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The UK Economic and Social Research Council ESRC (2010) recommend guidelines based on six principles which will broadly fall under research integrity, respect for persons, and beneficence. In the light of this and other ethical recommendations the proceeding discussion demonstrates the ethical measures maintained during the study.

Justification of the Study

At least 95% of research is indeed research for things that have been found long ago and many times since (Andreski, 1974). Based on this assertion, the researcher will need to show that a particular research is necessary. Iphofen (2009) suggested the following three questions to help a researcher make this decision:

Can the required information be found elsewhere?

Could the project be carried out as a secondary research?

If the researcher can answer ‘No’ to all these questions, then the research is viable as a primary research (Iphofen, 2009). In this case, no previous study had examined the development of nurse education in Cameroon and if such a study has been carried out it has never been made public through any scientific publication. For this same reason the study could not be carried out as a secondary research. Similar studies may have been carried out in other countries but such studies do not address the particular situation of Cameroon.

Research Quality and Design

It may be an accepted maxim that a poorly or improperly designed study involving human subjects…is by definition unethical (Rutstein, 1972). Therefore poorly designed research is inherently unethical since it wastes the researcher’s and participants’ time and energy if the results are less than useful, likely producing more dis-benefits such as contamination of the field by discouraging participants from future research engagements, which may be of better quality (Iphofen, 2009). This study was well designed with the goal of identifying the best method to achieve the research goal. The research methodology finally adopted was found adequate to meet this purpose by the principal and co-investigators and the University’s research ethics committee. The choice of methodology was thus determined not so much by researcher’s preferences as by its potential to answer the research questions.

Application for Approval

As a research student the authorization to conduct this study was obtained from the School of Health and Human Sciences, University of Essex. Ethical clearance was also sought from the Faculty of Health Sciences, University of Buea and the Regional Delegation of Public Health for the South West Region in Cameroon. Appendix IV, V and VI show respectively, the ethical approval from the University of Essex, the ethical approval from the University of Buea and the authorisation to collect data from the South West Regional Delegation of Health in Cameroon. Applications for access to archive services were also made and submitted to the relevant authorities for the collection of document samples.

The Principle of Beneficence and Non-maleficence

This principle obligates the researcher to do no harm (non-maleficence) and to maximize possible benefits as much as possible (Tappen, 2011). According to Polit and Beck (2004) most researchers consider that this principle contains multiple dimensions including the following:

a. Freedom from harm

The ESRC (2010) states that harm to research participants must be avoided in all instances. Researchers according to Iphofen (2009) have to be aware of the range of ways in which their activities can cause distress [harm] to others. Such harm could be physical (e.g. injury, fatigue), psychological (e.g. stress, fear), social (e.g. loss of friends), and economic (e.g. loss of wages) (Polit and Beck, 2004). No form of economic, social or physical harm to participants was anticipated in this research. The questions did not address overtly controversial issues that may criticize any person or organization and also did not include any experiments or activities that could lead to physical harm. That notwithstanding it’s necessary to heed Oliver’s warning (2003) that, participants can have very strong feelings when it comes to certain issues of/or at work. To guard against this, interviews were conducted in a manner that did not challenge the participants or put them in embarrassing or stressful positions. Participants’ views and positions were neither criticised nor rejected. Interviews were conducted at the convenience of the participants to avoid any chance of fatigue or other physical discomfort.

b. Freedom from exploitation

Exploitation according to Polit and Beck (2004) could be overt and malicious (e.g. sexual exploitation, use subjects’ identifying information to create a mailing list, ...etc.), or more subtle (e.g. subjects agree to participate in a study requiring 30mins of their time and the researcher goes back to them 1 year later for a follow up. He might be accused of not respecting the previous agreement and of exploiting the participant – researcher relationship). This researcher adhered to the terms of the consent agreement and did not attempt to take any form of advantage of the participants. No

promises of rewards were made, no subtle or overt threats were made and no rewards were given to influence participation.

c. Maximizing benefits

It is always worthwhile to consider if there are ways in which participants may gain anything from taking part in a research, though it is not usually essential that the participants gain something tangible from it (Oliver, 2003). Participants in this study earned no direct benefits from taking part in this study. However, it is possible that the adoption of the recommendations of this study could end up being beneficial to all stakeholders including nurses. The community will benefit from better care services because of the strong potential of the recommendations to improve nurse education and therefore care delivery.

The Principle of Respect for Human Dignity

According to Tappen (2011) individuals should be treated as autonomous agents, meaning the ability to make decisions. Other individuals are therefore expected to respect such a decision unless they as Tappen (2011) continues are detrimental to others. This principle is again subdivided into two according to Polit and Beck (2004):

a. The right to self-determination

Research participants must take part in research voluntarily, free from any coercion (ESRC, 2010) without risking any penalty or prejudicial treatment (Polit and Beck, 2004). Participants therefore have the right to answer or not answer the researcher’s questions or not to participate or to withdraw without fear of any form of reprisals. Despising this right means not respecting the dignity of a person. According to the National Institute of Health NIH (2009), a lack of respect for persons is shown when a person is denied freedom to act on his or her decisions or when information needed to make a decision is withheld without a compelling reason to do so.

In this study the participants were informed in very clear terms that they had the right to not participate in the study, to back out of the study, to have their questions answered and their doubts

clarified etc. They were no threats of punishment for refusal to take part in the study, and neither was any form of coercion applied. No form of reward was also promised or given to the participants.

b. The right to full disclosure

Full disclosure means that the researcher has fully described the nature of the study, the person’s right to refuse participation, the researcher’s responsibilities, and likely risks and benefits (Polit and Beck, 2004). It is this definition that makes this right and the right to self-determination inseparable. You can’t expect an individual to objectively and freely make his own decisions if some information is hidden from him or her. This contributes to why the ESRC (2010) explicitly stated that research staff and participants must normally be informed fully about the purpose, methods and intended possible uses of the research, what their participation in the research entails and what risks, if any, are involved. However, the ESRC recognizes exceptions due to the nature of the research and provides specific guidelines in such situations. In this study, the participants were given information on the goal of the study, why they are selected, their other rights, and the researcher’s responsibilities before, during and after the collection of data. Their questions were also answered and those who decided not to participate after full disclosure had their decisions respected.

The Principle of Justice

This principle according to Tappen (2011) addresses both the denial of a benefit without a good reason or imposing a burden unequally. The principle is divided into the right to fair treatment and the right to privacy.

a. The right to fair treatment

Fair treatment includes features like: fair and non-discriminatory selection of participants based on research requirements; respect for cultural and other forms of human diversity; non-prejudicial treatment of those who decline to take part in the study; honouring of all agreements between researchers and participants; access to research personnel at any point during the study; participants access to professional assistance for any harm incurred during the study; debriefing if necessary;

courteous and tactful treatment at all times (Polit and Beck, 2004). This extensive list shows the magnitude of the researcher’s responsibility towards the participants.

Fairness was guaranteed during this study according to the prescription of this principle. Participants who met study criteria were selected based on their availability and consent and no other subjective or discriminatory reason. They were given the researcher’s address and contact information of the University of Essex in case they needed to verify any of the information the researcher gave them.

b. The right to privacy

When people accept to take part in any research they are opening up their lives to varying levels of scrutiny. They may be expected to share their deepest and most secret thoughts with researchers they may not know, express their views and positions on controversial issues, sacrifice the privacy of their homes, their health situations, their family lives etc. depending on the type of study. They will therefore want to be assured and reassured that this ‘private’ information is not made public. This can be ensured either through anonymity or through other confidentiality procedures (Polit and Beck, 2004).

In this study, participants’ identifying information was not used during interviews. During the interview, transcription and presentation of data, participants were identified by false names which had no link to their real identities. The citations from the data were also made using labels that protected participants’ identity. Documents carrying participants’ information like the signed informed consent form were carefully locked away in a cabinet and shared with no one else. If for any overarching ethical reason someone else has to see these documents, they must sign a confidentiality pledge. Such documents however, will be destroyed as soon as possible after the research process is concluded. The research results were also released in the aggregate (Polit and Beck, 2004) and not individually.

Informed Consent

This has to do with the researcher obtaining the participants agreement to participate in the research. According to Polit and Beck (2004) informed consent means that participants have adequate information regarding the research, are capable of comprehending the information, and have the power of free choice, enabling them to consent to or decline participation voluntarily. This consent according to Pera and Van Tonder (2005) should be sought within a moral framework to ensure autonomy, confidentiality and anonymity; telling the truth and guaranteeing non-coercion and non- exploitation of the individuals concerned. These two positions clearly indicate that for a participant to decide to participate in a study he must have been given full information about the study and his role in it in an atmosphere that is free, cordial and non-coercive. Iphofen (2009) emphasizes the phrase ‘voluntary informed consent’ implying the participant was able to choose freely to give consent and subsequently participate in the research. The researcher has to equally ensure that the participant is competent and mentally fit enough to give consent after receiving information.

To obtain informed consent in this study, the researcher provided the potential participants with the full address of the supervisory institution and the researcher’s own address as well. They were equally told why and how they were selected for the study. The purpose of the research, the type of data and data collection method including the approximate amount of participant’s time to be taken during the interviews (maximum one hour per interview) was communicated to the participants. They were informed that there were no potential risks and no benefits involved in taking part and how their rights were to be respected. Considering that this study was qualitative with a grounded theory methodology, it was difficult to predict the flow of questions, the duration and frequency of interviews because these will all be determined by the emerging data. To circumvent this issue there should be an informed consent statement at the beginning with as much information as possible as well as adoption of the process consent (Polit and Beck, 2004) i.e. the researcher will continually renegotiate consent with participants during the course of the study as necessary. However, during the study the researcher explained to the participants that there was always a potential for subsequent interviews as the analysis was going. They were asked to give permission to be interviewed a number

of times as necessary and at their convenience. The informed consent document used in this study is shown on Appendix VII.

When the above information had been given and participants had their questions answered, a number of them declined. Of those who gave consent, one preferred not to take part in a second interview if it became necessary. However, all study participants expressed satisfaction with the study and complemented its potential to positively impact nurse education in Cameroon.

3.3 Conclusion to Chapter

In this chapter the argument for the study design was made. The researcher argued that grounded theory methodology was the most appropriate method to analyse nurse education development in Cameroon. In line with the researchers ontological and epistemological position the researcher demonstrated the rational for the selecting Kathy Charmaz’s constructivist interpretation of grounded theory. The researcher argued that the reality of the nurse education experience in Cameroon and its future direction could be created by the interaction between nursing and its environment thus presenting potentials for unique context-specific differences from international trends. The discussion on the application of the method in the study was also made with the goal of providing rich descriptions to demonstrate trustworthiness of the study process. Ethical considerations applied before, during and after the study process were also described. The next chapter provides a constructivist grounded theory interpretation of the study results. It shows how the subcategories and categories were created from the emerging data and establishes the link between the emerging categories.

CHAPTER FOUR

INTERACTING FACTORS INFLUENCING THE EVOLUTION OF NURSE EDUCATION IN CAMEROON

4.0 Introduction

A constructivist interpretation of grounded theory is applied in the presentation of the study results in this chapter. The data was collected from document analysis and in-depth interviews of study participants. The results are presented in two parts. The first part deals with results from document analysis and end with a summary model leading into the second part. The second part is based on data from the interviews which also builds from and incorporates the document findings and ends with a more elaborate model. This model shows the emerging categories and the interrelationship between them.