Professional Nursing in Oman

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Although it has made tremendous progress in improving and expanding its national health care system, this Middle Eastern country is still struggling to produce enough nurses to meet its people's needs.

By Mohammed Alghemini, MSN, RN, and Sharon A. Denham, DSN, RN

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Professional nursing in the Middle Eastern nation of Oman has grown rapidly since the country's 1970 modernization of its health care system. In fact, over the last 10 years nursing has become one of the fastest-growing professions in the country. Previously, nursing education was primarily vocational training, but since 1990 nurses must earn a diploma to practice as an RN. Despite many recent efforts to improve nursing education and practice, the profession is still attempting to catch up with nursing practices in the United States and other nations. Oman is currently struggling with a rapidly growing population, rapid expansion of health care services and severe shortages of well-trained nurses to meet the demands. The Ministry of Health has made great strides by supporting nurses' educational preparation, establishing and funding educational institutions and offering free education to individuals who choose nursing as a profession.

Ibra Hospital in Ibra, Oman, is one of the country's many government-funded hospitals operated by the Ministry of Health.
The Sultanate of Oman is located in the Persian Gulf region, bordered by the United Arab Emirates and Saudi Arabia on the west and by the Republic of Yemen on the south. It is divided into four governorates (country subdivisions) and eight administrative regions. About 82% of the country consists of sandy desert and rugged mountains with small agricultural areas. Muscat City, inhabited by more than 600,000 people, is the capital and the center of political, economic and commercial affairs. Nizwa, Salalah, Sohar and Sur are other large cities. Oil is the main source of the country's income, followed by industry and natural gas. According to the 2004 national census, Oman's total population was 2.57 million, with 33.3% of the population under 15 years old and only 2.2% aged 65 and older. Life expectancy is 74.3 years.1

Oman is an Islamic Arabic country that developed its own branch of Islam, called Ibadhism. It is the only country in the Islamic world with a majority Ibadhi population. There are no major variations in the Muhammadan law between Ibadhism and other branches of Islam, such as Shia and Sunni. However, Ibadhism is known for its moderate conservatism and its choice of ruler by communal consensus.2 Although other branches of Islam exist in Oman, there is a unity in the society between all branches, and the country is known for its tradition of religious broadmindedness.3 In addition to the largely Muslim population, there is also a minority of expatriate non-Muslim groups, primarily Christians and Hindus.

Religion and culture play important roles in Oman's health care practices, regulations and professional roles. Most hospital treatment areas are divided into male and female sections. In outpatient facilities, male patients are treated in the men's allocated areas and female patients are treated in a different designated area. Inpatient care is similar, with male and female patients admitted into separate wards. However, exceptions sometimes occur in areas such as adult intensive care, coronary care and dialysis units.

Oman's Health Care Renaissance

Before 1970, Oman's health care system was one of the poorest in the world. The mortality rate was high, especially among infants and children, with infant deaths estimated at 159 per 1,000 live births.4 Many people suffered from infectious and communicable diseases due to lack of health care services, inappropriate treatment and poor sanitation. Malaria, mumps, trachoma, diphtheria, neonatal tetanus, polio, gastroenteritis and diarrhea were among the most common diseases at that time.5

In July 1970, Oman's ruler, Sultan Qaboos bin Said, began to take steps to relieve his people's suffering by seeking to establish an excellent health care system. He issued a royal decree to create the Ministry of Health (MoH), which was charged with the responsibility of providing high-quality health care to all Omani citizens. In the years that followed, the MoH established hospitals and health centers across the country and brought modernization into all health care professions.6

As a result, in less than four decades health care services in Oman have expanded throughout all regions of the country, greatly increasing people's access to care. In addition, the MoH has initiated many public health programs, including a national birth spacing program and health education programs. Since the ministry's Expanded Immunization Program (EPI) was introduced in 1981, diphtheria, neonatal tetanus and polio have been eradicated.

Oman has a government-funded National Health Service that includes general and speciality hospitals. The MoH is the main health care provider, followed by the Ministry of Defense and the Sultan Qaboos University Hospital (SQUH). According to the 2005 World Health Organization census, the country has 17 physicians per 10,000 population and the proportion of nursing and midwifery professionals is 37 per 10,000 population. Today, nearly 100% of the total Omani population has access to health services, depending on where they live.7

Currently, Oman has 58 hospitals, which are classified as primary, secondary, tertiary or referral. Combined, these hospitals contain 5,270 inpatient beds, which equates to 21 beds per 10,000 population. Fifty-four hospitals are government-supported and provide free health care services for Omani citizens and for foreign nurses working in the governmental sectors. Fee-for-service care is common for foreign workers in the private sector. Royal, University, Sultan Qaboos, Khoula, Al Nahda, Nezwa and Sohar are the largest tertiary teaching hospitals in the country. Royal Hospital is Oman's largest health care institution, with about 700 beds and continued expansion to incorporate new facilities.

Other tertiary hospitals have inpatient capacity that ranges from 200 to 532 beds. Khoula Hospital is the Sultanate's central referral hospital for orthopedic, neurological, cosmetic surgery and burn care. Al Nahda Hospital is the main specialty treatment center for ear, nose and throat surgery, eye care, dental and jaw surgery and skin diseases. Royal Hospital is the referral hospital for heart disease, heart surgery and cancer.7 The tertiary hospitals serve as specialty centers, receiving patients from primary and secondary health care services, emergency patients and patients referred from other hospitals for medical management. The secondary hospitals provide primary and secondary health care services with some specialty care, such as gynecology and orthopedic care. Primary care hospitals provide general health services and refer patients to facilities with higher levels of care when specialized treatment is needed.

In addition to the hospitals, there are 897 health centers, dispensaries and clinics spread across the country. These facilities provide primary health care services with a few specialized care units. Health centers, which are usually located in low-populated areas, are staffed by general practice physicians and nurses, who provide services such as vaccinations and pre-and post-natal care.

History of Nursing in Oman

Nursing in Oman is widely recognized as an admirable, caring profession. For centuries, nursing was practiced by untrained household women who used natural remedies to treat the sick and assist with the delivery of babies. In 1904, the first missionary nurses from America arrived in Oman to work in an organized health center. In the 1950s, a small group of U.S. nurses serving in the American Missionary Association in Muscat began training Omani nationals to become nurses. This marked the beginning of modern nursing in Oman.

An Omani nurse checks a hospitalized patient's vital signs.
At that time, the capital city had only two small hospitals to meet the health care needs of the entire population. The American nurses joined the staffs of the two hospitals and in 1959, a six-to-nine-month training program was established at Al Rahma Hospital for 16 Omani nurse trainees. That training center continued to educate nurses until 1970, when the American Missionary Association established a two-year nursing program, Al Rahma School of Nursing, in Muttrah.7

Oman's modernization opened a gateway for the nursing profession. In 1972, Al Rahma School of Nursing was taken over by the Ministry of Health. The MoH increased the number of nurse trainees at the school and upgraded it to a three-and-a-half-year program offering a certificate in nursing. In 1980, the Directorate of Nursing was established at the MoH headquarters, an official acknowledgement that professional nursing was now seen as a vital aspect of health care.

From the beginning, the Sultanate's ambitious plans to improve and expand health care services have been hindered by an insufficient supply of nurses, nursing education programs and nursing educators. Therefore, the MoH began recruiting nurses from abroad. Until very recently, most nursing jobs in Oman were held by foreign nurses, primarily from India, the Philippines and Sri Lanka.

For the last 15 years the Sultanate has been working to Omanize the nursing profession by increasing the number of homegrown nurses and nursing schools. In 1998 Oman had 7,453 nurses, of which less than a quarter (24%) were Omani. By 2006, however, the total number of nurses serving in the MoH had grown to 8,278 and 63% of them were Omani. In addition, the nurse-to-population ratio has risen from 32.6 nurses per 10,000 population in 1998 to 37 nurses per 10,000 by 2005. However, despite ongoing efforts to increase the numbers of both national and foreign nurses, Oman's health care services still have a 30% shortage in nursing staff.

Nursing Education

At the present time, Oman has 12 basic nursing institutes that offer a three-year diploma program. These institutes operate under the administration of the MoH's Directorate General of Education and Training. Muscat Nursing Institute (MNI) and Oman Nursing Institute are the largest nursing education programs in the country; each graduates about 100 new nurses a year. The other 10 schools, located in different regions of the country, each produce about 35 new nursing graduates per year.

MNI was the first school to graduate diploma nurses and is considered the heart of nursing education in Oman. MNI assists other institutes with curriculum design and educational resources. To ensure consistent quality of nursing education throughout the country, all nursing schools share an identical curriculum with some minor course plan variations. The Nursing Education Board regulates nursing programs, licenses schools and also helps establish curriculum content.

The country's first baccalaureate nursing program was launched in 2002. The MoH continues to strive to prepare highly educated nurses and improve the quality of nursing care. Currently, there are two nursing schools in Oman that have BSN programs: Sultan Qaboos University (SQU) and Niswa University. In addition to the four-year program, both schools also offer a two-year RN-to-BSN program.

An Omani ICU nurse at work. Although all of the nurses pictured in this article are men, the proportion of female to male nurses in Oman is about seven to one.
Neither master's nor doctoral programs in nursing are currently available in Oman, but the MoH and SQU intend to begin offering them soon. In the meantime, Omani nurses who earn BSN degrees are sent abroad to gain a graduate degree. Every two years, the MoH sends a group of 20 nurses to the U.S. to do graduate study at Villanova University in Pennsylvania. The majority of these graduate students major in nursing education and the rest study nursing administration. The education specialties emphasized include adult medical-surgical care, pediatrics, community health and mental health, depending on the student's area of interest and the MoH's faculty needs. After completing their graduate degrees, the students return home to either join nursing institutes as faculty members or work at hospitals as nursing administrators or staff development officers. The MoH also sends nurses to the United Kingdom and Australia for preparation as advanced practice nurses in specialties such as adult critical care, pediatrics, neonatology, nephrology, midwifery and emergency nursing. Graduates of these programs work as nursing educators and clinical instructors in the Oman Specialized Nursing Institute and teach post-basic nursing courses.

Oman currently has approximately 180 bachelor's-prepared nurses, about 40 of whom have also completed master's degrees. Many of these nurses who did their master's studies abroad say they gained tremendous knowledge and experience from being exposed to education and health care systems in other countries. These growing numbers of nurses with graduate degrees are playing important roles in advancing the nursing profession in Oman. They are introducing new ideas in clinical and educational practice and they're helping to increase the supply of highly skilled nurses available to meet the nation's health care needs.

However, there are still not enough nurses with advanced degrees to meet Oman's urgent demand for more nursing faculty. Because of the severe shortage of nursing educators, about 50% of current faculty positions are held by nurses recruited from other countries, such as Jordan, India, the Philippines and England. These foreign faculty work under temporary contracts with the educational institutions. Even with good pay for nursing educators, the faculty shortage continues to be a challenge. Frequent vacancies resulting from the end of these short-term job contracts, and from resignations of foreign educators who want to return home, exacerbate the problem.

Students' admission to nursing institutes and university nursing programs is based on secondary school grades, passing an English proficiency exam and admissions interviews in Arabic and English. Each year, the Directorate General of Training and Education sets a predetermined number of slots for male and female applicants. Female students usually account for 80% to 85% of the typical nursing class. In fact, the proportion of female to male nurses in Oman is about seven to one.

A typical hospital nurses' station in Oman. The country is currently struggling with a 30% shortage in nursing staff.
This uneven gender distribution in nursing classrooms has created problems for men who are interested in nursing careers. Although male students want to become nurses, they lack opportunities to enter nursing. The MoH's justification for favoring female students is that female nurses can generally work in any area of health care, including obstetric and gynecology wards or delivery suites, whereas male nurses are prohibited from employment in some practice areas. All nursing courses are taught in English by nurse educators prepared at the doctoral, master's or baccalaureate level. The curriculum is designed to prepare nurses for a variety of roles in hospitals, health centers and community health settings. The coursework addresses content areas that prepare students to practice basic nursing—e.g., adult medical-surgical care, pharmacology, obstetrics/gynecology, pediatrics, community health and psychiatric health. Nursing students also take English language courses, nutrition and other basic science courses. The fall and spring semesters are a blend of theory and practicum experiences, while the summer is extensively practicum with few class meetings.

Licensing, Specialization and Research

Currently, the registered nurse is the only qualified level of nursing practice in Oman. To become an RN, students must graduate from a three-year diploma program or a four-year BSN program. After graduation, they are awarded a licensed RN certificate and are eligible to practice nursing. Nurses who graduate from one of Oman's nursing education institutions are waived from taking the national licensing exam, because passing the course exams and successfully completing the nursing program are considered measures of clinical performance. However, the licensing exam is mandatory for nurses who graduate from programs outside Oman.

Newly graduated nurses employed in most health care services must work under the direction of a supervisor for six months and complete an internship period before they are allowed to work independently. During the internship, novice nurses are assigned to work with experienced RNs who continue to teach, mentor and perform periodic evaluations. These preceptors have at least five years of nursing experience and have taken some specialized training courses.

Recognizing that continuing education is an important part of maintaining high-quality nursing care, in 1977 the MoH began to establish post-basic training programs—i.e., a two-to-three-year clinical for RNs who have completed a basic nursing program.7 These post-basic programs prepare nurses to specialize in specific practice areas that will improve their performance in clinical settings. The first post-basic specialty program offered was in nephrology. To expand specialized nursing education across the country, the MoH has also initiated a four-month on-the-job training program in which nurses work in teaching hospitals to gain practical experience and theoretical knowledge.

In 2001, the MoH opened the Oman Specialized Nursing Institute (OSNI) in Muscat to increase the supply of nurses with specialized skills. OSNI provides an 18-month program of post-basic specialty courses for nurses across the country and awards certificates in several nursing specialties. These include emergency care, midwifery, mental health, nephrology, nursing administration, adult critical care, neonatal and pediatric critical care. The MoH has also expanded the midwifery program, adding three additional programs to train nurse-midwives in other parts of the country. Selection of nurses for these specialized study programs is based on community health needs, MoH priorities, nurses' clinical achievements and employer recommendations. At present, there are no formal nursing research organizations in Oman, but the MoH has several research committees that oversee local studies and surveys. These research projects are conducted by teams of health care professionals, including doctors, nurses and other practitioners. Nurses in Oman generally lack the skills, experience, motivation or financial support to undertake research studies in clinical or academic settings on their own. Although there is a great need for research studies about nursing issues in Oman, few such studies have been published. Increasing the number of nurses with advanced degrees would help remedy this deficit. Nursing Employment Nurses in Oman work in all types of health care settings. Thanks to the nursing shortage, newly graduated nurses have 100% job availability in one of the country's health care systems or nursing institutes. Nurses employed by the MoH are guaranteed a job until the age of retirement (60 years).

A nurse reassures his patient in one of the hospital's male wards. Most hospital treatment areas in Oman have seperate sections for mlae and female patients.
In most cases, nurses do not have a choice of where they will work. Because most educational institutions and health care facilities are government-owned, graduating nurses are assigned to employment locations based on staffing needs. Furthermore, most graduating nurses cannot express a preference for a particular clinical area or unit. However, nurses who have specialized post-basic training are assigned to work in specialty units, such as intensive care, burns, renal care and dialysis. Many nurses in Oman work full time in governmental health care facilities, such as hospitals, health centers and clinics. Most of these nurses have a diploma in basic nursing from one of the country's nursing institutes and some have post-basic program certificates. Few baccalaureate-prepared nurses work in clinical settings.

Most nurses employed in health care facilities work 140 hours per month with eight days off each month. Duty roster plans vary depending on the facility. In some facilities, the work hours are distributed equally among three shifts, but in most cases nurses work more evening and night hours. Due to staff shortages, some employers often demand that nurses work more than the required hours. Extra work hours are generally compensated with time off. Overtime is rarely paid because most nurses prefer time off instead.

Nursing, like any other governmental job in Oman, has a salary-based pay system. All nurses employed by the MoH are paid equally according to educational degree and years of experience, regardless of the work location. In other words, nurses working in Muscat earn the same salary as those working in rural areas, and critical-care nurses make the same money as those employed in outpatient clinics. RNs with less than five years' experience are designated as staff nurses and paid the same wherever they work. Nurses are entitled to receive pay raises and job promotions every five years, starting at staff nurse and moving up to senior staff nurse, supervisor and, finally, nurse adviser.

Nurses in Oman often complain about staffing shortages, heavy workloads, lack of job choice and the difficulties of trying to meet their family obligations while working inconvenient shifts. In some hospitals, nurses have no formalized job descriptions and are therefore required to perform tasks that have nothing to do with nursing, such as dispensing drugs after midnight in the pharmacy and completing statistical reports. While the Sultanate's continued expansion of health care services, building of new hospitals and population growth are positive signs of progress, there is no denying that these factors also contribute directly to the nursing shortage. When foreign nurses working in Oman return home to care for family members or leave to take positions in other nations, the result is severe understaffing. The MoH has made significant strides in increasing the number of nursing education programs, nursing students and RN graduates, but these measures still seem inadequate to deal with the looming shortages. Professional nursing in Oman has come a long way in the last 38 years, yet it still has a long way to go.

Mohammed Alghemini, MSN, RN, is a nursing tutor at Muscat Nursing Institute in Muscat, Oman.

Sharon A. Denham, DSN, RN, is a professor at Ohio University School of Nursing in Athens, Ohio.

References

1. World Health Organization (2003-2005). "Oman Demographic Indicators." Retrieved from www.emro.who.int/emrinfo/index.asp?ctry=oma.

2. U.S. Department of State, Bureau of Near Eastern Affairs (2006). "Background Note: Oman." Retrieved from www.state.gov/r/pa/ei/bgn/35834.htm.

3. Oman Information Center. "Primary Health Care in Sultanate of Oman." Retrieved from www.omaninfo.com/mbbs22/boxx/knowledgebase.asp?iid=2529&Cat=3.

4. Hill, A.G. and Chen, L.C. (1996). Oman's Leap to Good Health: A Summary of Rapid Health Transition in the Sultanate of Oman. World Health Organization/United Nations Children's Fund.

5. Scrimgeour, E.M., Mehta, F.R. and Suleiman, A.J. (1999). "Infectious and Tropical Diseases in Oman: A Review." American Journal of Tropical Medicine and Hygiene, Vol. 61, No. 6, pp. 920-925.

6. "The Celebration of the Omani Renaissance Day on the 23rd of July 1970." Ain-Al-Yaqeen magazine, August 11, 2006. Retrieved from www.ain-al-yaqeen.com/issues/20060810/feat9en.htm.

7. Sultanate of Oman, Ministry of Health. "Oman's Nursing Profession Comes of Age." Retrieved from www.moh.gov.om/nursing/History%20of%20Nursing%20in%20Oman.htm.