The quantitative data profiling of the IRN’s were presented in tabulated form (Table 1) and the qualitative data was organized and classified into nine key themes.
● Reasons to work as a nurse in Oman
● Hiring and recruitment experience
● Preparation for transition
● Barriers and challenges
● New work environment experience
● Variations in practice
● Adjustment and acculturation
● Improving the hiring process
● Impermanence and Omanization
Profile of the participating IRN’s
The demographic details obtained regarding the profile of the IRN’s (Table 1) shows that the majority of them are in the Philippines and India, females with an average age of 33.5 years, with Bachelor's degree in nursing are widely working in the wards and general settings as a general nurse or junior staff nurse with an average of 24-36 months experience within Oman and at least 6- 10 years’ experience outside Oman.
Reasons to work as a nurse in Oman
This study reveals the various reasons IRN’s choose to work in Oman. These reasons can be broadly clustered into both personal and professional reasons. Personal reasons have stemmed from economic reasons that aim to further better the opportunities of earning more than what is regularly being received in their countries of origin and to help family members back home with their finances. There is also a desire to move in order to join relatives or family members who are already in the Sultanate. Other personal reasons comprise the desire to immerse in a new cultural environment and to relocate in a country wherein practice in terms of religion, belief, and values are tolerated.
R2 “I decided to work in Oman to help my family financially, it’s difficult for nurses in the Philippines to find a stable high-paying job. Oman is a safe country, knowing this after talking to my friends who have worked here, I felt relieved because they told me that Oman is a good county”( pg.4. Line 136-139)
R11 “one of the reasons for going out from the Philippines and working in Oman is that nurses in the Philippines are under-compensated” (pg.20. Line 773).
R7”I previously worked in Saudi Arabia, a man who worked in Oman before explained to me that people of a different religion can practice safely and freely their beliefs, I am a Christian and that is very important for me especially if I encounter a difficult situation ” (pg.14 line 483-48)
Professional reasons arise from the IRN’s desire to learn new skills, broaden their clinical experience, have access to more advanced equipment and to enhance professional development through in-service education with some saying they left to have better work situations.
R10 “One of my cousins and an uncle worked in Oman, they recommended me to an agency and encouraged me to work here, and they described Oman as almost the same with India in terms of climate and people. Oman has warm weather and friendly people and that there is no discrimination or racism in this country. I can also work on my specialization which is the intensive care unit and I was given a good salary offer” (pg.19. Line 690-695)
R10 “In the Philippines during that time I think I enjoyed waiting because of the opportunity of being promoted. I think the reason why I finally resigned is because of the stress I'm having at work. Feel I am under-compensated with the workload I was having then. I don’t have time to enjoy my social life. Even at home, I was still working. I was even being called during my off days. I was also stressed with a bunch of paperwork. I started to feel the burnout from work. (pg.21 line 794-799)
Hiring and recruitment experience
The majority of the IRN’s were recruited through agencies in their countries of origin. Mediating agencies advertise the required staff and their specialization based on the vacancies provided by the hiring institutions in Oman. The hiring process will take about 6 months to 2 years. The applicants are required to meet the expected minimum requirements such as passing the Oman Prometric exam, minimum 3 years bedside experience, and a minimum qualification of diploma in nursing and incumbent RN license from the country of origin.
R7 “I was recruited by a private agency in India. They gave an announcement through the newspaper regarding the interview. I have contacted them and they told me to take the Prometric exam which I passed with a 50% mark” (pg.14. Line 460-464).
R9 “I found out about the job opening in an agency in India and I felt I met the criteria so I applied, the agency informed me about taking the Prometric exam. I have to wait based on the vacancies available. I actually waited for at least four years. I applied in Oman also because I want to be with my husband who is working here.” (pg. 17. Line 601-607).
Preparation for transition
Many of the IRN’s are unfamiliar with Oman its background in terms of social norms, customs, culture, and tradition. Many did advance personal research, reading, and personally asking former colleagues and relatives that are residents of Oman about the country prior to being deployed. The majority came with little or no understanding about Oman and were surprised about the difference of what is being portrayed in the media about Middle Eastern countries, a Filipino IRN says. Since language is the main barrier to care, many of the IRN improvised ways to learn Arabic prior to being deployed through books, the internet, and by using translation applications.
R2 “I have friends also here in Oman before I came, so I asked them how the people here, the climate the interaction of locals here is to foreign people coming here in the country, mostly my feeling after talking to them I felt relief because they told me that Oman is a good country.”( pg.4 line 136-139).
R11 “it was a big transition for me. It was really stressful for me as I needed to endorse my position before leaving the Philippines. The representative from the ministry was very accommodating; it was not that scary. I was given free and comfortable accommodation. I was able to explore some areas near my accommodation. I have this notion before that a Middle East country is very scary. This is because of the news I heard and saw. People have a negative connotation about a Middle Eastern country. Based on the news a Muslim country has more strict regulations compared to my home country. My mental background about a Muslim country is there are a lot of restrictions, especially on social life.” (pg.21 line 800-808).
R13 “I did some research regarding Oman, the cultures, the traditions, and especially how to communicate with them. Some basic Arabic language I think I did that, I took some notes , used applications and I researched also about the do’s and don’ts when speaking with Omani people because at that time I know that they are very particular, what do you call this, hmm. Like traditional.”(pg. 26- line 995-996)
Barriers and challenges
While many IRN’s uses English as a second language to communicate, speaking the native language Arabic was seen as a challenge in the first months of being deployed in Oman. Many felt frustrated about their inability to send the message across patients and felt that it is important that proper training and orientation should have been given by the placement agencies as well as the receiving institutions in Oman. It is apparent that there is no established form of induction and orientation system in place for both the recruiters and the country recipients. When the IRN arrives in Oman they are expected to fill the position readily, sometimes abruptly, and to adjust into the system outright without proper induction and orientation. In many cases, this increases anxiety on the part of the newly hired IRN.
R2 “In nursing I feel communication is very important when I came here it’s also my first time in a foreign country, how I communicated them was using sign language because I didn’t know Arabic, sometimes they will laugh because they don’t also understand my sign language, and here it’s also different simple as saying yes or no other than that I can’t understand anything” (pg. 5 line 154-158).
R4 “I didn’t know Arabic when I came here too, I’m going to study and all and but slowly I’m learning some patients who know only Arabic so I can reply only yes or no.so what i do is i tell them I don’t know Arabic directly they will realize and they will laugh, and I’ll just ask somebody to explain to them. (Pg.10 line 320-323).
R9 “I had a communication barrier. Until now I have difficulty communicating with a patient because of the language, especially the accent. We have a fear that if he gives wrong communication it will end up in big issues. So we asked help from the locals to translate our communication to the patient. Prefer to be with a local during the shift duty or somebody who can speak Arabic.” (Pg.18. Line 650-653).
R10 “Though the communication is in English sometimes we have encountered miscommunication like the use of words or interchanging of terms. Like English used in an American accent or through British accent example is the use of a torch and a flashlight or the use of lift and an elevator. I think one of my problems is adapting to the language in both Arabic and English. (pg. 21. Line 818-822)
Food is seen as an integral part of culture and tradition. Different countries and nationalities may have different food preferences. For some IRN’s adjustment in terms of food was seen as a challenge at first. Varying levels of unfamiliar spices is something new to IRNs coming from the Philippines. Omani food draws from influences of Persian, Arabian, and Indian cuisines which use abundant amounts of spices highly unfamiliar among the Filipino IRN’s. Acculturation programs that involve orienting newly hired staff about food, where to get products and supplies that they are familiar with, such as the nearest Asian store and restaurants are important details of the induction and orientation that are not being done when staff from supplying countries reaches Oman.
R2: “Food here, taste different it’s a big adjustment so I prepare my food, people are kind but not that sweet like our countrymen they offer and kind, religion-related food restrictions, we are already familiar with Muslim culture because we have also Muslims back home.” (Pg.6 line -183-185)
R14 “The first week, ah, it was, I'm a little bit shocked about the food, because that time, they gave us the food, this biryani because as a Filipino I am not used to that food so at first I did not eat for 2 days. I didn't know where I could go to find or buy products that I could eat at first. (Pg.33 line 1245-1247).
Many IRN says that there were no formal orientation programs or even induction programs in place when they arrived fresh in Oman. Although the staff were cooperative, especially the local nurses were expected to fill the role of the staff on the very first day of their duty without being fully immersed or given a period of adjustment to familiarize themselves with the new environment. A couple of IRN’s was promised to be assigned in a special area where they have extensive years of experience as nurses before coming to Oman were later on informed that they will be assigned on other areas than that promised during the interview and contract signing. Some staff were asked to sign a form or document written in Arabic without any explanation of what the contents are which made them really anxious.
R13 “I was really confused because when we were transported from the airport to the accommodation, there was no orientation, there was no one talking to us. This is what we will do and afterward, you will be deployed here, you will temporarily stay here. No, no information at all, in general, just waiting day after day what they will say. For one week we were confused, most of us because we were 20 Filipinos. 10 – 15 Filipinos in a group when we went here in Oman.” I was also promised to be assigned to the ICU, I was later placed in the Health Center ( pg. 27- line 1034-1039).
R2 “When I arrived at the guest house, we were informed to report in the Ministry office the following day, we were asked to sign another paper which is written in Arabic, no one explained it to us. I don’t speak or read Arabic so I was anxious about it. (166-169).
New work environment experience
When asked about their new work environment the majority of the IRN’s responded that they are generally happy with the health care system in Oman, they were positive also about their Omani co-workers who seem very welcoming and helpful in their period of transition in the workplace. Although a big number of the IRN participants were highly experienced they felt that there is a big difference in the practice of nursing Oman compared to their country of origin. Clinical skills were observed not built on ideal principles as taught in nursing schools.
R8 “I felt welcomed in the first few weeks upon joining my area. The locals and my Omani colleagues are very helpful, but I observed that staff from different nationalities didn’t welcome me as much as the locals did. They sometimes don’t inform me of what is happening around the area and usually delegate the most difficult patients to me. I felt left behind. (pg. 20 - line 456-459).
R4 “It’s still difficult till now because of differing practices depending on where they trained especially. If principles are not followed. I will not mention the nationality, like principles followed are book based some of them do what they are used to. A staff member once asked me to endorse a patient who is not assigned to me because she is a female staff member. Conflict with what is taught and what is practiced. (pg. 8 line 255 -262)
Oman and Omanis are known for their welcoming attitude and politeness but for IRN’s who are deployed for the first time in the clinical area factors such as language, difference, and practice can lead to miscommunication and can further, escalate into heated arguments among staff and patients or staff to staff. Although rarely experienced some IRN’s felt some degree of discrimination from patients and patient relatives. IRN’s mostly experiences segregation or discrimination as they feel dissociated from the societal structure and seen only as foreign workers or labor force but not integral to the overall community structure. Discrimination was most felt among differing nationalities rather than with the locals. Dominant nationalities in one area creates an informal community structure that has its own unspoken guidelines and norms in this occasion any other nationalities other than those that are in the majority are seen as foreign or even a threat.
R6 “A patient relative came rushing into me, shouting about his relative, I cannot understand anything, it was only my 2nd week in the unit. I went to my charge nurses. I was really scared. I cried. Most local patients see us only as workers here. (pg. 9. Line 367-369).
R11 “But I have challenges with my direct supervisor. I feel she is biased in terms of her own countrymen. She treats me differently compared to my colleagues from her own country. I find some difficulties because of the language. I cannot understand the way she talks because of the accent. I have difficulty understanding how they articulate words which I find difficult for me to work with them.”(Pg.22 line 881-883)
While the above findings show very little percentage among IRNs, the majority of the IRN felt welcomed as soon as they joined the clinical area. The following comment is reflective of the many views of the participants.
R14 I feel very blessed working here it because it’s the first time for me to work in a foreign country, I felt like I am home because for example my colleagues, they are treating me like family, for example when my mother came here to visit me, they are all like welcoming my mother, they are family like this, and also for the patients when they knew that my mother is coming, they are all excited and happy, that’s why I felt more secure, working here in Oman and it is such a nice experience here” ( pg.34. Line 1282 -1287)
Variations in practice
Even upon arriving in Oman the IRN’s have a higher expectation of the quality of the healthcare system and service provided in the Sultanate. IRN’s coming from low-income countries expect a much better work experience in high-income countries like Oman. The varying practices, as experienced by IRN’s, may stem from the diversity of staff working in Oman who handed over some practices to younger staff members with most not done in an ideal way. One IRN appreciates the opportunity to be able to work with sophisticated types of machineries and gadgets that enhance her work experience in Oman. This is evidently true among IRN’s who reside in low-income countries where there is a scarcity in resources as well as updates in the most recent equipment. There is a high expectation in terms of performance and skills among IRN’s recruited since IRN’s are seen as specialists with more extensive experience and rigorous academic background.
R7 “It’s my first time to see some equipment and machines. Even a simple ventilator looks new to me. The ventilators here are more complicated/ complex but more sophisticated and are in the latest model in terms of ventilators. We back home the ventilators we use are the same in all age groups but here in Oman, we use a specific type of ventilator for a specific age group of patients. I am happy and thrilled to use the most updated and sophisticated machines.” (pg. 15 line-490-496)
R8 “before I was working in the neonatal critical care area now I was posted at ward level. I’m used to taking care of neonates now I'm taking care of adult patients. Though the classification of patients changed from critical care to the independent type of patient the number of the patient increased. I think the workload is heavier this time. If given the chance I would like to go back to my specialization which is the neonatal intensive care unit. I was only posted because of the vacancies in the ward. Initially, I was surprised and had difficulties being able to sign the ward level but my manager helped me to adjust. I feel tired sometimes but there is teamwork. Some days are busy, some days are hectic. But we try to manage our work.” ( pg. 16. Line 564-572)
Gender segregation is apparent in Oman similar to other Middle Eastern countries that practice Islam as a religion. Male IRN’s are expected to abide by the norms and traditions related to handling female patients and the customs traditionally followed while interacting with them. IRN’s coming from India and the Philippines are trained to handle patients across gender and age and are expected to perform tasks equivalent to those of female nurses.
R15 “Me as a male staff, I cannot just do the nursing interventions or any procedures ordered by the doctor to perform on female patients, we always give considerations that if there’s like physical contact with the patient, it's already expected that a female staff will perform it on a female patient, like if the patient has permanent access which is located in the subclavian, so male staff like me doesn’t do it, so we already allow only the female staff to perform that.”. (pg.39 line 1471-1475).
Adjustment and acculturation
Participant IRN’s expressed the adjustment period and the cultural experiences they went through, most adjusted easily owing it to their own cultural background that allows acceptance and flexibility, supportive staff members, and the availability of immediate family and relatives have greatly impacted their smooth and steady transition in the Omani society. For some adjustments were difficult as it is their first job abroad, while those who have already worked in other countries especially countries in the Middle East adjustment was faster.
R2 “ I think now I’m more confident with communicating although I still have difficulty with the Arabic language but at least now somehow I can communicate , I can ask simple questions and I can understand their answers also. The practice is mostly similar back home nursing procedure is almost the same. (pg.6 line 178-181)
R2 “I think from my experience as a Filipino nurse are trained to adjust to different environments ,we are trained even in the Philippines we are trained to be resourceful, like when we don’t have ideal materials and resources we are able to give the interventions to our patient that helped me a lot when I came here in Oman.” (pg. 6 line 178-181).
R8 “Being with my husband or my family helps me in adopting in Oman. I feel I can express being free or more freedom here in Oman compared to my previous work. I feel relaxed. We can go out, we can go to the beach and we can enjoy it. We can also practice our religion by going to the church, going to the park. In terms of lifestyle like wearing clothes, Oman and Indian have similarities. Very supportive in charge or manager and helpful preceptors which guide us and correct us in the ward.” (Pg.15 line 575-580).
R9 “My preceptor is one of the keys for me to adopt in my professional work. There is not much restriction or someone compels us to do something that makes us comfortable staying in Oman. If we are comfortable we will adapt easily. Maybe I am with my family, that's why I adapt easily. I don’t have a problem with my social lifestyle here in Oman.” (Pg.18 line 661-665)
R15 “Professionally, my adjustment was I guess not that easy since it is my first time to work abroad especially in Arab country where the culture is like different from ours, but I was able to adapt more than I expected because I think here, a month after, more Filipino staff came so I had some resemblance, I mean, my adjustment became easier that time since I have more friends, more Filipino friends here in Oman” ( pg.40 line 1522-1526).
Improving the hiring process
Participants expressed many unmet expectations upon joining Oman in terms of the hiring system and processing, living conditions, work arrangements that were immediately resolved or managed. The biggest challenge among the IRN’s upon arrival is the lack of proper training, orientation, and induction programs to ease the transition into the new work environment. Almost all participants mentioned the lack of an acculturation program that will help them assimilate into a country totally foreign to them. It is known that language can be a major obstacle in the practice of nursing since caring is largely dependent on effective communication with the patient, relatives and coworkers. The lack of basic Arabic courses and culture integration programs from both country origin placement agencies and catchment institutions in Oman is seen as a factor in the difficulty transition experience of IRN’s especially those who are working abroad for the first time. The high cost of hiring on both the IRN’s who pays placement fees and the receiving catchment institution in Oman that shoulders the recruitment process demands a more systematic approach in transitioning Internationally recruited nurses from non -Arabic speaking countries. IRN’s are left to fend for themselves to immerse and learn while taking on the responsibility in a new environment that can at times become too overwhelming.
R11 “the agency notified me that within a month I need to go to Oman or else my visa will expire. From my work, I need to notify the hospital two months prior to my resignation. It was a dilemma for me whether to resign or not. It will take hours for me to travel from my home to the recruitment agency. The reason for me going there personally is because no one is picking up the phone. I need to go there just to ask or inquire about the question. It took a lot of effort for the processing of my papers. I don’t have any idea about Oman. It was an abrupt notification from an agency, a great distance between the agency in my home and a long waiting time for the processing of my papers.”(pg.21 line 783-790).
R2 “The agency should provide training specially Arabic language, my first struggle is language, maybe they should include some small curriculum about the language although the agency gave some list of words like greetings but being a nurse communication is very important to be included before they are deployed.( pg.6 line 188-190).
R9. “I feel the recruitment agencies are profiting money from the applicants. I wish that they would orient us with the culture of the country, especially on how to communicate. I hope they can teach basic Arabic language. At least two sessions for Arabic class.” I hope recruitment agencies will move from private to government. ( pg. 18- line 668-670).
R10 “I hope the agency will provide an orientation program regarding Oman. Particularly if they can provide at least important Arabic words for the nurses to learn before going to Oman. If the agency can provide details on the posting details or area where we will be working on. This makes us confuse and makes us worry” (pg.20 line 755-758)
R14 “ah I think they should explain more to the nurses before, especially the culture in which they will be going so when the nurses go there if they will not be in shock, I used to cry because it's hard working in a new environment there's so much anxiety ” ( pg. 35 line 1326-1327).
Impermanence and Omanization
Participants were all very thankful for the opportunity given to them when they were asked to work as nurses in Oman. The promise of better income, and working conditions were motivating factors identified by the participants but in spite of these comforts provided in the country the looming perspective of termination, job loss, and replacement are felt. The nationalization drive may put an end to the dreams of IRN’s in Oman. Instability in the economic standing, clamor for better job positions for locals and the pandemic situation has escalated the move to replace IRN’s with locally trained nurses.
R9 “I am very happy with work here in Oman, but there’s also fear and anxiety. We are not permanent here, every year more and more nurses are being terminated because of Omanization. We have to be prepared” (Pg.19. line 654-656)