Life History of an Omani Woman, Nursing Pioneer, and Nurse Leader

Abstract

This study explored the lived experiences of an Omani nursing pioneer and nurse leader whose life and career have evolved amidst a time of rapid modernization in Oman that began in 1970, widely known as the Omani Renaissance. The life history method of qualitative research was used to examine personal and institutional facilitators and barriers to professional development, as well as aspects of the history of the nursing profession and healthcare in Oman during this time. This paper provides insight about the successes and challenges she faced in choosing nursing and along her career path. Inductive thematic analysis revealed three dominant themes: opportunity, visionary, and nurse; with subthemes: national identity, country building, nursing pioneer, leadership, perseverance, resilience, mentors, advocacy, caring, and fulfillment. Conclusions from this study are that opportunities, personal attributes, and motivations shaped decisions about employment and played a role in overcoming barriers to professional development in the workforce.

Introduction

Nurses play an essential role in providing health services throughout the world. Studying the lives of nurses can establish the significant contributions of nurses to the provision of healthcare for all. In addition to establishing the contributions of nurses to healthcare, examining nurses’ lives allows better understanding of how personal values and motivations, as well as individual and institutional circumstances shape nursing practice and nurse leadership skills.

Life history methodology is a qualitative research approach that aims to understand individual life stories in relation to the influences of the context in which they occur (Hatch & Newsom, 2010). In this method, the focus of analysis is on an individual’s personal experiences within a historical framework of time and place (Hagemaster, 1992). Life history research is derived from cultural anthropology as a form of ethnographic fieldwork. It is used in a wide variety of disciplines, including sociology, feminist studies, and health sciences (De Chesnay, 2015). The purpose of this approach is to examine how life events influence individuals and how they have made sense of these events (Wiseman & Whitefield, 2007). Life history methodology is well suited to building knowledge about personal and institutional facilitators and barriers to professional development of nurses, as well as aspects of the history of the nursing profession and the contribution of nurses within a particular context.

This study used life history methodology to examine the life of Azza, an Omani woman who chose a career in nursing and evolved into a nurse leader in the Sultanate of Oman (hereafter referred to as Oman), a country on the southeast coast of the Arabian Peninsula in western Asia. Azza’s life has taken place during a period widely known as the Omani Renaissance that began in 1970. This was a time of rapid country modernization across all sectors of society, including foundational development of the healthcare system and nursing profession (Jones & Ridout, 2015; Peterson, 2004). The purpose of this study was to explore the lived experiences of Azza’s life that she felt were important to her getting to where she is today. This paper adds to the limited knowledge about being an Omani woman, choosing a career in nursing, and becoming a nurse leader during this period in Oman’s history. Azza’s account of the development of contemporary nursing and healthcare in Oman adds knowledge which can inform and influence nursing in Oman and elsewhere, particularly countries undergoing rapid modernization. Given that there are no studies that subjectively describe what the nursing profession was like for individual nurses during this time in Omani history, Azza’s story also provides insight about the successes and challenges she faced in choosing nursing and along her career path. Azza’s perspective and experiences also add knowledge about the status of nursing in Oman, which has the potential to impact development of an adequate Omani nursing workforce.

Background

All lives are situated within a setting or context, which includes the physical, geographic, temporal, historical, cultural, and aesthetic environment, within which the life takes place (Cole & Knowles, 2001). Understanding the context in which Azza’s life is situated is important to place her life in time and space, and to offer some appreciation of the influences on her actions. Background information and context are described so that the reader can understand some of the external influences on Azza’s life choices.

Oman

Oman is a Muslim majority country, with Islamic and traditional Arabic culture influencing all aspects of society. Additionally, Omani culture is deeply rooted in the Sultanate’s proud history of seafaring, trading, and exploration. As a result of its location at the tip of the Arabian Peninsula, historically Oman played a major role in trade along the ancient Silk Road and Spice Routes, where it served as a gateway for all ships traversing the Strait of Hormuz, Indian Ocean or the Arabian Sea. During the seventeenth to nineteenth centuries Oman expanded to include cities along the East African coast, from Mombasa to Zanzibar. Throughout the nineteenth and first half of the twentieth centuries, many Omanis resided in Zanzibar and other parts of East Africa. It was also common for Omanis to travel regularly to and from East Africa, engaged in trade or seeking employment and income when drought and depression affected areas of Oman. In 1951 Oman gained independence from Britain and became an independent country (Jones & Ridout, 2015; Peterson, 2004).

The system of government in Oman is absolute monarchy, with leadership conferred to a hereditary sultan who has authority over all branches of government. In the 1960s, Oman’s ruler, Sultan Said bin Taimur, maintained isolationist and anti-development policies, which resulted in widespread poverty, and poor basic infrastructure throughout Oman (Al-Sinani, 2012; Chatty, 2000; Funsch, 2015; Haddad & Esposito, 1998). In 1970, Sultan Qaboos bin Said took power with a well-defined vision to improve conditions for Omani citizens (Kéchichian, 2008). At the time he became sultan, the country had just over 6 miles of paved roads, and only three government funded primary schools, enrolling less than 1,000 boys (UNESCO, 1972). There was also an extreme rate of disease and inadequate healthcare services, with an average lifespan of about fifty (Alshishtawy, 2010; Funsch, 2015). Since 1970, Oman has developed advanced technology and progressive political, economic, and social structures (Al-Lamky, 2007; Al-Sinani, 2012; Goveas & Aslam, 2011). Today Oman’s human development indicators are vastly improved from what they were in 1970 (Phillips & Hunt, 2017).

Beginning early in the 1970s, women were encouraged to play an active role in the national development of Oman. A policy of gender equality in education, encouraging preparation of women for all levels of the Omani workforce was first adopted in the 1970s. Additionally, a basic statute of the country proclaims equal rights and opportunities for all (Al-Lamky, 2007; Funsch, 2015). These policies, as well as others that support women, have encouraged and gradually increased the overall participation of Omani women in the Omani workforce and the highest levels of the government (Besamusca et al., 2015; Goveas & Aslam, 2011; Haddad & Esposito, 1998).

A priority of the Renaissance from the beginning was major investment in health and education sectors (Al-Sinani, 2012; Funsch, 2015). Since the 1970s, the Omani government has placed a high priority on education to develop a strong domestic workforce. There has been an emphasis on the relevance of education responding to the development requirements of Omani society (The Education Council, Sultanate of Oman, 2017). In recent decades, Oman has also made significant strides in the evolution of healthcare with vast improvements in population health (Kronfol, 2012). Improvements in healthcare have dramatically decreased maternal, infant, and child mortality rates (Funsch, 2015).

Nursing in Oman

Prior to 1970, American Nurses provided nursing education in Oman through a 6 to 9-month hospital training program; however this program had very few Omani students (Al Maqbali et al., 2019). According to Al-Riyami et al. (2015), in 1970, there were only five Omani nurses. The Ministry of Health was established shortly after Sultan Qaboos took power, which hastened the development of the healthcare system. During this time, foreign educated workers helped establish the nursing profession in Oman and begin nurse training programs for Omanis. In the early 1980s the government sent many Omani nurses to Britain, Canada, Australia, and the United States to obtain advanced nursing degrees in various specialties. Through these initiatives in nursing education the nursing profession was strengthened and the quality of healthcare in Oman improved (Al Maqbali et al., 2019).

As in most of the rest of the world, nurses in Oman are predominantly women; therefore, “. . .the position of nurses in society and the power they hold, the respect in which they are held and value which is given to their work, is usually closely aligned with the position of women” (Youssef et al., 1997, p. 16). While Omani policies that support women have resulted in active participation of women in the Omani workforce, employment as a nurse has additional barriers, because the nature of nursing work is contrary societal codes of behavior for women, such as working at night, caring for men who are not family members, and working with men in the workplace (Al Awaisi et al., 2015; Kemp & Zhao, 2016; Maben et al., 2010). Evidence of these barriers can be found in other studies as well. The authors in a study on Omani nurses and teachers stated, “Compared with teaching- which is considered prestigious and suitable for women—nursing is considered less prestigious and sometimes, it involves work situations that would not be appropriate for Muslim women” (Zerovec & Bontenbal, 2011, p. 376). In a study by Al-Riyami et al. (2015), Omani nurses and nursing students considered nursing their last option of study because of the cultural, religious, and public perceptions of the status of nursing. In interviews with new graduate nurses in Oman, Al Awaisi et al. (2015) found that the low status of nursing in Oman created intrapersonal conflicts that reduced their confidence and satisfaction with the profession.

Rapid growth, as well as a lack of necessary skills, has made a dependence on migrant workers in all sectors of the workforce necessary throughout Oman’s modernization. By the late 1980s the government recognized the limitations that dependence on a migrant workforce would have on the future development of Oman and adopted a policy known as Omanization in 1988. The Omanization policy, to replace migrant workers with trained Omani citizens, stresses the significance of education and training for development of Oman’s national human resources so that Omani citizens are prepared to do work that was previously done by migrant workers (Aycan et al., 2007). Omanization of the healthcare workforce, as in all other employment sectors, started in the 1990s. The basic strategy for achieving Omanization of the nursing workforce has been the availability of quality nursing education programs. Even so, the percentage of Omani nurses in 2015 only reached 47% overall, and 58% within the Ministry of Health System, so there is still a strong reliance on a migrant nursing workforce (Ministry of Health, 2015). In order to achieve Omanization goals, cooperation between Omani nurses and migrant nurses is needed to transfer nursing jobs from highly skilled and experienced migrant workers to less experienced Omanis without compromising the quality of care. Zerovec and Bontenbal (2011) suggested that this could possibly create tension and competition between the two groups, or it could open new opportunities for collaboration and working relationships. Two studies (Al-Riyami et al., 2015; Zerovec & Bontenbal, 2011) found that both Omani and migrant nurses were concerned that replacing migrant nurses too quickly will not allow enough time for Omani nurses to gain the knowledge and skills needed to continue to provide quality healthcare.

Methods

The key participant in this paper, Azza, is a nurse leader at a large hospital in Oman. Azza chose to use a pseudonym because she prefers to keep the personal details of her life private. Information that could potentially allow identification of the participant is intentionally vague to maintain her anonymity. Azza was recruited because she is an Omani woman who chose to join the workforce, pursue a career in nursing, and follow a path to nurse leadership. The researcher had worked on several projects with Azza in the 3 years prior to undertaking the study, so a relationship had already been established. Azza was asked to identify members of her family and professional network to be interviewed who could offer their perspective of her success. Family members that she identified were her husband, her son, and one of her sisters. From her professional network she identified some of her mentors, a supervisor, some young nurses, and some colleagues with whom she has worked for many years (n = 10). Some of her colleagues were Omani and some were expatriates. These interviews were used to corroborate and expound on themes identified in Azza’s life story.

To ensure protection of human subjects, Institutional Review Board (IRB) approval was obtained from Kennesaw State University in Kennesaw, Georgia (Study #18-396), and Sultan Qaboos University in Oman (REC/2017-2018/08). Written consent was obtained from the primary participant to be asked questions about her life and career. The primary participant selected colleagues and family members who she thought could add information about her life and nursing career. To allow the primary participant control over disclosure about the project, family and colleagues were asked by the primary participant if they would be willing to be interviewed, and only then were they contacted by the researcher. Written consent was obtained from these individuals to be asked questions about the key participant’s life and her nursing career.

The interviews took place in Oman at venues selected by the participants (homes, places of employment, restaurants, and coffee shops). A semi-structured interview guide (see Appendix A), with questions designed to include all life stages, was created to direct the interviews with Azza. The work of Smith (2012) and Casey (1993) informed the approach to the interviews. Their approach allowed participants to contribute to setting the agenda for the research by simply asking them to tell the story of their life. This approach gave Azza the freedom to tell her story on her own terms and identify for herself what was important, rather than responding to an agenda set by the researcher. Allowing her to select family and colleagues who could contribute was also based on this approach. All interviews were conducted in English. I am a native English speaker, with only rudimentary understanding of Arabic. Even though Arabic is the national language of Oman, English is the official language used by the multinational healthcare workforce in Oman, so Azza and her colleagues are required to be highly proficient in English. Family members who were interviewed were also proficient in English. Respect for Omani cultural norms was an explicit consideration for interviews with all participants. These considerations included my dressing conservatively, not asking for photos, and providing gifts for all participants. All interviews were audiotaped with permission of the participants.

Four formal interviews were conducted with Azza, each lasting a little more than an hour. Additionally, many hours of informal time in both personal and professional environments over 5 weeks was spent with her. Each formal interview was opened with a broad topic, and other questions asked were only for clarification. Probing questions were not used. The question for the first interview was, “Tell me how you got where you are today.” The second interview was a continuation of the first. The broad topic for the third interview was the key participant’s personal and family life, and the final interview focused on nursing school and nursing. The semi-structured interview guide was used more as a checklist to make sure topics were covered, however it was not used to direct questions, because the key participant addressed the topics in the interview guide without direct questions. Interviews with family and colleagues each lasted less than 1 hour. Interview questions from the semi-structured interview guide (see Appendix B) were adapted to each participant, based on the participant’s relationship with the key participant. All participants were asked to make comments about the key participant’s nursing and leadership qualities, as well as their perspectives regarding obstacles she has faced. As soon as feasible after each interview, verbatim transcription was completed by a professional transcriptionist and field notes with descriptive and reflective information were recorded by me. These notes were then added to, and correlated with, the verbatim transcripts.

Many topics not included in the structured interviews were discussed in informal social encounters with Azza. These discussions mainly served as a means of building rapport and trust, however, were also a valuable opportunity to seek clarification of previously discussed topics. Field notes with descriptive information, topics discussed, opinions expressed by the key participant, and reflective information were recorded about each encounter.

To ensure rigor, the researcher intentionally bracketed feelings about cultural issues in Oman that she does not understand or with which she disagrees. Interview data from the key informant’s family and colleagues that did not relate directly to her life were also bracketed. Additionally, Azza was asked to review the narrative which resulted from the collected data and make corrections and comments. This resulted in a few corrections to the narrative. Additionally, she added comments that improved the detail in the narrative, which she forgot to share in the original interview. She also asked that a few stories be deleted or modified. Virtually all requested changes were made because none of the changes she requested made a difference in the overall story and resulting themes, and I felt that this is her story and should be told the way she wants it to be told.

Thematic analysis is a way to identify and report themes or patterns within data, and to describe and organize a data set (Braun & Clarke, 2006). The data set used for initial analysis included all transcribed interviews and field notes from primary participant interviews, and field notes from informal time with the primary participant. Family and colleague transcribed interviews were then used to corroborate and expound on identified themes.

Azza’s Life

Azza is an Omani nurse leader who is a nursing pioneer in Oman. Her adult life and career have evolved during a period widely known as the Omani Renaissance that began in 1970. This time of change in Oman brought exceptional opportunities, as well as unique challenges for Azza. Throughout her life, she has been a person who does not hesitate to stand up for what she believes is right, which has been demonstrated throughout her career by her unwavering advocacy for quality healthcare for patients and families, as well as her advocacy for the rights of nurses. Azza feels that personal and professional challenges in her life have strengthened her and contributed to her success as a nurse leader today. As a young girl, Azza had a vision of what she wanted and did not want for her life. In the first interview, when asked how she got where she is, Azza responded,

It wasn’t easy. There were a lot of challenges that I had to go through with my career and my personal life. I felt like I was clear with my goals, where I’m heading and what I wanted with my life.

Early Life

Azza was born in Burundi, a country in east-central Africa in the 1960s. Her parents were Omani but lived in east Africa like many other Omanis at that time. She had two brothers and five sisters, some half and some full. Her father died when she was 9 months old, so she was raised in Burundi by her older brother, along with the nine children he already had. She did not know he was not her father until his daughter (who Azza thought was her sister) told Azza when she was 8 or 9 years old. This upset her, but her brother reassured her he loved her and that she was an equal member of the family, so in line with the resilience she has shown throughout her life, she accepted that he loved her and got on with her life.

In the 1970s, many Omani families who had left Oman returned to assist with the modernization efforts (Jones & Ridout, 2015; Peterson, 2004). According to Azza, her life in Burundi was comfortable and even though her brother knew it would be difficult for them to adapt to new life in Oman, he felt it was important to move to Oman so they would not lose the culture and language of their country. Azza had gone to school in Burundi, but her brother wanted her to be educated in Oman. Azza moved to Oman from Burundi when she was 13 years old. Conditions were difficult—it was extremely hot with no air conditioning, and there was poor infrastructure throughout the country. The next year, when she was fourteen, as was common at the time, her brothers arranged her marriage to a slightly older man who was a friend of the family. He was in the Omani military, which meant he was away most of the time, so she continued to live with her family, and when he came home, he would to get her and take her to his village where his family was. She was not prepared to be a wife, mentally, or in the household skills that she was expected to have. At this time in Omani society all Omanis, women and men, were being encouraged to contribute to the modernization of the country. Azza had a strong desire to continue in school and be trained for a career. During the second year of her marriage her sister and some of her cousins decided to go to nursing school, so she decided she would go too—even though she did not really even know what a nurse did. When her husband returned from military service, he came to get Azza and take her to his village, but she told him she was not going with him because she was going to nursing school. He told her if she did not come, they would be divorced—in Islamic law if the man says it, then it is so. She said, “fine” and they were divorced. This upset her, but she knew this was not the life she wanted.

Early Career Growth Experiences

English language proficiency was important at the beginning of the Omani Renaissance because it was needed to communicate with the British and other international officials and advisors in the early development process (Jones & Ridout, 2015; Peterson, 2004). Nursing school was taught in English, as the common language for healthcare providers, and one of Azza’s biggest challenges was becoming proficient enough at English so she could be admitted to nursing school. She attended classes to learn English for several months before was admitted. She struggled with nursing school at the beginning but worked hard and after a short time started doing very well. She set high standards for herself and was highly motivated to excel. While one of her teachers was from Oman and played an important role in motivating and coaching her, most of her teachers were from India and had a very authoritarian style of teaching. This was difficult for Azza because she liked to question everything.

After graduation from nursing school in the early 1980s, Azza began working in pediatrics. After a year or so, she looked for ways to further her education and experience. On two occasions Azza spoke with great enthusiasm about her work with an Omani pediatrician who was trained in the US (because there were no medical schools in Oman), then returned to Oman to improve the care of children. She credits him with motivating her to develop her skill of advocating for patients. His main issue was to reduce child mortality in Oman due to communicable diseases and gastroenteritis. He focused his efforts on childhood immunizations and teaching proper nutrition, as well as the benefits of breast feeding. He taught the pediatric nurses who worked with him that children must be properly treated because the future of Oman depended on it. Azza was involved in going regularly with this pediatrician to the remote areas of Oman to provide immunizations and basic healthcare to Omani children.

Throughout her entire life, Azza has had a constant desire to grow, to challenge herself with different things. After working in nursing for about 2 years, she took a leave from nursing and tried working in a bank for a few months to see if it was something she might like. They really liked her and wanted to keep her, but she found the work boring—something anyone could do.

At that time, if you know how to write, you know how to calculate, you can do the banking job. When it comes to nursing, not just anybody can do it. You have to have that sort of passion. You have to have tolerance, to be able to work nights, evenings, and weekends, sometime compromising your social life. You have to study pathophysiology, pharmacology, and skills essential to the profession such as critical thinking, cultural variation and decision-making. You have to be able to give hands on care to patients to be able to be a nurse.

After 3 months she decided to quit the banking job and returned to nursing with renewed passion. At that time, the government was funding Omani nurses to study in Britain, Canada, Australia, and the United States, to learn advanced skills and bring them back to Oman. She was nominated with four other Omani nurses to be sponsored by the Omani government to go to London to study pediatric nursing in a specialized program at the Great Ormond Street Hospital for Children, one of the leading pediatric hospitals in the world.

When she returned to Oman, she requested that she be placed in the neonatal unit rather than general pediatrics. At that time, neonatal was new specialty in Oman, and not many Omanis were interested in working in neonatal intensive care units (NICU), but for Azza, it was an opportunity to grow faster in her career and advance to a senior post. She was moved to NICU and loved it. A year or so later, the government again sponsored her to return to London for a year to study neonatal nursing.

Marriage and Family: Striving for Work-Life Balance

Some time in the mid to late 1980s Azza got married for the second time, and during the second year of her marriage she had her only child—a son. She really struggled with issues of work-life balance when her son was young. She did not feel that her husband was helpful, as he was away from the home most of the time in the beginning. She tried to do things on her own but ended up turning to her sisters for help. After several years, her relationship with her husband improved and as her son got older her life improved. Her experiences during this time gave her an appreciation for the difficulties women face balancing work and personal life which she would act on later as a nurse leader.

Throughout this challenging time in her personal life, Azza found strength through her nursing career. When asked whether her nursing career was enjoyable or stressful during this time, she said that it was stressful, but she enjoyed it and it was something not just anyone could do.

Middle Career

After returning to Oman from her second government sponsored training in the UK in neonatal nursing, Azza began working in the NICU of a large government hospital in urban Oman. At that time most of the managers were western people because according to Azza, there were very few Omani nurses with the necessary clinical or management skills. Slowly, the western people resigned to go back to their home countries, and because of her education and experience Azza progressed up the management ladder. While she found the work enjoyable and challenging, there was inadequate financial compensation, so Azza left nursing to take a position as a sales representative for a medical product company to earn a higher salary. She hated the job because she did not find it at all interesting. She missed interaction with patients and nurse colleagues, and after 2 years she decided the higher salary was not worth it and returned to neonatal nursing at an academic medical center as an assistant nurse manager. One of the highlights of her career during this period was being part of the team that cared for the only sextuplets ever delivered in Oman. This new position brought opportunities to hone her skills as an advocate for patients and nurses.

Leadership Development

Azza spent a year or two in the assistant nurse manager role. She used this experience to refine her clinical skills and begin development of leadership skills. Most top management positions at that time were held by migrant nurses because they had more experience than Omani nurses. A Southeast Asian nurse was recruited to the head nurse position in the neonatal unit. Azza learned much from this mentor and this is when she really began to develop her leadership skills.

By the mid-1990s Oman had begun the nationwide policy of Omanization, which was to replace expatriate workers with qualified Omani workers as much as possible across all employment sectors. Leaders of the medical center focused on finding Omani nurses to take positions in nursing administration. It was a competitive situation with many challenges, and when Azza was appointed to positions of leadership, she felt she was not always accepted because many of the expatriate nurses thought the Omanis were not qualified. All the things Azza had experienced before were the foundation for her leadership development, but at this point, she began a new focus on becoming a leader. Initially, Azza was not chosen for leadership development, but as she had always done in her life, she found other opportunities for growth toward her vision of herself as a nurse leader.

In a competitive process, Azza applied and was funded to go to Australia for a two-year master’s program of study. When she was informed by the nursing director that she had been selected for the award, Azza got the distinct impression that the director did not think Azza would successfully complete the masters, however, she did so with distinguished marks. When she returned, she felt even more competent in her work and continued to compete for leadership positions. Ultimately, after several more years of leadership development, Azza was appointed as the highest-ranking nurse in her organization.

Moving Forward

Azza has been in the highest nursing leadership position in her organization for several years now and while her challenges continue, she is more comfortable in the role. She is supported by the leader above her who described her as a strong and compassionate leader and listener who knows how to solve problems with a mature personality.

Currently, her most challenging issue is related to working hours for nursing professionals. Based on a study conducted in her institute, 70% of the nurses are not happy to do shift hours. She is now advocating for new models to help nurses achieve better work/life balance. She strongly believes that if the health institutes do not look for ways to help nurses balance their work/life, it will be very difficult to retain them. She commented that she remembers how difficult it was for her to balance work with her personal life when her son was young, and she is trying to improve those conditions. She is also advocating for better compensation for nurses who work evening and night shifts. At the request of the senior leadership, she worked with a researcher who investigated why nurses have left the medical center. The reasons included the need for an on-site childcare center and the desire for shift differential for evening and night shifts. When Azza discussed these findings with the senior leaders, who were all men, they did not agree because they said nurses are supposed to work shifts. Azza told them bluntly that women are expected to do two jobs. They are expected to do their work at home, as well as their nursing job, and Azza told the leaders that they should not compare themselves to nurses because even though many husbands help women with house and childcare, the women feel more responsible for making sure it is completed. Azza has come up with several possible solutions, but they all require more nursing staff. When the leaders told her that this will cost more money, she told them that was not her concern, that it was up to them to find the money to improve the conditions for the nurses. Improving work/life balance and compensation for nurses is a goal that Azza wants to achieve before she finishes her career and she is confident that she will succeed.

In talking about the future, Azza expressed concerns about leadership succession planning for her position. At this moment, she feels that it is very difficult to make any judgment about who the next leader will be. She currently has a few nurses on her team that will have their PhD and have the potential to take the high position in nursing. She commented that the maturity required for leadership is essential. She knows that when the time comes, she will fully support whoever steps into the high post in nursing.

Themes and Subthemes

As the data were analyzed, three dominant themes in Azza’s life story were apparent: opportunity, visionary, and nurse. Each dominant theme has subthemes that describe aspects of the dominant theme. Subthemes of opportunity are national identity, country building, and nursing pioneer. Subthemes of visionary are leadership, perseverance, resilience, and mentors. Subthemes of nurse are advocacy, caring, and fulfillment. These themes were sometimes simultaneous, sequential, and/or interconnected, however they are separated in this discussion for clarity in presentation of results.

Theme: Opportunity

Azza’s life and career have taken place during the Omani Renaissance, a period of tremendous social and economic change in Oman. This time of change presented Azza with personal opportunities for education, employment, and professional advancement, as well as opportunities to contribute to the modernization of healthcare and nursing in Oman.

Subtheme: National Identity. Being Omani is central to Azza’s story within the context of Omani modernization. Throughout her life, being Omani has presented both opportunities and responsibilities. Evidence of this sense of national identity began early in her life. When her family lived in Burundi, prior to moving to Oman, they identified themselves as Omani and referred to Oman as their country.

In the 70s, His Majesty took over Oman, and most of Omanis who [had] left Oman, they want to go back. And he [father/brother] started coming here to Oman just to catch up with the life, catch up with the rest of our properties in our country. Then he thought the best idea is we move. . .. And his idea was to take the youngest first, so they can start to be educated in our own language, our own culture, not to lose our own culture.

In an informal discussion with Azza about different occupations within Omani society, she explained that Omanis do not really consider one job better than another. They do not worry about what others think. In a famous speech by Sultan Qaboos calling for all Omanis, both women and men, to contribute to the modernization of the country, Azza explained that this desire to contribute is an important aspect of what it means to be Omani. In her view, the speech articulated their culture and supported the Omani emphasis on the importance of the contributions of each individual to society regardless of the form of the contribution.

The opportunities and responsibilities of national identity appeared to also be understood by an expatriate nursing colleague as evidenced by comments regarding Azza’s leadership.

“In the current time they won’t get anybody that is better than her. I mean I’m talking about the Omanis”.

Subtheme: Country Building

Early in her story Azza spoke about opportunities for all Omanis to develop themselves so that they could contribute to building the country.

At that time. . . Anybody who could do the work to get through the training. . . this is where the Omanis started to be developing. They needed to bring up more Omanis, to offer them jobs, and there were a lot of opportunities, all over, in all fields.

The ideas of Azza’s pediatrician mentor impressed her with how important the health of children was to the future of Oman. This greatly influenced her desire to specialize in the care of babies and children.

He said, ‘If you don’t treat the children right, you never have equality of a human being. And this is where you need to start. If you give the best [in this time] of their life, this best will be the better outcome of the Omani future.’

The Omanization policy began in the 1990s (Aycan et al., 2007). The policy allows opportunities for Omanis to contribute to the building of their country rather than depending on expatriates. There is an understanding by both Omani and expatriate nurses that Omanis will be given preference for positions if they are qualified, and that Omanis will be trained for all top leadership positions because this is important for the building of the country.

At that time, they were looking for somebody to be developed into the Director of Nursing because the Director of Nursing had [about] five more years before retirement. So they were looking for an Omani who can be developed.

While the Omanization policy means opportunities for Omani nurses, it also creates some difficulties in the workplace because sometimes the Omanis are not accepted as qualified and have to prove themselves. This is evident in Azza’s comments about taking a new job for which she was highly qualified, however, her head nurse, who was an expatriate, did not accept her because she was an Omani.

She [head nurse] had her own plan with the people who were there, and she said, ‘It isn’t fair because there are the people [who have] been working here and you bring us somebody, and she is an Omani, and you want to put her in a higher position.’

Opportunities during a time of country building, require hard work. Nurses like Azza have accepted opportunities for education and development, along with the effort required, and therefore have been important to the attainment of the country’s vision for the modernization of healthcare and development of the nursing profession.

Subtheme: Nursing pioneer

Merriam – Webster defines a pioneer as “a person that originates or helps open up a new line of thought or activity” (“Pioneer”, 2018). Azza has been a nursing pioneer by forging the direction of nursing and healthcare in Oman. Early in the modernization period, western nurses were called on to serve in positions of leadership and help make decisions about the future of nursing and healthcare in Oman; however, once Omani nurses attained the needed education and experience they have begun to step into leadership positions to shape nursing and healthcare in their own country. Early in her career Azza seized these opportunities to help Oman reach milestones, especially in pediatrics and neonatology. She traveled to remote areas to immunize children against communicable diseases.

We used to go in the helicopter. You go somewhere, there is no life - nothing. Some people (called Bedouins) live under the trees with their beloved animals, mountains, and some in the caves. You found people are coming from the caves, running when they see the helicopter because they knew they could get some help. Some of them are just coming for the food. We used to take our medication kit with medication and thermometer and blood pressure meter (sphygmomanometer). We just take some sort of medicine if they need anything - mainly pain killers, and we would just give vaccination to them and we moved on to the different mountains, and here . . . some of them they just hand their children to us - seeking for help. It was very painful to see how they were desperate for help. Those who are really sick, we would bring them with us in the helicopter and they would be treated, and they would be sent back. And some of them were not even able to come for the follow-up and [the pediatrician] had to create a budget for those kind of people, to make sure they were getting follow-up. Thanks to His Majesty Sultan Qaboos to provide free health services to all Omanis and people living in Oman. I said [to those who asked about what we were doing], ‘you do not see what is the real need of Omani people. What you see here is nothing. There are really people who are desperate.’ We were helping in many aspects, but thanks to His Majesty, the help was expanding day by day.

She chose to specialize in neonatal, because it was new specialty developed in Oman, and not many Omanis were interested in working in NICU. Azza’s career journey has included involvement in committees that made recommendations about the organization of healthcare and nursing throughout the country. She is a nurse who has always recognized her role in advocating for quality care for patients, as well as the rights of nurses. A colleague described the significance of the work she has done in nursing.

I think she is one of the pioneer nurses. . . . She communicates well and . . . I think she has very good vision for nursing, but I’m sure she has faced a lot of obstacles, and it’s not an easy job for her because I see her sitting in many boards as the only nurse representing this large population of nursing. So she has to convince everyone of so many things they are not convinced because 99% are doctors. . . . and what she thinks is important, they may not think that is important. So I think she is a fighter, that she can do all this alone in nursing.

An Omani nurse leader from the Ministry of Health, who worked with Azza for many years said,

We had a professional relationship because we had a lot of things we needed to do together. It was important for us to talk about how we organize maternal and health services for all of Muscat. And we formed committees, on which Azza was a member, and we had obstetricians, we had pediatricians. We produced policies in terms of transferring babies from one institution to another. . ..

Theme: Visionary

Visionary is defined by Merriam-Webster as “having or marked by foresight and imagination” (“Visionary”, 2018). Azza has been a visionary throughout her entire adult life. Being visionary means that Azza has set significant goals, then worked tirelessly to accomplish them without fear of failure or opposition. She made decisions about her life based on how she saw herself in the future. She also had a passion for growing that drove her decisions about her life course.

“When my husband comes back from work, I have to go with him to his hometown and this is how it went on, and I did not see myself for that kind of life.”

Or here is what she said about her time in banking,

“I felt no, this isn’t my job because I felt it was so boring and I felt like anybody can do it. I did not see myself, this is what I want to do.”

Regarding her time studying in the UK she commented,

“Some of them were very, very nice and . . . there were other people, they were not as nice. Anyway, it did not bother me much, because I had my own goals to achieve.”

Subtheme: Leadership

Aside from being a visionary for her own life, Azza has also been a visionary leader for nursing and healthcare in Oman. Early in her career she identified opportunities to improve healthcare and contributed to improvements in these areas through her pioneer activities into the Omani interiors, as well as her willingness to train in an area of need for the country. She also saw needs for vast improvements in nursing, such as developing new Omani nurses, developing nurses in needed specializations, and developing nursing leadership, and she has made these priorities in her leadership positions. One young nursing colleague commented about her leadership vision regarding education for Omani nurses.

She thinks that education is very important, and she supports that 100%. So she would never say that oh, we have a shortage . . ., or can you postpone your studies, or we will focus on the institute. She will never say that. When you go with opportunity, especially when you fulfill the conditions of the institute as whole, she will never stop you. She will never come in between you and your higher studies because she thinks it’s important for us to get specialized and to get that knowledge from outside the country.

Another young colleague described her vision in mentoring others.

She has a vision about people. I would appreciate really that about her. The vision and the wisdom when she sees somebody and she works with them she has this idea about the person and she will have the career path for them. She can see it.

Several young nursing colleagues commented on her leadership,

When she gives direction, she doesn’t give it really in a harsh way or demeaning way; she will give it with respect. So, we would take that message positively and we will do whatever she is asking us to do.

Subtheme: Perseverance

Azza described many aspects of her life as not easy, yet she persevered despite difficulties, failures, and opposition. She spoke many times of showing her strength in difficult times by proving herself – she just keeps working toward whatever goal she is trying to achieve.

So these are the two people who are supporting each other and were really, really challenging me in a way that I’m feeling “this is a nightmare”. It’s really stress for me in a way that I’m just trying to adapt myself in the new role and I want to prove myself as a leader and people were challenging me and not accepting me and there was quite a group of them, they were not even supporting me because they are supporting [someone else]. But I said to myself, I will try and prove myself that I can do it.

Regarding a time that she felt her supervisor did not like her and was not offering support, she said,

“I just tried to be more professional and I tried to respect her and tried to prove myself.”

Another aspect of her perseverance is her passion for growing. Anytime in her life that she has felt bored, she has looked for new opportunities to keep her interested and challenged.

“. . . I had this passion for growing and doing something because it was a different from doing the routine, coming from morning shift to evening shift and doing the same thing.”

Another way that Azza has increased her confidence in difficult times so that she has been able to persist, has been through preparation and education.

Subtheme: Resilience

Azza has also displayed the ability to recover from any misfortune or adjust to any change she has faced. Early in her life when she found out that the man she believed was her father was actually her brother, she showed resilience.

“. . . I thought, okay, now I know he is not my father, but he loves me, and I continued to be me, and live that normal life and go to school together and play together [with his children].”

She spoke often of feeling stronger after times of adversity.

“So it was like a really ongoing challenge in life you know at that age. And . . . it made me to be even more stronger and stronger. . .”

“And it was really, really very, very tough. But thank God, it made me even stronger. . . “

She also developed her sense of independence as another means of resilience. Her first marriage, arranged by her brothers, gave her little opportunity for independence. Nursing school was the path to independence at that time. She never gave any insight about her husband or his family, she wanted out because it was not how she saw herself. She reinterpreted the norms of social life and left her husband after only a couple of years. It is unclear how common this desire for independence was for Omani women at this time, however, it is clearly important to Azza.

“. . .it was good experience for me to be out of home you know, being independent and to be on myself, you know for everything.”

Subtheme: Mentors

Azza has sought out mentors to help her make the best possible decisions. She has been influenced by those from whom she feels she can learn and does not hesitate to ask for help making decisions.

“[When] I need to make the right decision. . . I need to ask people who know exactly what is happening.”

An expatriate nurse who has worked with Azza for many years said,

She was always somebody who was very willing to listen, to learn. One of the things about [Azza] is that whenever she has to make a decision, she doesn’t take it alone. She always consults, she always seeks some advice. She would consult me if she’s not sure, she’d come, and she’d ask me, ‘this happened and I was thinking it was like this, but I just need to go by you.’

Theme: Nurse

Azza chose to study nursing out of convenience, because she saw it as a means to get more education, or a job to start her career, but nursing was a perfect fit for her abilities and desires. Being a nurse is more than a career, it is part of her identity. Twice in her career Azza left nursing to try other jobs, but both times she returned because she recognized that nursing requires the special skills that she possesses.

When it comes to nursing, not just anybody can do it. You have to have that sort of passion. You have to have tolerance, to be able to work nights, evenings, and weekends, sometime compromising your social life. You have to study pathophysiology, pharmacology, and skills essential to the profession such as critical thinking, cultural variation, and decision-making. You have to be able to give hands on care to patients to be able to be a nurse.

Subtheme: Advocacy

Throughout her entire life Azza has had strong skills for advocating for herself, her patients and their families, and nursing. She stood up for herself and what she believed was right even before she became a nurse, but a passion for advocating for patients is what she enjoys most about being a nurse.

“I. . . have this sort of passion for advocating for the patients and the mothers. . .So this is how I started liking my job.”

Many of her colleagues believe her greatest contribution is her advocacy for nurses and what is right.

[Her greatest contribution is standing up for] the nurses’ rights in this hospital, . . . that’s a huge progress that I thought I would never see. And also keeping nurses always updated, [with] education. She works for the well-being of their training. She’s even on a project of work life balance now and it’s going to be the first workshop in the whole country.

She has developed excellent advocacy skills throughout her life. Her colleagues describe her as persuasive, level-headed, well informed, and skilled at making rational arguments.

She had to advocate everything for nurses. . . . and dealing with a lot of people who do not understand nursing.

She is strong advocate for her patients’ mothers. One of her greatest contributions is she is a strong advocate of the nurses. Not only for the Omani but for the expatriate nurses.

Subtheme: Caring

Azza cares deeply for others and nursing has given her a way of demonstrating her caring.

[Caring] is why I found myself in nursing. I love children and I love those kids. . . . I had like a bonding with these mothers and these babies. And some of them you know, even when I go home, it’s just that my mind is still thinking about them.

I know they needed someone to talk to them, to lower a level that they can understand. . . [someone who] feels for them. And before even I talked to them, I keep always in my mind, if I would have been their mother, how would I have felt about this. Whenever you feel that way in that situation, definitely you’re talking to somebody not only as a nurse – you are talking to somebody also as a mother. And this is where you get connected.

Early in her career she struggled with watching the suffering of others and the expectation by other nurses that she should not react with strong feelings. This expectation made her consider leaving nursing, but she learned to handle her feelings and continued.

I said, ‘No way - I’m a human being! I cannot see somebody this kind of [suffering] and [not have feelings] for it! . . . I ended up going home and I couldn’t sleep. It took me sometime to forget the girl. They were expecting me to not get affected with any death at my working place.

I asked one of my colleagues who had worked in nursing for more than 10 years, ‘How do you feel if your patient died?’ She replied proudly that [she feels] nothing, ‘Because we are nurses, we should be strong,’ and I felt like really, I did not want to continue this job [if that is what is expected].

She also conveys this caring spirit as a nurse leader. Several colleagues expressed their appreciation for her being such a caring leader.

I just adore her. It’s not that we are friends, but you just know a person who cares. I’m not her neighbor or not related to her. I don’t even work in the same area with her, but I know that if I’m in trouble or I think there is something wrong, I can always go for her support. I don’t even need to come; I send her a message. Where on earth are you going to get someone like that? Well, she’s here.

Subtheme: Fulfillment

Being a nurse is a tremendous source of fulfillment for Azza. She spoke about her pride many times in telling her story.

When talking about the nursing job - it’s better than the people who don’t do anything and I’m proud of myself.

[I saw nursing] as a job I can do, and I can do better. I can be somebody which I feel like is important to me. And I was proud of what I was doing.

I always felt that nursing was a challenge of which I like to do the challenging job. And I always felt that a nurse job, not everybody can do it, and this is what made me even more proud.

Conclusion

The results of this study have potential implications at individual, organizational, and societal levels. Azza’s story demonstrates how nurses can make contributions to solving health and healthcare problems, individually, and nationally. Stories of nurses and nurse leaders have the potential to inspire young persons, particularly women, to choose careers in nursing because of the power of nurses to change and save lives. Stories that inspire more young women to enter nursing and encourage nurses to stay in nursing, have the capacity to impact the global shortage of nurses. Stories are an important means for enlightening those with limited exposure to healthcare, about the significant roles nurses play, particularly in developing countries where opportunities for exposure to healthcare are often limited. Stories of nurses’ contributions are also a means of informing healthcare stakeholders so that the contributions of nurses are recognized and the influence of nurses within healthcare systems is enhanced.

Knowledge about nursing history is relevant to understanding the past, informing the present, and influencing the future of nursing (Fairman & D’Antonio, 2013), therefore, Azza’s account of the development of nursing and healthcare in Oman adds significant knowledge which can inform and influence nursing in Oman and elsewhere, particularly those undergoing rapid modernization. Prior to the current study, there were no studies that subjectively described what the nursing profession was like for individual nurses during this significant time in Omani history. Given that there are no other studies that describe the life of an Omani nursing student or nurse during this time, Azza’s account of her career development also adds to the existing body of knowledge on Arab and Omani women’s employment, as well as Omani nurses and the path to nurse leadership.

On a personal level, becoming a nurse was a means for financial independence and autonomy for Azza. A career in nursing also provided her opportunities for international travel and advanced education. The results of this study suggest that perseverance and resilience were personal qualities that helped her overcome barriers on her path to becoming a nurse and a leader and that Azza’s desire and ability to advocate for the needs of others, as well as her need to care for others, aligns with a career in nursing, resulting in a sense of fulfillment. This sense of fulfillment likely serves as an enabling factor for her retention in the profession and her development as a nurse leader. It is important to identify qualities to help nurses overcome barriers and persevere in the profession and develop into nurse leaders. Once qualities that help nurses overcome barriers and persevere in the profession and develop into nurse leaders are identified studies should be conducted to determine how to measure and develop these qualities in nursing education programs.

Knowledge about facilitators and barriers to choosing and staying in nursing can help nursing and healthcare policymakers put policies in place to continue to attract and retain nurses. For example, the current results suggest that policies that increased opportunities for educational development in nursing facilitated Azza’s career growth, therefore institutional and government policies which increase these opportunities have the potential to serve as facilitators to retaining women in nursing in addition to expanding the profession, as a result of nurses being more highly developed. While results of the current study are not generalizable to all populations, they serve as a starting point for studying the impact of institutional and government policies which increase opportunities for professional development. The current study found that government policies designed to develop a local nursing workforce (e.g., Omanization, government funding for education) positively impacted Azza’s development as a nurse leader. Studies to examine the effects of these policies on the quality and character of nursing care are vital for development of future policies. These studies should employ varied methodologies to reveal the perspectives of patients, as well as empirical knowledge about patient outcomes. Studies about the effects of localization policies on the nursing work environment are also vital. Globally, it is essential to add to existing knowledge about the effects of localization policies within the context of nurse migration on nurses and patients in source and destination countries.

Azza’s internal motivation to work as a nurse, which is similar to the Western conceptualization of a calling to nursing, is another finding that has implications for several aspects of nursing. The concept of calling has not been studied in Omani or Arab nurses, so it is unclear whether it is conceptualized in the same way in this population as it is in Western cultures. Results from the current study suggest that persons who do not have knowledge about the nursing profession may enter the profession without a calling, then realize their calling once they study nursing and begin doing nursing work. Whether nurses have a calling could possibly have implications for patient perceptions of the quality and character of nursing care. Helping young people recognize a calling could impact recruitment and support of nursing students and practicing nurses. Because perceiving a calling has been linked to greater career commitment (Duffy & Dik, 2013), perhaps institutional support for identifying and supporting nurses with a calling to nursing may have implications for the nursing workforce through recruitment and retention in nursing.

Studying the lives and careers of nurses globally is foundational to understanding the discipline of nursing. Use of life history methodology to study the lives of ordinary nurses throughout the world has the potential to provide rich knowledge about the values of nurses and to identify similarities and differences in nursing practice and nurses within the context of differing cultures. Nursing scholars have identified four major concepts as the organizing framework around which the conceptual development of nursing knowledge has proceeded: person, environment, health, and nursing (Thorne et al., 1998). Life histories of nurses globally have the potential to enrich disciplinary knowledge about perspectives of these concepts, which is integral to the development of nursing practitioners and researchers who can provide leadership in addressing key healthcare issues.

Author Biography

Christie Emerson, RN, DNS is an assistant professor at Kennesaw State University, Wellstar School of Nursing in Kennesaw, GA, USA.

Appendix A: Key Participant Interview Guide

• Where and when were you born?

• Can you help me put together a genogram so I can understand your family?

• Tell me about your childhood years.

• What was school like for you as a child?

• How would you say Oman has changed since you were young?

• Tell me about your marriage.

• Tell me about your time after graduation from secondary school.

• Tell me about your nursing career.

• How did you become a nurse leader?

• What has brought you the greatest satisfaction in life?

Appendix B: Support Participant Interview Guide

• What is your relationship to the primary participant?

• Describe your observations of the primary participant in her nursing career.

• Has the primary participant’s nursing career ever effected on you?

• Describe the primary participant’s most important contributions.

• What haven’t we talked about related to the primary participant that you would like to share?