Nursing Education and its Cultural Congruency in the Sultanate of Oman : Case Study

Background: The purpose of this study is to explore whether the cultural aspects of client care as included in the nursing curriculum in the Sultanate of Oman are satisfactory. This concept will be examined by reviewing the Omani Ministry of Health‟s (MoH) approach to designing, developing, and implementing a general nursing curriculum. Method: This case study was explored qualitatively to determine whether nursing education addresses culturally congruent care adequately through the review of educational policy documents, semi-structured qualitative individual interviews, and focus groups. The data was collected from the MoH‟s nursing education decision-makers, educators, students, and service users (public) over a period of six months. To identify themes, the data was analyzed using Ritchie and Spencer‟s five-stage analytical framework. The study used purposeful sampling to select study participants from the MoH nursing education decision-makers, educators, students and service users. Results: The study revealed that the MoH‟s current approach to nursing curriculum falls short of what Denis Lawton considers a culturally competent curriculum. Conclusion: The study proposes to reexamine the cultural care content in the nursing education in Oman.


Introduction
The cultural aspects of care are crucial for nursing curricula in addressing the holistic needs of patients [1,2].In the Sultanate of Oman, the expansion of the Ministry of Health"s (MoH) healthcare facilities and services, combined with the Omanization policy, has led to an increased need for well-trained national (Omani) healthcare professionals [3].In response to this need, Ministry of Health Educational Institutes (MoHEIs) were established and designed nursing and allied health disciplines educational programs in support of its national health policy.The MoH proclaims that the MoHEIs programs were designed to emphasize culture, family, community, and the healthcare system.
There are several challenges faced by nursing education in the Gulf Cooperation Council (GCC) countries, including Oman.The nursing curriculums are founded on the Western model of nursing education.This is due to the lack of an alternative regional healthcare model and the limited number of Arabic nursing textbooks [4].The adoption of Western-based nursing models often conflicts with local cultural values and beliefs [5,6].The majority of the nursing faculty is expatriates who originate from diverse cultural and linguistic backgrounds, such as India, Philippines, Jordan, Egypt, South Africa, and United Kingdom.With the prevailing view that nursing is a technical and low-level profession, the social image of nursing in the Gulf Cooperative Council (GCC) countries, including Oman, remains negative [7].Nurses in Oman are simply seen as a doctor"s assistant [8].These viewpoints, when combined with a social preference for prestigious academic fields of study and a lack of family support, have resulted in a lack of awareness regarding nursing as a career choice in Oman [9].

Literature Review
"Good care" is a culturally-based phenomenon [10].While caring for patients, nurses may project their own culturally based values onto them who might come from backgrounds different to their own [11 ].To address this issue, several cultural competence models have been developed.These include [12] culture-based care requires proper communication skills, which are vital to building a strong nurse-patient relationship [13].Culture is an important concept for individuals and communities as it shapes the way health, illness, and quality of life are perceived [14].Leininger the founder of the movement, defined culture as "the learned and transmitted values, beliefs, and practices that Citation: Junaibi SA, Chambers D and Narayanasamy A. Nursing education and its cultural congruency in the sultanate of Oman: Case study (2019) Nursing and Health Care 4: 6-12 7 provided a critical means to establish culture care patterns from the people" (pg.91).Yet, this definition by Leininger seems to ignore the culture of the nurse in the relationship and assumes that increased knowledge and understanding of other cultures would lead to tolerance, respect, and cause prejudiced behaviors to change [15,16].In addition, this definition seems to promote the idea of "us versus them", which may lead to discrimination.The culture care construct is a holistic perspective that involves a cognitively learned, conveyed professional and native values, beliefs, and ways of life [17].Numerous authors emphasize that it is crucial for a healthcare system to respond to patients" cultural values, beliefs, and traditions [18][19][20][21].Culturally congruent care is that care which is tailored for compatibility with the patient"s own values, beliefs, traditions, practices, and lifestyle [22].Therefore, the inclusion of cultural competence in nursing education programs would provide student nurses with the knowledge and skills necessary to serve culturally diverse patients [23].Indeed, as Omani people are adamant in preserving their cultural traditions and customs, Omani nurses must understand and work effectively within this cultural context.Therefore, it is vital that the nursing programs prepare student nurses to understand the key concerns and emerging challenges faced by healthcare service users and professionals within a cultural context to provide effective, competent care.

Central Concepts Curriculum
Any curriculum is based on the educational philosophy of its developers; therefore, it represents the developers" values and beliefs concerning the acquisition of knowledge.When designing an educational program, the developer must also incorporate the philosophical values and beliefs of the educational institution and its views on learning.According to Lawton [24], curriculum is essential and is a selection from a societal culture.This includes aspects of the culture or society"s way of life, knowledge, attitudes, and values perceived as important.Therefore, the transmission of these aspects to the next generation should be entrusted to specially-trained professionals (educators).

Professionalism
A profession is determined by certain identified work standards, a body of knowledge, and an established codes of ethics.Professionals are generally defined in terms of a specific body of knowledge obtained through formal education, an expanded level of skills, certification to verify entry to the profession, and a set of behavioral norms known as "professionalism" [25].Professionalism indicates attitudes that represent high levels of identification with and commitment to a specific profession.Attributes of professionalism include educational preparation, research, scholarship, participation in professional organizations, and community service.Using theory to maintain competence in the field and abiding by the code of nursing ethics are all part of professionalism.In the area of nursing, professionalism is focused on the expansion of the role of nursing in a rapidly evolving healthcare setting.The healthcare system is constantly changing due to societal needs, service-user demands, government policies, technological developments, and economical pressures.The development of high-quality nursing care should incorporate these cultural changes into their educational programs.To enhance public perception, nursing must reflect the level of professionalism as presented in other professions.
How do the MoH"s approaches to the nursing curriculum impact nursing education in the Sultanate of Oman? 2.
How culturally congruent is the MoH"s nursing curriculum?

Methods
This is a qualitative multiple-case research design which will investigate whether Oman"s nursing curriculum adequately addresses cultural congruency [26,27].The investigator used educational policies, semi-structured individual interviews and focus group interviews to collect data.Using purposeful sampling, nursing education decision-makers, educators, students, and service users (public) were interviewed over a 6-month period (Table 1 and Figure 1).The participants" inclusion criteria were nursing administrators, nursing educators, nursing students, service users or the public.

Data Analysis
All data were initially collected and recorded in either English or Arabic, with the Arabic sequentially being translated into English.All recoded interviews with their transcripts were reviewed for any inconsistencies.Using Ritchie and Spencer"s [28] framework analysis, the data was analyzed with a case-within and cross-case approach.This analysis consists of five stages: familiarizing, identifying a thematic framework, indexing, charting, and mapping and interpretation (Figure 2, Tables 2 and 3).

Reflexivity
As the researcher is the primary who collected and analyzed the data, reflexivity is essential [27,29].According to Patton [30] reflexivity allows the researcher to be aware of not only the cultural, political, social, linguistic, and ideological origins of their own assumptions but also the viewpoints of the study participants.It is important that the researcher is aware of their own personal assumptions and beliefs throughout the study [27,29].Field notes were incorporated into the charting and indexing of codes and themes, which enabled the investigator to track theoretical perspectives, assumptions, and emotional reactions.

Results and Discussion
Meeting the healthcare needs When examining the data, several themes emerged.These emerging themes included whether the nursing curriculum was meeting the needs of Oman.The study revealed that the MoH nursing curriculum was intended to educate future nurses needed to fill expanding healthcare facilities.Along with biomedical support courses such as anatomy and physiology, biochemistry, and nutrition, the focus of the curriculum is centered on core nursing courses.The findings support that the MoH nursing curriculum is almost entirely nursing discipline-focused and is purely to educate nurses who will be employed in the hospital setting.
An example statement is as follows: He the minister wanted to create a cadre and have numbers and he was establishing new nursing institutes, so he needed to fill the institutes, so that is a major problem here with nursing education (Admin 5).This is consistent with the essentialist philosophy of education, which proclaims a philosophy that focusses on the process of learning rather than the content of the curriculum.Furthermore, the case study findings indicate that this approach has led to the general belief that nursing education should be strictly discipline-focused and rich in content.The findings suggest that the Omanization of nursing education and practice is beneficial in Oman because it reduces the reliance on expatriate nurses and lessens the cultural incongruences in healthcare services.
A culturally congruent nursing education would facilitate nurses to provide patients with care that is familiar, supportive, and meaningful within their cultural context [1,31].By excluding international nurses, the Omanization of nursing may become so parochial and inward looking, resulting in a lack of cultural diversity and mutuality.The main aim for Omanization of the nursing profession is to minimize misunderstanding between the healthcare providers and service users.However, the MoH"s approach to nursing education only seems to place emphasis on how many nurses are produced rather than the quality of education.As one subject explains: Repeating exams twice or more is not appropriate if we want better we need a better, rigid system that is able to filter graduates … we do not have to have 100 percent graduation, or even 90 percent (Admin 9).These findings are in accordance with those of other studies, where all GCC countries have adopted policies based on the beliefs that indigenous nurses are more suitable to care for the population of clients within their own locals.These assumptions are based on the belief that local nurses are best able to provide good quality nursing care because they already understand the language and culture [32].A study conducted in Saudi Arabia highlighted the positive impact of healthcare satisfaction and outcomes when Arabic language for communication is used.Not only does using Arabic improve client satisfaction and outcomes, speaking in Arabic decreases conflicts and miscommunication between healthcare professionals and clients [33].
Therefore, language barriers between the nurse and patient may result in miscommunication that could negatively influence their relationship [34][35][36].This failure to communicate with healthcare providers not only creates a hurdle in accessing healthcare but also challenges trust in the quality of the provided healthcare [37,38].As language is vital to how culture operates, even a nurse"s ability to speak a few words and phrases of the patient"s language may increase trust by reducing communication barriers [39].

Attitudes and behaviors of nursing graduates
The image of nursing as "a dirty job" posed a challenge for the MoH.It is believed that the lack of interest in the nursing profession may be derived from this poor image, or a lack of awareness of the profession"s vast opportunities.The nature of nursing work with heavy workloads, long shifts, and holiday coverage often clashes with the traditional Omani family lifestyle.Other factors such as low wages, limited professional development, and absence of support for working mothers are often stated as problematic to entering the profession [40].
These challenges detriment the quality and type of applicants to the MoH nursing programme.Participants commented as follows: The Omani culture still sees nursing as a low job and regards the mixed (female/male) working environment as unfavourable, which means nursing is not seen as a reputable profession, and this is the cause of the students" bad attitudes (Teacher 2).
There are seven women in my family who are nurses… but still I did not think nursing can be the career for me because of the long hours and different shifts.I saw how hard they had to work (Nursing Student 3).
The analysis of the data indicates that the current MoH nursing curriculum does not address the negative impact of the poor image of nursing with the nursing students which is echoed in their negative attitudes and behaviors toward the nursing profession [41].The poor image of nursing and the lack of interest in nursing as a career is a global phenomenon that is not exclusive to Oman.These findings correlate with several studies that address the image and perceived status of the nursing profession [42][43][44][45][46].According to a study by Al-Omar [9] only 5.2% of a sample of high school students in Saudi Arabia intended to pursue nursing after graduating secondary school.While, in Tanzania, the nursing profession was the least popular of all allied health profession that were indicated, with only 9% indicating an interest.This is consistent with Fletcher"s study which states that most nurses do not hold a positive sense of worth or think highly of themselves.
Despite, the social image and professional status of nursing still being negative in Oman and other GCC countries, there are certain emerging positive perceptions of nursing profession in Oman.An example statement is as follows: "Nursing is a profession which makes us closer to Allah (God), because helping people in need is a religious duty, and Allah rewards us when we help others in need" Nursing Student Assisting a person in need is regarded as a religious duty and a way to be close to God (Allah).Other studies positively suggest the nursing profession as a "calling".Other studies positively suggest that many students are driven to select nursing from a desire to help others.3: The generated cross-case themes and sub-themes across the four cases

Caring: An Omani perspective
The current MoH nursing curriculum does not place emphasis on the concept of caring as an essential value in nursing education.The importance of prayer rituals in patient care were not part of the nursing curriculum.The participants interpreted the concept of "caring" to represent compassionate care and effective communication with patients and their families.Participants" interpretation of caring is attributed to their cultural understanding of the meaning of care.Hence, they stressed that caring involved respecting the spiritual and religious needs of the patients and their families [35].According to the study, patients appreciate the nurses" caring approach and presence more than their nursing knowledge and skills.Example statements are as follows: We know for a fact… that we have a problem with our students" attitude… and how they approach and interact with patients in hospital when it comes to issues such as confidentiality and the rights of the patients (Teacher 7).
Our culture, as Arabs and Muslims… even without the code of ethics, we have the code of ethics of our religion… our Islamic laws… which guide us in how to behave and act… how to respect and listen to others (Admin 10).
In general, the MoH healthcare providers had no smile, no warmth, no care, no compassion… that is the problem with the current healthcare….no care in healthcare (Service User 8).
When nurses try to display a caring attitude toward their patients, this positively impacts the nurse-patient relationship [34,47].In this study, the characteristics of care involved being physically present with the patient, conversing with the patient and employing active listening, avoiding prejudice, maintaining confidentiality, flexibility in patient care, and optimism.In Islam, caring is associated with the intention to be responsible, sensitive, and concerned about others with the drive and commitment to act rightfully [48].Therefore, caring in Islam is to understand what, when, who to care for, and why [48].The current MoH nursing curriculum defines the value of caring as a continuous demonstration of feeling and exhibiting concern and empathy for others, together with respect, fairness and transparency (MoH, 2008).This definition of caring reflects the Western Judeo-Christian values and beliefs, with a notion that nursing has a common value system [32,[49][50][51].This is very problematic, as it does not help the graduate nurses or educator to make culturally sensitive, appropriate decisions, actions, and innovations.Within non-Western nursing educators, there is recent acknowledgement that while nursing theory has universal aspects, differences in philosophy and culture which are unique to each country need to be reflected in the nursing education [34].

Teaching/learning approaches
Due to limited funding and duration of nursing coursess, the nursing curriculum may not be able to include such things as the caring aspects of nursing.Limited budget allotted for and the goals of the MoH for nursing education often limit innovation in nursing education.Furthermore, this study revealed that the nursing curriculum inflexibly hinders the learning process.Therefore, many of the study participants viewed the current curriculum to be ineffective in improving students" learning capabilities.Examples statements are as follows: If we pass the exam the teachers will say "good student"… but if we fail they will only say the exam was easy and we told you everything coming in the exam… no one cares about the quality of the student (Nursing Student 4).
I believe the nurses are lacking the correct knowledge to deal with patients… they do not care for the patients" needs… some patients dislike coming to hospitals (Service User 3).
These viewpoints are in alignment with Bruner"s theory that uniform instruction will not meet the needs of all learners, because everyone understands the world in their own unique way.According to Bruner, learning is an active process in which learners construct new ideas based upon their current or past knowledge interacting with new information.Through this, the learner selects and transforms information, constructs hypotheses, and makes decisions.Hence, the learner "focuses on the "how" to learn, rather than "what" to learn".However, the findings revealed that the current nursing curriculum guides nursing students to rely heavily on teachers" lectures, which limits the development of their critical thinking skills.Hence, the findings acknowledge the need to move away from the teachercentered approach and toward a learner-centered process.
Educational theorists have advocated to replace teacher-centered pedagogies with learner-centered approaches.In teacher-centered approaches, judgements about appropriate areas and methods of inquiry, legitimacy of information, and what constitutes knowledge rest with the teacher.This often leads both students and educators to resist switching to the learner-centered approach.There are several factors contributing to this resistance [52].Society"s emphasis on success leads students to avoid difficult work and to develop inflated perceptions of their abilities.Traditionally, educators have taught according to the students" comfort level.Now, this is the norm that students expect.Others have suggested that students and educators have low tolerances for challenges and change [52].

Stakeholders and nursing education
The study acknowledges that there is limited stakeholder involvement in developing the MoH nursing curriculum and lack of transparency in the decision-making process.and teachers.The stakeholders also include the consumers of healthcare who are well-positioned to contribute to decisions relating to the appropriate qualities and skills required in graduate nurses.Stakeholders bring unique perspectives to the process of development of the nursing curriculum.This perspective arises from the ability of the stakeholders to discern compassionate care as a direct result of their personal experiences.
This strength of this multiple-case study is based on its originality in exploring the phenomena of the cultural aspects of client care in the nursing curriculum in the Sultanate of Oman.According to Eisenhardt, the multiple-case study approach pursues phenomena that bring together multiple perceptions and experiences from a range of various sources (documents and interviews).Additionally, the use of purposive sampling in selecting study participants facilitated comparison and contrast of the findings (cross-case analysis) of the four cases to develop a framework for a culturally congruent nursing curriculum.
This study was conducted in the context of Oman, which limits the generalizability of the findings.However, generalizability was never intended.Second, the pressures of political office may have influenced the statements of the MoH nursing administrators.Furthermore, non-Omani participants may have been cautious of making negative statements against MoH policies and policymakers.Additionally, the focus group participants may have been reluctant to make statements that were too negative or critical of the MoH as an organization, due to their potential impact on the dynamics of the group.

Conclusion
These findings illustrate that there is minimal content in the nursing curriculum which addresses caring and cultural competency.The current method of instructor-driven education needs to give way to student-centered learning to truly develop the nursing students" critical thinking skills.Nursing educators should critically examine their teaching strategies for teaching the caring and transcultural components of nursing care.The interviewees emphasized that cultural knowledge is a critical component to prepare nurses to care for the increasingly diverse society.This increased understanding will enable nurses to be more effective while providing care that is within the cultural context of individuals, families, and communities from diverse cultural backgrounds.However, this author acknowledges that there may be other considerations such as a hidden curriculum agenda which might interfere with the participants" answers.

Future Research
Further studies are recommended on the cultural congruence of the nursing education/curriculum. Factors that facilitate or hinder students" cultural competency to make judgements and decisions regarding nursing care issues in a multicultural world requires additional investigation.Furthermore, an evaluation of the effectiveness of the nursing curriculum after implementing the concepts of culture in nursing education would be beneficial.

Figure 1 :
Figure 1: Recruitment Sites.Ethical Considerations Approval was obtained from the Medical and Health Science Ethics Committee at the University of Nottingham and the MoH Research and Ethical Review Committee of the Sultanate of Oman.Data collection methods 1. Documents: Nine relevant documents were identified.These include the Directorate General of Human Resources Development (DGHRD) mission/vision/objectives, curriculum competences, the nursing programme, foundation programme, Omani midwifery and nursing council codes of ethics, the student handbook, the MoH"s fiveyear plan, MoH mission/vision/objectives, and MoH patient satisfaction surveys.2.Semi-structured interviews:The interview guide was founded on Lawton"s cultural analysis model, which is based upon the assumption that the main purpose of a curriculum is to initiate learners into the cultural heritage of society.With cultural analysis applied to nursing education, the following questions were asked: What is the status of nursing education?In what ways is the nursing education provision developed?How do members of the profession wish to see nursing education develop?What kind of values and principles will be involved in deciding how nursing education should develop?and How should future nursing graduates prepare for their role?

2 :
to be self-reliant & meet the healthcare needs of its community A A A A Omani nurses were familiar with the indigenous language & culture A A A A Expanding the nursing programme to regions to accommodate the students" needs A were uninterested in nursing as a career A A A A The MoH lowered scores required for admission to increase intake, mostly for male students A A N/A N/A Nursing was not viewed as a proper profession by the public A A D D Bad attitudes of nurses were related to lack of interest in nursing as a career A A A A Sub-theme 2: Quality versus quantity in nursing education Agree Agree Agree Agree The MoH was concerned with dealing with the shortage of nurses A A A D The current curriculum was designed to start students at work as soon as possible A A A D The current diploma programme meets the needs of the MoH A D D D The programme duration was too short to cover the required knowledge & skills A A A A A degree programme would increase students" competency, knowledge, & skills A A A A Entry to the nursing profession should be at the degree level A A A A Mentorship would provide guidance and support for the students & new graduates A A A A Ethics were an important issue to cover in the nursing curriculum A A A A Students" attitude was not assessed by the current nursing curriculum A A A A Omani cultural values were not emphasised in the current program A The Impact of MoH Curriculum Decisions Sub-theme 1: Student nurse preparation Agree Agree Agree Agree The MoH was focused on preparing students to work in hospital-based facilities A A A A Nurses were not encouraged to be independent practitioners A A A A Critical thinking & innovation was not encouraged A A A A Nursing educators were not competent in their knowledge & skills A A A N/A Some faculties did not have the qualified training to teach A A A N/A Lack of appropriate teaching/learning facilities, e.g.libraries, laboratories A A A N/A Students should be sent abroad for further studies A A A A Teaching/learning methods were an issue in the current curriculum A all the stakeholders were involved in the development of the nursing curriculum.A A A A MoH decision makers did not communicate well with all the stakeholders A A A A Stakeholders" needs & concerns were not reflected in the current nursing curriculum A A A A Involvement of all the stakeholders would improve nursing education A A A A *(Note: Agree= A, Disagree= D, Not applicable= N/A)

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Junaibi SA, Chambers D and Narayanasamy A. Nursing education and its cultural congruency in the sultanate of Oman: Case study (2019) Nursing and Health Care 4: 6-12 9

Figure 2 :
Figure 2: Phases of qualitative multiple case study analysis.

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Junaibi SA, Chambers D and Narayanasamy A. Nursing education and its cultural congruency in the sultanate of Oman: Case study (2019) Nursing and Health Care 4sub-theme1: Competent nursing education •Teaching/ learning style •Educators" competency •Availability of educational facilities Cross-case sub-theme 2: Community involvement in nursing education •Involve all the stakeholders in the decisionmaking process •Improve communication with the stakeholders Table

Table 1 :
Data Collection Schedule.

Table 2 :
Within-case themes and sub-themes from the four cases.