection: archival material

For document analysis, official texts relevant to nurse education from 1960 through 2015 were considered. The researcher accessed all the information that was made available to him, but there is no way of establishing, with any degree of veracity, if this was all the data available. Texts were copied from the regional archive offices, archives of different nursing schools and some from informants who had copies.

Data analysis: interviews

Interview transcripts and audio files were imported into NVivo 10 software. ‘Initial Coding’ (Charmaz, 2006), undertaken by meticulous line-by-line examination of the transcripts, resulted in the emergence of 600 initial categories. ‘Focused coding’ (Charmaz, 2006:57) followed, using the strongest or most significant codes to categorise data, leading to emerging subcategories.

‘Constant comparison and theoretical sampling’ moved some focussed codes to categories as their properties became more complex and demonstrated viable links between subcategories. The process continued until theoretical saturation was achieved; when ‘… fresh data no longer sparks new theoretical insights or reveals new properties of emerging categories’ (Charmaz, 2006:113). At this point, categories and their interconnections were supported by sufficient data and further analysis did not generate new insights.

Memos

Coding was facilitated by memos. Memos are analytical notes on the data and conceptual links between emerging categories (Holton, 2010). Some initial memos highlighted the sense of ‘surprise’ the researcher experienced. Memos allowed researcher reflection on emerging codes in a reflexive manner, while identifying new directions from the codes. e.g. a memo: ‘stopping Ministry of Health training’, captured the researcher’s surprise at the emergence of such a bold unanticipated position from an informant.

Data analysis: archival material

Administrative documents were primarily policy statements, signed by the President of the Republic or Minister, and/or texts of application explaining policy implementation. Scanned copies of documents were imported into NVivo 10 software for data analysis.

Charmaz’s approach to studying texts helped to establish context; categories; unintended information and meanings; and the target of the texts (Charmaz 2006:39–40). Data, in the form of documents, were examined and interpreted to elicit meaning, gain understanding and develop empirical knowledge (Corbin and Strauss, 2008). Document analysis thus generated additional questions; supplementary data; a means of tracking change and verifying findings (Bowen, 2009) from interviews.

Findings

From the analysis of the interviews and archival material, eight categories emerged (Figure 1 and Table 1). These categories highlight factors that have influenced nurse education evolution in Cameroon during the past 60 years.

Figure 1.

Eight categories emerging from analysis of interviews and archival material.

Table 1.

Eight categories emerging from analysis of interviews and archival material.

Historical events in nurse education whose influence remains active	Fluid contemporary currents whose direction and form are still unfolding
Multiple births and formation	The change mode
Reactive growth and development	Moving nurse education to higher education
Liberalisation and nurse education expansion	Harmonisation of nursing programmes
Turf wars and intra-professional conflicts	Professional nursing

Multiple births and formation

… health systems in those days were meant to serve the white establishment and the colonial masters … and those who were working in the big cities. (Int7:1).

Nurse education in Cameroon is described as having ‘multiple births’; formal nursing originated from colonialism without integrating indigenous care. At independence, the government organised nurse education under the control of physicians:

The general aims are the training of state registered nurses … who are generally qualified and are capable of fulfilling the various responsibilities devolving on them in the implementation of the health policy defined by the government … as regards the development of the basic health services. (Ch1:3 Order No.22, 1970)

The director of a cycle B (Cycle B is a class on the public service employee classification system. Cycle B schools train professionals with at least a High School Certificate) school has to be a holder of a degree in medicine or the advanced nursing diploma from Centre for Advanced Nursing Studies. (Article 10 Decree No.80/198, 1980).

Reactive growth and development

The growth of nurse education was reactive to the needs of the population.

In the francophone area because we were not having too much [sic] health facilities … there is need of qualified personnel to carry out some activity and they started training of nurses. (Int6:2).

The educational model was reactive, training nurses for immediate ‘consumption’ by the health system. However, insufficient nurses led to physicians training their own nurses; this was essentially unregulated:

… doctors in particular decided to train their own nurses in their clinics for their use … and we don’t even know whether to qualify them as the nurse’s aide, nursing assistants or even the qualified registered nurses. (Int7:3).

Liberalisation and education expansion

The government introduced reforms in the 1990s and early 2000s as part of an international negotiated agreement to support the country’s struggling economy. The agreement required the liberalisation of many sectors of the economy including higher education. This process saw many nursing programmes come under the control of the Ministry of Higher Education

Higher education is made up of all programmes and post-secondary education provided by public higher education institutions and private higher institutions authorised … by the state. (Law No.005, 2001)

[MHE] launched its HND programme … using a higher education model … with the hope of giving those nurses the opportunity to advance … becoming bachelor of nurses, masters … etc. (Int7:2)

With Liberalisation other government ministries became involved in nurse education but did not always share a single coherent policy agenda.

Somebody comes from the Ministry of Health, another goes to the Ministry of Professional Training and gets his own programme, the Ministry Higher Education sets its own programme. (Int1:11).

Turf wars and intra-professional conflicts

The term ‘Turf War’ was selected to describe the various battle grounds on which the fight for dominance of nurse education occurred. These were played out in recruitment patterns and the membership of various professional associations:

… there are … Higher Nursing Diplomas … state registered nurses … in the public service … , during recruitment they take both … But if the Ministry of Health has to organise its recruitment it doesn’t take … the higher nursing diploma. (Int12:1)

You’re at A-levels … and start doing a degree course when you have not yet been a professional. There is a jump … and that is why we are not registering them. (Int8:2)

Also, by nurses themselves:

They somehow feel threatened that if they allow these young people to go into universities … [They] will come out with higher qualification … that may jeopardize their job and … position. (Int9:1).

The change mode

This category describes the appetite for change across Cameroon, for example, some nurses acknowledge the need for change:

The profession is going down the drain … training is in the hands of the wrong people and … people are beginning to market nursing … There needs to be a change as far as nurse education … nursing practice is concerned. (Int11:3)

Some nurses expressed, very directly, the opinion that the Ministry of Health should stop training nurses:

… somebody should come out and clearly tell them [to stop] but nobody has been able to say that. (Int10:3)

The potential for positive and structured change within nurse education was perceived to be hampered by career limitations and weakness in nursing leadership skills.

In the beginning … in the public service there is a limit, even if you have a PhD, you cannot go into [employment] category A2, only category A1. This discouraged nurses going further. (Int1:1)

Nobody is there to think through policies … to design policy … to plan policy. The people who plan policies have no nursing orientation. (Int3:2)

The educated nursing elite, the university and a regulatory nursing organisation were identified as education change leaders:

… all our doctorates of nursing, all our masters will become a think tank that … will form a new board of nursing. (Int7:8)

So a key proposition is that the university should lead...come up with a position paper on which that policy will be based on. (Int7:5).

Moving nurse education to higher education

The first bachelor nursing programme in Cameroon was initiated by a medical professor:

[Professor] McMoli came in from Nigeria, she had learned the Nigerian system, the English system … against all controversy introduced the Faculty of Health Sciences training … the nursing cadre and the medical laboratory cadre. (Int4:4)

The higher education model of nurse education moved nursing beyond bedside competence:

The bachelor degree programmes come with extra skills like management, like research, like teaching, and … in as much as it is training the nurse at the bedside, it is also preparing them to be in managerial positions, to go onto teaching, to go into research and things like that. (Int9:2)

However, this model was criticised for being too theoretical:

There they know the theory, but strength in practice is a little bit negligent … In fact they’re not very practical … those of Ministry of Health … are practical. (Int13:3)

Harmonisation of nursing programmes

A standard competency framework was considered critical to initiate change in nurse education:

by harmonisation, I mean basically – an agreed competencies or skills that every nurse … leaving a bachelor’s degree programme for example … must have acquired. (Int9:4)

Harmonisation should lead to clarity and regulation of nurse education to improve accountability:

At each level they should be guidelines … to be obeyed concerning recruitment criteria … training … duration … people who have to train the nurse, different categories of personnel, their various qualifications … and all that. (Int12:6)

… in order that we meet the exigencies of the society and … the holistic health care which we want to give the patients. (Int12:4)

Professionalising nursing

Professionalisation was described by participants in terms of a ‘conceptualisation’ of nurse education, to emphasise the value of nursing:

Conceptualising nursing is a way of … education that says that when you are giving that injection what does it mean for the patient?... When you were doing that dressing, you have done it so well but then what does it mean for the patient? What have you done for that patient? How has that patient conceptualised your practice during the dressing? (Int3:5)

However, the existing lack of autonomy within nursing was seen as a drawback to professionalisation:

Nurses need to be the main actors driving their profession. They are not! They are not in the driving seat! Somebody else is in the driving seat … somebody who does not have a listening ear … That’s the big issue right now. (Int7:1)

Linking the categories

Based on Charmaz’s (2006) constructivist approach, the researcher moved from a descriptive model (Figure 1) to an analytical model showing how categories were reconstructed to generate a unique theory. Figure 2 shows the framework of the emerging theory of ‘seizing the opportunity of the moment’.

Figure 2.

Seizing the opportunity of the moment; nurse education in Cameroon: a grounded theory.

This framework shows the present as a product of the past. Up to the immediate pre-liberalisation era, nursing’s evolution in Cameroon was uncoordinated; multiple births, continuing reactive growth and erratic development were incited by events outside of the control of nursing.

Liberalisation brought nursing into higher education, an unplanned change that coincided with an internal desire for change. It also generated multiple educational frameworks, which, in turn, provoked turf wars and intra-professional conflicts, all of which could have a potentially regressive impact.

However, harmonisation in nurse education as an emerging strategy brings nurses together to address conflict and risk, offering empowerment and a coordinated future. It gives nursing the unique opportunity to take charge of its educational evolution; to seize the opportunity of the moment. Figure 2 is now explored in more detail with reference to the recent history of Cameroon.

Discussion

Time and national events

In states where control is exerted centrally, the development of professions is often reactionary and growth, sporadic. Smith and Tang (2004) described how Chinese understanding of health influenced the professional development of nursing in China.

In Cameroon, as in many African colonies, government control of nursing rejected indigenous care models, transitioning away from the local African training on the causes and management of diseases to ‘modern education’ (Mackie and Bagallay, 1954).

National agenda: liberalisation and expansion of higher education

State dominance over professions has been explored by many authors (Fielding and Portwood, 1980; Gieson 1984; Cocks and Jarauch, 1990). The liberalisation of higher education in Cameroon in 2001 was a consequence of reforms forced on the government during the 1990s through a combination of economic crises, multiparty politics, civil disobedience and international pressure (Konings, 2011). Liberalisation led to increased access to nurse education; gave entrepreneurs a role in nurse education; introduced degree-oriented education and ‘marketisation’ (Furedi, 2011); crowding the playing field of nurse education.

Despite the associated concerns, liberalisation improved quality through competition; increased choice; increased institutional autonomy and responsiveness to students’ needs and global trends. This, in turn, provided higher qualifications for nurses thus raising their status and wages. Lindley and Machin (2012) argued that, even with increasing numbers, demand for highly educated employees continues to remain steady.

Current opportunity for nursing to take control of development

Conjunction of the desire for change and move to higher education

Alongside centralised state control, nursing has identified failures in its own leadership. Fortunately, this awareness is coinciding with the consolidation of nursing in higher education. The move into higher education is a planned policy for nursing, known as ‘Academisation’ (Burke 2006; Laiho, 2010; Friedrichs and Schaub, 2011; Ayalaa et al., 2014). In this study, ‘academisation’ is a consequence of liberalisation.

Traynor and Rafferty (1999) identified context, convergence and contingency as the conditions necessary for change. This study shows that these conditions are met with change providing context; liberalisation providing convergence; and academisation providing contingency. However, Cameroon currently has no national nursing body to seize this unique opportunity.

Turf wars and intra-professional conflict against opportunity for harmonisation

Moving to higher education broadened the range of nursing competencies from bedside to management, creating a clash between the old and new. This new tension, alongside existing tensions over control of nurse education and embedded resistance, constituted a significant resistance to change.

In this study, resistance is reinforced by the perceived effect of overall change on individual careers; for example, a diploma-level head nurse may fear loss of status to a younger degree-qualified nurse. A change strategy must include powerful individuals, occupying leadership positions who can frustrate change; addressing their concerns will reduce the forces of resistance (Lewin, 1951).

Realising educational advancement and professionalisation through harmonisation

The harmonisation project

The ‘Bologna Process’ aimed to create a more coherent strategy to facilitate the transition from vocational training to Higher Education, within the European Higher Education Area (EHEA) (Davies, 2008; Hengen, 2010; Patricio and Harden, 2010). Harmonisation in this study is a comparable process; it provides a framework to integrate the education policies of different stakeholders, a pathway for resolving conflicts and a professional forum for debate.

Professionalising nursing

Harmonisation is anticipated to increase professionalism through the delivery of a coherent professional nursing service. With increased autonomy nurses may be ready to provide services that demonstrate the unique input of nursing, with recognition from service users and stakeholders. This desire reflects the functionalist definition of professions (Parsons, 1954; Marshall, 1963).

The harmonisation project to achieve control of nurse education: an opportunistic model

Professions recreated by governments in post-colonial societies typically build on colonial foundations, thus retaining the characteristics of their foreign origins. If the colonial model failed to incorporate indigenous approaches professional identity crises inevitably follow.

When such crises combine with strong state control, professional growth is sporadic and erratic. Even with an espoused desire for autonomy, rigid control is disabling, and, when change opportunities arise, professions are unable to take advantage. In this study, liberalisation provided such an opportunity, but instead of seizing the moment, nursing became embroiled in intra-professional conflicts and turf wars.

Change in the national agenda could present professions with a unique opportunity to seize control. This, in conjunction with a strong desire for change and the advantages of higher education, become key engines in the forward drive for autonomy. However, a strategy for overcoming opposing forces like turf wars and intra-professional conflicts must be developed. Harmonisation emerges as such a strategy.

Implementation of the harmonisation project holds the promise of consolidating educational advancement and the professionalisation of nursing through education. Significantly, it also lays the groundwork to both seize the current narrative and set up for future challenges.

Recommendations for nursing in Cameroon

Nurse education should be designed, validated and implemented by nurses within higher education working collaboratively with the Ministry of Health. The historical problems associated with interference from multiple ministries should be acknowledged and resolved.

A new national curriculum and competency framework for nursing should be developed by nurses. Appropriately educated nurses should take the responsibility to lead nursing through strong visionary leadership and role modelling.

A new identity for the nurse in Cameroon should be defined, creating indigenous nursing programmes. This will increase the cultural significance of nursing with added benefits to the health system. It will also allow Cameroon’s nursing to make a unique and valuable contribution to the expanding global nursing knowledge.

Professions in state dominated systems must wrest control of their education and practice. Drawing from the experience of nurse education in Cameroon, professions in every country must study, document and teach their history, with a focus on how it is influencing their evolution.

Conclusion

‘Seizing the opportunity of the moment’ is a grounded theory demonstrating the complex relationship between the educational project of a profession and its historical context.

Taking advantage of the opportunities that evolutionary development offers depends greatly on a profession’s ability to overcome internal conflicts and adopt a strategy like harmonisation. When combined with a desire for change and the higher education experience, harmonisation becomes a vital tool to address conflicts and turf wars, in order to achieve educational growth and professionalisation.

For nurse education in Cameroon, ‘seizing the opportunity of the moment’ has been 60 years in development. The findings and interpretation offered by this study reveal a dire situation as well as hope. If the recommendations of this study are not adopted by organised nursing in Cameroon, the evidence here suggests that another period of reactive and erratic development will be unavoidable. If the recommendations are adopted, these nurses can march forward with the confidence of a shared purpose, to meet the needs of Cameroonians for world-class nursing care.

Key points for policy, practice and/or research

Through a constructivist grounded theory, this study evidences the complex relationship between state and the minor professions like nursing.

The study underlines that opportunity to create positive change is often dictated by circumstances beyond the control of any single professional group.

The study also shows how leadership can instil in professions like nursing, a readiness to ‘seize the moment’ for positive change.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article

Ethical permission

Ethical approval was obtained from the School of Health & Human Sciences, University of Essex, UK (4th January 2015) and from the Faculty of Health Sciences, University of Buea, Cameroon (Ref: 2015/346/UB/FHS/IRB of August 15, 2015).

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Michel N Maboh

Susan Stallabrass

Michel N Maboh teaches nursing education, nursing research, theory and practice at the Biaka University Institute of Nursing Buea, University of Buea, and is a researcher at Health Research Foundation Buea, Cameroon.

Peter J Martin is Professor and Director of the School of Health and Social Care. His teaching interests include mental health and practice, nursing theory and practice, and organisational development.

Susan Stallabrass teaches public health and research methods at University of Essex and is completing a PhD exploring the social gradient and vertical health inequalities in the right to health.

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