Constructing Category Two

After its birth and early years of nurse education, key subcategories were identified showing the evolution of the profession

External influences

The growth of the nurse education system was influenced subtly and overtly by external forces. The focused code ‘recognising external influences’ developed from ‘identifying external individual influences’ and ‘projecting collective external influence’ helped to capture data showing this.

Some nurses were able to travel abroad for both undergraduate and postgraduate studies:

“Most people who had the first degree were trained outside, either in Nigeria or in London” (Int2:1)

Foreign exposure would have influenced their perception of nursing, style of practice and content for advocacy. If not at macro-level such exposure would surely have influenced at the micro level.

“I cannot really say what happened but I know that Nigerians were here and everything we did here was more of Nigeria. So even the nurses were trained from Nigeria and sent here. Some started here…But most of them were trained in Nigeria” (Int5:1)

Foreign models influenced pioneer educators and programmes. This influence caused nursing programmes in West Cameroon to be designed exactly after the Nigerian format. Nurses who studied in England came back to teach in the early nursing programmes:

“…teachers came from the old nurses who had been trained in England and those who had been trained in Nigeria…” (Int7:5)

The culture from Britain and Nigeria emerged as one of the dominant external influences on nurse education in West Cameroon.

Candidate selection

Initial codes like: ‘questioning candidate’s motivation’ and ‘screening unsuitable candidates’ were used to capture relevant data. The codes were later merged during focused coding into ‘visiting entry into nursing programmes’ from which the sub-category ‘candidate selection’ emerged.

As already seen in 4.2.1 entrance to nursing school was by written and oral exam. A final screening exam took place just after start of school:

“It was a written exam, it was like you have studied for these 3months nah, and you were writing the exams…they are going to test for all the things you have done. So if you pass then continue, if you don’t you…go out of the school.” (Int10:2)

The selection process was multi-layered after which the successful candidates were allowed to continue their nursing studies.

In recent years candidates just take a single entrance examination:

“I remember even here there was a time in this hospital we had some…a disabled student or girl who had to join the nursing field (Int5:1)… But if they were interviewing as they did in

our own days they will see that this student, this girl or student cannot be a good nurse because she cannot run physically.” (Int5:2)

Nurses think that taking off the interview part of the process makes it difficult to screen candidates whose physical capabilities are unsuitable for nursing. This is thus perceived as dilution of the standards and status:

“So one of the reasons that made nursing not to be regarded was that the entry qualifications were not well defined” (Int1:7)

A consequence of this is the perceived lowering of the status of nursing in the country.

Polluting nurse education

‘Polluting nursing education’ emerged as an in vivo code representing data on nurses’ perception of the creation of pre-registration certificates. The ‘pollution’ is associated with the francophone influence on nursing education:

“…But is just after that that this people brought this thing of 2years and 1year, that was around 1964. That is when they started talking about nursing aide and brevete nursing.”

(Int5:1)

The creation of nursing assistant programmes was therefore not appreciated by nurses at the time. It threatened the professional value of nursing:

“We told them that nursing was being polluted and that we will lose meaning that we had acquired from the British training via Nigeria. The British training was being polluted by these Francophones” (Int4:2)

The inherited Anglo-Saxon approach to nurse education was a source of pride for Anglophone nurses. The introduction of lower programmes was taken as an affront on this culture. Nurses tried to convince the authorities against pre-registration programmes:

“We…wrote a memoir to inform the ministry of health that we were spoiling nursing with this multiplicity of training, and…growth in nursing will be hampered. We were envisaging a single cadre that SRN cadre…” (Int4:3)

The SRN diploma was perceived as the right minimum level training for professional practice.

Hospital-based training

From birth through its early years nursing programmes remained under the ministry of health and were run from hospital-based schools:

“These diploma programmes or hospital based programmes are meant to train those nurses who will much more stay at the bedside…the main focus is to train that person who will nurse at the bedside” (Int9:2)

This location facilitated a training model where students easily moved from the classroom to the ward for clinical sessions. There was a strong focus on bedside practice or clinical skills as compared to other important non-clinical nursing skills:

“I will tell you that even when we receive them here they are still lacking in the research work” (Int10:5)

This focus on clinical skills presented challenge for nurses who pursued further education. They had difficulties in acquiring knowledge and skills in research.

Another characteristic of hospital-based training is the use of a national curriculum:

“…health has one programme for all the schools of the same category, everything and they the ones supervising you see from beginning, from competitive exam until they are going out…so that all of you come out with the same standards and everything.” (Int8:1)

A national curriculum enforced by the ministry of health was seen to guarantee a similar learning experience for every student nurse. In addition the programme is seen to be ‘professional’ by some nurses

Keep the SRN level, that level brings – starts bringing professional nursing” (Int3:5)

The argument is that the programme is valuable and should be retained because it is an acceptable level for entry into professional practice. Its strong focus on multifaceted clinical skill and professional values development is its main strength.

The francophone perception

This subcategory developed from the initial code ‘a limiting francophone perception of nursing’ to represent data showing how the politically dominant francophone subsystem see nursing. This perception of nursing never saw nursing developing beyond the diploma level

“There is still one francophone driven ideology that does not see nursing beyond the diploma level. That is one, and that is very, very fundamental, and given that they are in the majority they are holding everybody back. It’s a big problem” (Int7:5)

Nursing is not seen as an autonomous profession that can train its members, right up to doctoral levels.

“They don’t see the nurse capable of doing research, they don’t see the nurse even becoming a PhD, doing research and improving the quality of nursing.” (Int7:6)

“They don’t see nursing influencing and setting the pace for the role of nursing in the overall health policy and in the overall policy of providing health care services to the rest of the country. “ (Int7:7)

The nurse’s potential to become a researcher who can use research evidence to contribute to improving healthcare quality and health policy development is not recognised in this view. This view point also supports the strong emphasis on clinical skills development at the expense of other skills needed by the nurse.

If the Anglophone perception was dominant, participants predict that the profession would have advanced at a faster pace.

“If we were only Anglophones we would have been like Britain and America. It is because we are joined to them and most of them in the ministry are those in policy making. So they are the ones who are tying us down, and to fight through them – we are in the minority – it’s difficult.” (Int8:6)

Changing the perception of the politically dominant culture is a challenging prospect for nursing. So moving nurse education forward will include changing the perception of not only the majority but also of the dominant political culture.

Advanced education at CESSI

There was significant data on CESSI which was created as the most advanced institution for nurse education in Cameroon in the mid-1970s.

The programme content revolved around administration, teaching and research methods. However, research is not mentioned in the curriculum documents of the school as a main objective:

“During the CESSI programme there were three important courses: research methodology,

administration and teaching methodology.” (Int12:2)

So the programme was directed at training teachers and administrators of nursing schools and nursing services. It did not have an academic orientation even though it was domiciled at a university campus:

“It was not really academic it was basically administration again opening in university level!” (Int7:8)

The university lodging added the sense of higher education but the award remained a diploma which was uncommon for typical university based programmes. The school was created to meet the needs of French Africa and did not take into consideration the English-speaking nurses in Cameroon:

“Training there was, was purely in French, so you can imagine! You must give credit to some of our candidates who left Bamenda in those days who are nurses and were able to cope in that school without necessarily having a French background.” (Int7:5)

For Anglophone nurses, succeeding in CESSI required that they overcame the hurdles of studying in language they did not master.

Some years later, without explanations training for Cameroonian candidates was later suspended

“You know…they came and closed it down for Cameroonians. I don’t know, it looks like they say the school is still going but not for Cameroonians” (Int8:1)

The reason for the suspension of this training remains unclear as until the university came no other programme prepared nurses for advanced roles CESSI was created to achieve.

Suspension of training

The suspension of SRN training occurred at some point in the growth process:

“…that gap was almost 10-15years enh!” (Int10:3)

“Now before the bachelors program there was a gap in training in Cameroon. Precisely between 1987 and 1997 yes, about a ten – year gap” (Int7:1)

The University of Buea stepped in in 1997 but the SRN training was probably still under the moratorium. The reason for this moratorium was not evident even in studied documents. However it was associated with the economic crises that started in the late 1980s and early 1990s:

“So for some reason they said there was an economic crisis and as such they could not operate nursing schools and train the nurses that were required. However, the…sole medical

school in the country in the University of Yaoundé continued to train medical doctors but no nurses were trained for this ten year period.” (Int7:2)

Suspending nurse training and maintaining physician training, is perceived as discriminatory against nursing.

The consequence of the suspension is that there was a manpower shortage:

“…this lack of training led to an incredible shortage of manpower. A decade is too long!” (Int7:3)

The shortage of nurses generated a need for more nurses, a need aggravated by the reduction in mentorship opportunities:

“The gap was too much because when we were in school we met old nurses who had been training, who had been working and they trained us and we picked at least our models from them. Now you go there the person that is there had no training from an older nurse, no experience, so she is working with what she has.” (Int10:2)

There is therefore an added value associated with the opportunity to work with experienced nurses for young nurses. This was lost during the suspension because newly recruited nurses had fewer nurses to mentor them.

The suspension also led to a situation where nursing assistants became the dominant force within nursing and assumed leadership positions.

“They were doing only…nurse assistants…many years like that. Finally now before that they were managers of places, health centres, they were the chiefs of post and all what not” (Int8:2)

So there is a scenario where nurse managers were actually nursing assistants and not nurses. With their training based on taking instructions these nurses being in charge of nursing services were thus acting beyond their competence and would have strengthened physician domination.

This emerged as a subcategory covering data reflecting how nursing education was driven by healthcare needs. Codes used here included ‘increasing need for quality healthcare’ and ‘meeting nursing shortage’.

The basis of development of nursing was the need for healthcare

“the basis of this development has been the increasing need, the ever increasing need to render high quality health care especially in this era of increasing human health needs” (Int1:1)

There was need for people to carry out certain health activities to meet the needs of the population:

“In the francophone area because we were not having too much…health facilities, we were limited (Int6:2)… And then later on there is need of qualified personnel to carry out some activity and they started training of nurses” (Int6:2)

In private practice, doctors opened training centres to train their nurses during the period when training was suspended:

“…doctors in particular decided to train their own nurses in their clinics for their use.…when they finish they cannot hire all of them, the rest go into private practice…and we don’t even know whether to qualify them as the nurse’s aide, nursing assistants or even the

qualified registered nurses that we know.” (Int7:3)

The idea was to train for private use but gradually they could not use all the nurses and the others went into private practice. This training posed difficulties because the level of nurses trained could not be ascertained.

Training of nurses at all times was influenced by needs: either physicians’ prior to formal training, the healthcare needs of the colonialists, the healthcare needs of the public health system, or of physicians in private practice.

From formation through its growth into ‘adolescence’ the evolution of nurse education has been influenced by many factors that make it difficult to define its ‘shape’. External influences defined the structure and implementation of the first programmes. The reunification of the two Cameroons brought together two very different perspectives (Anglophone and francophone) bearing on the young profession. The former saw nursing more as an autonomous profession while the latter saw it more as a ‘supporting’ profession to medicine. Training was built on a hospital-based model which emphasised clinical skills development as opposed to research and other non-clinical skills. Nursing training due to the economic crises was later suspended in favour of training assistant nurses. The overarching goal of training was for consumption i.e. meeting healthcare needs in public and private practice. These subcategories reflect a growth pattern that is not organised or planned over the long term. It rather reacted to surrounding circumstances hence the name reactive growth and development.

4.2.3 Constructing Category Three