Los docentes de las escuelas rurales

Data was collected through document analysis and in depth interviews of nurses. Coding and categorisation of data occurred simultaneously with data collection.

Document analysis

Document analysis is a systematic procedure for reviewing or evaluating documents both printed and electronic (computer-based and internet-transmitted) material (Bowen, 2009). He adds that

documents contain text (words) and images that have been recorded without a researcher’s intervention. Document analysis requires that data be examined and interpreted in order to elicit meaning, gain understanding, and develop empirical knowledge (Corbin and Strauss, 2008). The analytic procedure entails finding, selecting, appraising, and synthesising data contained in documents (Bowen, 2009) and generates data as excerpts, quotations, or entire passages that are then organised into major themes, categories, and case examples specifically through content analysis (Labuschagne, 2003 in Bowen, 2009).

There are typically two types of written records i.e. the episodic and the running records (Buttolph and Reynolds, 2012). They describe the episodic record as ‘records that are not part of an ongoing, systematic record-keeping programme but are produced and preserved in a more casual, personal, and accidental manner’. While to them the running record is more likely to be produced by organizations and is carefully stored and easy to access even over long periods of time. Document analysis will be relevant to meet objective one of this study because they describe a historical underpinning of the contemporary ideas, practices and identities that subtly affect our present (Rapely, 2007).

The documents that were targeted included texts on issues related to nurse education from government sources. Policy documents from the defunct West Cameroon Nursing and Midwifery Council (WCNMC) were also targeted but none was found. Documents from other associations were not considered because none of them has assumed the powerful regulatory role once played by the WCNMC. In its time the WCNMC regulated entry into and exit from nursing schools and maintained a register. The aim of studying these records was to get insight to the historical and evolutionary basis of nurse education in the country – the ‘history of our present’ (Rapely, 2007). Documents from government agencies usually come in two forms – policy statements and texts of application. Policy statements usually announce major policy decisions and are signed by the President of the Republic or by a Minister. Texts of application on the other hand usually explain how a policy statement will be implemented. For example a policy statement might announce a new level of training or qualification for nurses while its text of application will provide details on curriculum structure,

student selection criteria, programme management etc. In the past there have been instances where a policy statement is made and text of application only comes out some months or years later. This study took both types of documents into consideration. Excluding all other types of texts and from more diverse sources reduces the risk of being overwhelmed with substandard data and conceptual blindness (Morse, 2007:233) thus weakening the conclusions that could be drawn from the findings.

Prior (2008) suggest four ways to approach documents in research: focusing on the content; focusing on how the document ‘comes into being’; focusing on how the document is used for purposeful ends; and focusing on how documents function independently of their producers. Using any of these approaches will definitely depend on the purpose of the research. Prior (2010:419) explained that focusing on content has been the common approach in sociology, social science and health research with the goal of ‘scouring for evidence’ by concentrating on what is in the text using content, thematic or grounded theory approaches to analysis. The primary focus was on the content of the texts in an attempt to get from them the philosophies underpinning nurse education policies over time. To give the process more structure, the researcher also made use of Charmaz’s (2006:39-40) approach to studying texts. So the focus on content was fine-tuned by establishing the context of the text (i.e. how it was produced, the authors, their purpose and assumptions they seem to be based on), categories within the text (including how they change in sequential texts over time and meanings they imply), any unintended information and meanings and who benefits or is the target of the text. Document analysis was thus expected to provide background and context, additional questions to be asked, supplementary data, a means of tracking change and development, and verification of findings from other methods (Bowen, 2009). Appendix VIII shows a summary of documents analysed during this study and their detail descriptions.

Semi-structured interviews

Fitzpatrick and Boulton (1994) contend that the primary advantage of in depth interviews is that they allow the investigator to focus maximally on the participants’ perceptions of the issue under study

and responses to them, rather than imposing his own categories. This they say leads to a new and more meaningful typology of participants’ concerns.

The interviews in this study were semi-structured and in depth with the initial questions derived from the research questions and then the follow up questions derived from participant’s response and emerging data. Follow up questions were not new questions but questions that probed or explored emerging categories further. Interviews were tape recorded and later transcribed verbatim. The interviews typically lasted between 40-60minutes. Memo writing (Goulding, 2002) also influenced the development of further questions. Appendix I shows a copy of the initial interview schedule designed for the primary interviews in this study.

Analytical process

Once interview transcripts and scanned copies of documents were ready, they were imported into NVivo 10 software for data analysis. The researcher conducted the interviews, transcribed and typed the transcripts personally, all of which offered the opportunity for prolonged engagement with the data. The whole process was guided by Charmaz’s (2006) constructivist approach.

Once documents and transcripts were imported into NVivo, the coding process was immediately initiated. The initial coding was characterised by line-by-line coding (Charmaz, 2006; Glaser, 1978). Charmaz (2006) argues that this this approach keeps the researcher open to the nuances in the data. This initial coding started giving the first indications of what was in the data and resulted in over 600 codes. It also pointed to new questions that will be needed to make later interviews richer. Without applying any coding frame (Glaser, 1978) this process was guided by the desire to identify what the data was actually saying or not saying as well as the first signs of any trends within the data. An example here was ‘administering treatment’ was used to label data describing this activity as a nursing function. The choice of label was determined to cover aspects of the nurse’s expected activity that captures issues of treatment. For example:

“To control the effective daily application of all treatments, diets, and care given to patients” (Chap I MINSANTE Order 22, 1980)

“To supervise and control the rate of medication consumption…” (Chap I MINSANTE Order 22, 1980)

Another example of a line by line coding was “conducting health education” which captured data describing teaching expectations of the nurse for example:

“Give consulters and their family elementary notions about individual and collective hygiene…” (Chap I MINSANTE Order 22, 1980)

“Organise and carryout in collaboration with the local authorities and personalities, health and nutritional education campaigns amongst the population…” (Chap I MINSANTE Order

22, 1980)

“Teach the principal notions of sanitation particularly to young people of the country…”

(Chap I MINSANTE Order 22, 1980)

At times in vivo codes were generated during this phase of coding. For example ‘conceptualising nursing’ and ‘protecting your turf’ emerged from the participants own words to describe certain

aspects of the data:

“…we begin to see a change in mentality, in conceptualising nursing…this is at the level of

education, university, uhmm conceptualising nursing” (Int3:1)

“Of course there is no rationale, there is no rationale! Again it has to do with what we call

protecting your turf, enh protecting your turf! (Int7:1)

From this first coding new questions still within the objectives of the study were generated and the process continued on to focused coding. Focused coding is about using the strongest or most significant codes to categorise data incisively and completely (Charmaz, 2006:57). Focused codes were thus considered primarily as those that could be applied to data across the different sources and

were generated from initial codes. For example, a number of initial codes demonstrated the itemised functions of the nurse in different settings. During focused coding, ‘describing the nurse’s role’ emerged as a focused code that increasingly captured data describing expectations of the nurse across data sources. It absorbed many initial codes for example “administering treatment” and “conducting health education” (seen above) as more data was found to strengthen the code as an emerging

subcategory. Based on the amount of evidence present in the data, codes were raised to subcategories and categories as will be demonstrated in the results chapter. In another example, in-vivo codes rose to become focused codes and eventually sub-categories. The code “conceptualising nursing” was fleshed out with data from different interviews capturing participants’ expressions of a more scientific approach to educating nurses:

“There become a need to adequately train people in this domain so that we shouldn’t only

train people who will come and give physical care, but it should be broad based, have a multidimensional approach” (Int1:2)

“We want them to understand if you are carrying up you have the principles that are backing you up and we insist on that…because we need you to show a difference between the one that you call a senior nurse and you. And so you cannot just sit there and wait for the doctor to come and order a nasogastric tube you should be able to assess and see that the patient needs a nasogastric tube yes!” (Int10:1)

“Conceptualising nursing is a way of nursing 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? This is where there is a big problem” (Int3:5)

Evidence was collated by comparing data, codes and even the categories which resulted in the merging of some focused codes and the elimination of certain initial codes. The rejected codes were mainly generated from initial coding and were not supported by sufficient evidence from the data to

strengthen them. Some of the rejected codes included: “categorising from public service”, “uplifting nursing”, and “compromising quality of care”.

The constant comparison and the use of theoretical sampling helped to move some focused codes to categories as their properties became more complex and demonstrated viable links between subcategories. Theoretical sampling means finding important evidence to support emerging categories and clearly define their properties (Charmaz, 2006). As certain codes moved from initial codes to categories e.g. ‘harmonising nursing programmes’ both the data and study participants were sampled to find more data explicating this category. The process did not lead to selecting different study participants but led to follow-up discussions with participants to address the emerging categories in more detail. As will be shown in the discussion chapter, theoretical sampling was done to establish the meaning, method and goals of harmonising nursing programmes. Appendix X shows an example of code and it’s supporting data as exported from NVivo to facilitate analysis and discussion. The process continued until theoretical saturation was achieved. This is the point at which ‘fresh data no longer sparks new theoretical insights nor reveals new properties of emerging categories’ (Charmaz, 2006). It is questionable whether such a point can be literally reached prompting Janice Morse (1995) to argue that most researchers just proclaim it, rather than proving it. In similar arguments Dey (1999) says the term can be easily misinterpreted as it does not truly fit a process that continues until all data is coded. It is easy for ‘saturation’ to be declared after coding the first few interviews if the researcher is just looking for a point where no new insight is emerging. Dey‘s point therefore is that the researcher proves saturation by actually doing the work. Thus he adds, the researcher should talk of categories generated by data rather than saturated by data and proposed ‘theoretical sufficiency’ (p.257) as a better term for grounded theory. Charmaz, (2006) concurred by warning against the risk of ‘foreclosing analytic possibilities’ resulting in ‘superficial analyses’. In this study the point of theoretical saturation was that point at which the categories had sufficient supporting data to demonstrate their properties and the links between them.

Coding was greatly facilitated by the use of memos from the onset of the coding process. The initial memos picked up ‘surprise’ elements in the data and questioned their occurrence and their

implications. It allowed the researcher to put down his thoughts with respect to the emerging codes in a reflexive manner while identifying directions being evident by the codes. For example a memo titled ‘stopping ministry of health training’ reflected the researcher’s astonishment at the emergence of what was perceived as a very radical and entirely unanticipated position. Notes were made on how this will play out and how it will be received by other participants thus provoking questions for follow up interviews. While some of the memos were short, others were comparably elaborate defining the direction for theoretical sampling in some situations. In Appendix XI an example of one of the analytical memos is shown. This memo explored the researcher’s thoughts on the emerging ‘Role of the nurse’ sub-category generated from document analysis. The highly itemised description of the nurses’ functions revealed a mostly technical competence expected of nurses. This expectations were compared with ‘Conceptualising nursing’ a sub category emerging from interviews for the links between the two. As the memo shows, the need for conceptualising the nurse education system could be linked to practical skill orientation at the conception of formal nurse education. Seeking training that only prepared the nurse to carry out specific task may have contributed to what participants in the interview described as a very basic and technical training orientation. Questioning this further link required theoretical sampling in subsequent interviews as well as already collected data.

As analysis progressed, memos and theoretical sampling gradually helped to ‘flesh’ out the emerging categories. The links between the categories were sought as well as that between the subcategories within the same category. Looking for this connections and weaving them towards a theory is what Charmaz (2006:115) describes as theoretical sorting. Using this process, the links between the categories was established as shown on figure depicting the summary of results. The analytic process did not stop at seeing this clear links as more questions were now asked of the results. The goal was to transform those links into a defensible model that demonstrate a more complex interaction between the categories. A sort of theoretical coding was applied at this point. This expression was used by Glaser (1978) to describe the process of conceptualizing the relationship between substantive codes to incorporate them into an emerging theory. Charmaz (2006) noted that if skilfully used these

codes could add a ‘sharp analytic edge’ to the research. Glaser (1998; 1978) presented coding families that could be used in the process of theoretical coding. While these were not applied to this study directly, they influenced the search for the link between the eight major categories that emerged from the analysis. From this process the complex link was gradually constructed linking the categories such that some categories emerged as ‘central points’ and others became the links between these points in the emerging theory as demonstrated in chapter five.