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The history of nurse education in Cameroon as emerging from the data provides a context that fosters understanding of other emerging categories from the data.

The origins and conception

Formal nurse education was introduced by the colonial powers:

“In fact you can’t separate it from colonialism” (Int1:2)

Nursing practice and training was thus established as part of the western-styled health care system. Its ‘modern’ format was not based on indigenous practice rather it was an imposed model.

The ‘nurse’ at this time learned by assisting the doctor or nurse. In the French section of the country the ‘nurse’ learned under the doctor:

“Somebody coming to stay with a doctor or so and then eventually learning a few things, acquiring knowledge, you know, in dispensing drugs, in dressing a wound and in…other simple situations of care” (Int4:2)

In the English section the ‘nurses’ trained under nurses who came from Nigeria.

“…they were the Nigerian nurses, staff nurses who were running our hospitals” (Int4:23)

The apprenticeship model was used to train the dressers. In East Cameroon apprenticeship took place under the doctor while in West Cameroon it also took place under nurses thus giving it a ‘nursing’ touch.

“The first nursing programme that started in East Cameroon was in 1930 in a small town called Ayos…It was a nursing aide school, recruiting mostly men and again the main actor in those days was Dr Jamot” (Int7:2)

The doctor needed assistants to help him with his practice. The choice of males may be a reason why there were more males than females in nursing. This situation established and early physician influence on nurse education.

In West Cameroon training was styled after the British model introduced in Nigeria.

“So the British again started the first training school, I think was in Victoria around the 1930s. Again I think it was a state registered type of nursing program or midwifery program based on the British system” (Int7:5)

So formal training started with an actual nursing programme thanks to colonial administrative structure. The French, British, Nigerians, and foreign physicians all influenced the creation of the nursing profession. Here also, the root of two fundamentally different orientations to nursing is seen.

Contextualisation

The code ‘contextualising nursing practice’ was used to capture how nursing was adapted to local needs. Further analysis changed it to ‘evolving contextualisation of nursing education’ to show that it occurred over time.

Nursing was part of western-oriented healthcare system:

“the local context was such that of course health systems in those days were meant to serve the white establishment and the colonial masters who were there and those who were working in the big cities” (Int7:1)

The health system was for the foreigners and those locals who worked with them. Nurses were trained to be part of such a system implying that the training was not based on local care approaches.

“…when the western medicine came, they rejected them, they relegated them to the background on the basis that they were not scientific so involved their own” (Int1:6)

The implication is that ‘modern’ nursing built from that system failed to incorporate local models in practice and training. Therefore the inherited system of nurse education at independence was a very foreign system.

Overtime the contextualisation of nursing programmes occurred gradually especially in the area of primary health care where nursing students learned about traditional health practices.

“…the things that have value…we try to readapt them, so this new practice – formalised practice is not all just abstractions but contextualised.” (Int1:16)

Community health nursing courses were the principal way in which nurse education validated aspects of indigenous care. Some programmes include courses that focus on culture and indigenous practices

“There are some courses dealing with traditional medicine, influence of traditional medicine, aspects of cooperation between traditional medicine and orthodox practitioners so it is a synergy yes!” (Int1:20)

There is therefore no evidence that indigenous care models have been integrated into nursing programme designs. Learning about the practices and their value is different from incorporating the indigenous models into the curriculum for nursing.

Early education structure

Initial codes here included ‘describing education structure,’ ‘entering nursing programmes’ and ‘funding mechanism’.

In the English subsystem the GCE Ordinary Level certificate with a pass in the science subjects was the entry requirement:

“In our own time we entered with the GCE ordinary level to the state registered nursing and…with that qualification you must be a holder of the science subjects…” (Int12:1)

A significant level of general education was required including knowledge of the sciences. Thus basic sciences were seen as an essential pre-requisite to study nursing. In East Cameroon the entry requirement for the nursing aide programme was the First School Leaving Certificate

“You know that Ayos is the first centre of training of nurses it started training nurses then…at the level of – first school leaving certificate and then you have nine months”

(Int6:3)

Staff nursing candidates in addition had to pass through a pre-training probationary course:

“…for you to go and have a knowledge of just the environment, the practical work in the hospital before you go…some people decided to even run away because when you talk of

uhm a bed pan enh! A patient is going to stool you carry the bed pan to go and empty, you are there to go and wash the toilet, you are there to go and bathe the patient.” (Int5:5)

Probationary training was therefore a kind of apprenticeship that was also used to gauge the candidates’ readiness for a nursing career. After reunification the entry requirements were modified according to the variety of programmes:

“…After that there was a system that there are nursing assistants who are doing nine months training…breveté nurses who were entering with O-level or brevé in the French system and

who are doing 2 years and there were diplome nurses who were training with probatoire or A-level. I think 2 paper and they were doing three years” (Int6:1)

There were now two levels of pre-registration practice before the SRN programme seen as the professional entry level. This established a number of pre-registration training options.

After the introduction of these different levels of training there was a transition scheme from the enrolled to the state registered nursing programme:

“…at first it was that when you did two years and you put in two years of service you could go directly into the diploma course otherwise at the second year of studies you could now

enter next year for the diploma course. But then later on they asked that we should work for two years then sit in for a concours to enter to do the diploma course…” (Int10:2)

The transition scheme allowed enrolled nurses to get reduced study period in the SRN programme. There could be direct continuation upon completing the enrolled nursing training or after two years of working. Eventually this transition scheme was abolished.

After the SRN programme, it was possible to pursue specialisation studies:

“...you specialised in midwifery …psychiatry …periculture...pharmacy and all the rest. And that training was for two years, two academic years. After the two academic years now you had to go to the field and work and then after, to go…higher in what they used to call in our time the advanced nursing school in Yaounde CESSI” (Int12:1)

Clinical specialization programmes were available as post-registration programmes after two years of working. There is persistent emphasis on clinical experience as a precondition to further studies.

Physician domination

This subcategory emerged as evidence showed physician domination of nurse education. The main code here was ‘setting nursing as assistants to physicians’. Historical events set the doctor above the nurse from the very onset:

“Although we are not having back-up documents, the truth is that the nursing profession at the beginning in Cameroon…during the colonial period – who was the doctor? The doctor

was the colonel or the well, the highly grade officer of army. He was the one who was called doctor. And the person, I can say the body guard of that colonel was the one that was called the nurse. So that is when our problem start in this country” (Int6:1)

Nursing was thus conceived not as an autonomous profession but as a supporting role to physicians. This is an aspect recognised as a key underlying obstacle to nurse advancement in the country. The physicians were already established in the healthcare system:

“Get this point very well! ...the first stakeholder, the people who we may call – they were the doctors na! And so therefore they were simply looking for people to carry out as robots their instructions, and so therefore the nursing concept in the practice was never their boredom.” (Int3:2)

Physicians were most influential in designing nurse training and so focused on skills that will make nurses useful to physicians. The focus was therefore on skills development and execution of instructions. So the conception did not perceive nursing as autonomous.

This perception continued with the introduction of the SRN programme in East Cameroon:

“The people graduating with SRN were simply called doctors - in fact they were assistant doctors in East Cameroon” (Int4:1)

“…Why called assistant doctors? Because the conceptual framework of nursing as a specialty was never their call…” (Int4:2)

The trained nurses saw themselves as assistant doctors because their training lacked the nursing professional framework to see themselves as autonomous professionals with a collaborative but distinct role from that of physicians.

The passage of time saw the strengthening of this physician domination:

“Up till now nursing profession is, I can say is conceived in Cameroon as a basic, as a support of medical profession which is not true enh! It is not true! That is where the problem is” (Int6:7)

The era of liberalization of higher education further strengthened physician influence in nurse education:

“The present scenario is that physicians have money to open their nursing schools and employ teachers who are there to come up, so the qualification is never their problem.”

Serving as proprietors of nursing schools gives physicians, significant influence on both the training programme content and staff recruitment. These two factors increase their influence on nurse education in the recent era.

Category One: Multiple Birth and Formation

The history of nursing education in the country emerged from the data as one that was born out of colonialism and not indigenous practices. An emerging pattern linking the history, the beginning of formal training, the structure of training through the influence of physicians from the early days is seen to be influencing the evolution of nurse education. The pre-educational apprenticeship model dominated by physicians, the French and English colonial influences, are all part of a narrative that show how nursing was conceived, born and groomed in its early years. It shows a profession that was created and influenced by others as well as historic events like the reunification of Cameroon.