An inductive, descriptive, qualitative design, based on Strauss and Corbin [18] Grounded Theory, was used to collect and analyze qualitative data on barriers that hinder nurses from using their health advocacy role in practice in Ghana. Qualitative data was obtained using interviews to enable the Ghanaian nurses to share their views on what hinders them from performing their ethical and professional role as health advocates.
The study was conducted in three purposefully selected regional government hospitals in Ghana to ensure cultural homogeneity of the results. These facilities serve as referral, research and teaching hospitals for nurses and other health professionals, and facilitated a comparison of the findings during the data analysis, which is a key feature in Grounded Theory [19].
Participants and Sampling
A sample of 24 participants, seven male and 17 female professional nurses, were interviewed, their education ranging from Diploma to PhD qualifications. The age of the participants ranged from 31 to 51 years. Their years of clinical nursing experience ranged between five years to 15 years.
Open and theoretical sampling techniques were used to identify the 24 nurses, these being the main sampling methods used in Grounded Theory [20]. During the initial stages of data collection, open sampling was used to select and recruit the first five professional nurses who met the inclusion criteria in each of the regional hospitals, equating to 15 nurses. The additional nine participants, consisting of three from each hospital, were recruited later using theoretical sampling to maximize the opportunity to establish variations among concepts and to densify categories through constant comparisons. The sample size was based on the data saturation principle [21], which means that sampling stopped when no new information was obtained.
Data collection and analysis were conducted concurrently between August 2018 to February 2019, this being in line with Grounded Theory and fully accepted in qualitative studies [19, 22]. The individual interviews were conducted using a semi-structured interview guide that was developed by the researchers, according to the study objective. The semi-structured interviews approach enabled in-depth probing while permitting the interviewer to keep the interview within the parameters outlined out by the objective, as supported by Berry [23]. The interviews were conducted in English, the formal communication language in healthcare in Ghana, lasted 60 – 90 minutes, and were audio-recorded, with field notes being made as part of data collection.
The recorded interviews were transcribed verbatim within 24 hours of collection and saved in Word documents, after which they were uploaded into QSR International NVivo version 12 for Macintosh for analysis. The transcripts were read over systematically to carefully review and analyse the contents, and if need be, refine the interview questions to ensure that the phenomenon under investigation was well defined and understood, in accordance with the principles of Noiseux et al [24] and supported by Morse [22]. Immediate data analysis following the collection of the initial data assisted in constant comparative analysis and theoretical sampling, with Strauss and Corbin’s general guidelines and framework being used for the data analysis. The recursive line by line data analysis entails three stages, namely; Open coding, Axial coding and Selective coding: the first two being performed concurrently. Open coding was done to identify concepts and their properties from the data [19] and involved two processes, namely labelling and categorising, with the steps repeated by an inter-coder. Axial coding then made it possible for the generated codes to be regrouped to generate conceptual codes. Subsequently, a search was done to establish any relationship among the concepts from data, with selective coding helping to integrate, refine and describe the concepts [25].
Lincoln and Guba’s model of trustworthiness [26] was used to ensuring rigour of the findings. Member checking and validation entailed asking nine participants to read the interview transcripts for confirmation to ensure credibility. For confirmability, the senior researcher and co-author assessed and validated the codes from the raw data, with adjustments being made to the subcategories and the categories as needed. Detailed data, including field notes, were kept to enable an audit trail, which entailed outlining the decisions made throughout the research process. This provided a rationale for the methodology and interpretative judgement of the researchers, as supported by Houghton, Casey, Shaw and Murphy [27], and may assist in transferability. An inter-coder was used to repeat the Open coding process, and a calculation of intercoder reliability established, as recommended by Yang, Pankow, Swan, Willett, Mitchell, Rudes, Knight and Quantity [28]. Dependability was ensured by accurately applying all the Grounded Theory principles and procedures of data analysis.
The data analysis revealed three categories, namely: intra-personal, inter-personal and structural barriers that hinder nurses from practising their health advocacy role in their daily nursing practise, as summarised in Table 1.
A. Intra-personal barriers
The intra-personal barriers refer to the innate characteristics of the individual that prevent the nurse from practising their health advocacy role. Three subcategories were identified, these being nurse’s personal fears, nurses’ personality attributes and nurses’ professional inadequacies.
This subcategory related to their real and or perceived fears of punishment for practising their health advocacy role. Participants mentioned the fear of being labelled ‘as knowing too much, getting into trouble and being victimised as preventing them from performing their health advocacy role, as indicated in the following data extracts:
“They have labelled some of us as being too knowing because we speak out for our clients” (PN02, 39-year-old Female).
“We are not able to speak for our clients, most of us wouldn’t speak out, we fear to get into trouble or to be labelled too known” (PN15, 43-year-old Female).
“Well, if it is a very sensitive issue…you might not be bold to come out, because the fear that people will lambaste or victimize you is evident” (PN23, 51-year-old Male).
b. Nurse’s personality attributes
This subcategory relates to the individual nurse’s personality attributes that prevent them from practising their health advocacy role. These personality traits included being timid, unassertive and lacking confidence, as demonstrated in the following extracts from participants’ data:
“With nurses, a lot of us are timid, we are not able to speak for our clients, most nurses wouldn’t speak out, they will be pushing others that they believe are brave and can speak to go forward” (PN11, 41-year-old Male).
“A lot of us are unassertive and that is why we cannot perform the advocacy role…we need to be assertive” (PN19, 41-year-old Female).
“Nurses are not bold to come out because they fear the outcome to speak up for their clients” (PN23, 51years old Male).
“Most nurses lack the bravery to stand up for their clients,” (PN05, 31-year-old Male).
c. Nurses’ professional inadequacies
This subcategory relates to the nurses’ inadequacies that are profession related and prevent them from practising their health advocacy role. These inadequacies include professional inexperience and lack of confidence, as depicted in the following extracts:
“The confidence and the knowledge are what we mostly lack, if these two things are there we can advocate very well” (PN01, 33-year-old Male).
“Sometimes, you are limited as to what you can do, as a professional even though you have the desire to speak for a client, you lack the experience” (PN20, 33-year-old Male).
“You don’t even want to say what you think and what you see if you don’t have the knowledge because you don’t know what is happening” (PN19, 41-year-old Female).
B. Inter-personal barriers
The inter-personal barriers relate to the relationship between the nurse and their patient clients as well as other health professionals. The two subcategories being clientele traits and perceived collegial persecution emerged.
These participants reported their clients’ inconsiderate behaviours as barriers that prevent them from performing their advocacy role. These include situations where patients are seen to be inattentive to the nurses’ professional advice, and lack of gratitude for what the nurses do, as demonstrated in the following extracts comments from data:
“Clients themselves are part of it, you will stand up for them and at the end of the day some of them will behave in a way that will rather make it difficult to advocate for them in future” (PN16, 31-year-old Female).
“Some of the patients are ungrateful when you speak up for them, they don’t appreciate so, you don’t even have the zeal to do it for somebody else” (PN02, 39-year-old Female).
e. Perceived collegial persecution
Nurses behaviours, as perceived by other health professional colleagues, prevents them from performing their advocacy role. The collegial persecution reported was intimidation from other professionals and senior colleagues, and name-calling and victimization from colleagues as barriers, as depicted in the following comments:
“Sometimes, even our colleague nurses would intimidate you just because you stand up for client rights, especially if it is against a professional” (PN01, 33-year-old Male).
“They have given some of us names because we speak for the less privileged clients” (PN04, 37-year-old Female).
“What am saying is, as a nurse, I may know or would have seen that it is right to be a health advocate, but may not want any trouble, or want other people to sabotage me. So, I keep quiet to prevent victimisation from others, including my own colleagues and seniors” (PN22, 35-year-old Male).
The structural barriers are organisational and institutional issues that prevent nurses from practising their health advocacy role. The four subcategories were red tape, professional alienation, poor educational preparation and structural victimisation.
“It’s the dysfunctional chain that we go through that impedes our desire to advocate” (PN11, 41years old Male).
“Some policies in this institution are just not favourable for nurses to work as advocates” (PN19, 41years old Female).
“We don’t advocate sometimes because people have advocated and did not see any result” (PN15, 43years old Female).
g. Professional alienation
This subcategory emerged from data related to isolation and divisions within the profession that prevent nurses from advocating. This includes the ‘keep quiet and obey syndrome’, professional snobbery and negative professional socialization, as indicated in the following comments:
“You have to keep quiet and obey, when you step behind the nurse-in-charge to take any action you may be in trouble” (PN11, 41-year-old Male).
“We are not able to advocate because the seniors will snob us if we try to suggest or initiate any action of advocacy” (PN18, 50-year-old Female).
“Professionally we are negatively socialised, and this has some impact on us with regards to not advocating…we are negatively influenced” (PN24, 33-year-old Male).
h. Poor educational preparation
This subcategory emerged from data related to the absence of health advocacy in the nursing curriculum and a lack of students’ empowerment to advocate during training. The barriers include inadequate curriculum content and training on health advocacy, and not being empowered to advocate, as depicted by the following extracts:
“The content in the curriculum did not adequately prepare us to be serious health advocate [or advocate for health]” (PN23, 51years old Male).
“Well, I think that health advocacy is not that much heard during training,” (PN15, 43years old Female).
“Personally, I hold a view that our training from the nursing schools, particularly the nurses training, most of the time don’t empower us as health advocates,” (PN14, 37years old Female).
In addition to the poor educational preparation, the nurses reported a poor description of health advocacy in the curriculum, with little attention being paid by instructors as a barrier to its success. They stated that instead of tutors cultivating assertiveness during training they encourage submissive attitude in all instances, without critically considering the situation, as reported by some participants:
“It starts from the training schools, in school you don’t want to be seen as someone who speaks out, or stands up for your rights, because all those that do that, the tutors will have their eyes on them and they will frustrate them with their grades” (PN20, 33years old Male).
“There is something going on that you don’t like but you can’t talk for fear that from the final exams they will fail you” (PN15, 43years old Female).
“So sometimes we see problems as nurses and are unable to voice it out because of the way we were trained at school” (PN21, 31years old Male).
i. Structural victimisation
This subcategory emerged from data related to direct or indirect victimization of the nurse as barriers that hinder them from performing the health advocacy role, including healthcare settings and nursing education institutions. The barriers are institutional victimisation, fear of institutional punishment and victimisation during training, as demonstrated in the extracts below:
“Some nurses fear that the authorities will lambaste them or victimize them…so victimization is also a hindrance” (PN23, 51years old Male).
“Some of us are usually afraid of the fact that we may be penalized by the authorities if they speak out” (PN03, 36years old Female).
“The principal had to report him to Nursing and Midwifery Council and every year he was referred. Every year he was referred until about 6 years before he passed. The intimidation is real during training so how can you speak out when you qualify” (PN20, 33years old Male).