This presentation discusses the results of a qualitative study done in Oman to determine nurse staffing levels in the ICUs.

1. Perceptions of ICU Stakeholders
toward Nursing Staff Levels in Omani
Hospitals: A Qualitative Case Study
Dr. Majid Al Maqbali, RN, DHA
Director of Nursing & Midwifery Affairs
MOH(HQ) – Sultanate of Oman

2. Outline
 Background
 Problem statement
 Purpose
 Why qualitative case
study?
 Theoretical framework
 Research questions
 Data collection
 Results
 Findings
 Implications
 Limitations
 Further studies

3. Background
• Studies examining the relationship between nurse staffing and
health outcomes strongly support the importance of effective
deployment of nursing resources.
• High nurse staffing and an effective skill mix are associated with
improved patient outcomes (RCN, 2010)
• A strong link between quality of care, patient safety, and nurse
staffing (Spetz, 2004).
• Policies and regulations requiring an increase in the number of
nurses would reduce the risk of medical errors (Spetz, 2004).

4. Background
• Skill mix of nurses, not merely the number of nurses, strongly influences
patient outcomes. Despite poor nurse staffing levels, positive patient
outcomes could still be attained (Blegen and Vaughn, 1998) .
• If nurse managers are well-prepared in their human resource planning
and conduct adequate staffing projections, cost savings occur.
• A higher ratio of nurses is associated with reductions in cost and length
of stay (Wiest et al. 2009).
• The adequacy of registered nurses can also prevent unnecessary stays
and reduce the possibility of cross infection of other patients that may
lead to costly adverse effects (AHRQ, 2004).

5. Background
• There is significant disagreement about the best way to
determine an appropriate number of nurses.
• Nurse job satisfaction, organizational commitment, and intent to
leave/stay were interconnected.
• A significant relationship between ineffective deployment of
nursing resources and negative patient and organizational
outcomes.
• When determining an appropriate level of staffing, the RCN
(2010) recommended healthcare leaders incorporate staff
involvement, triangulation, and regular performance reviews.

6. Problem Statement
 Excessive Nursing workload in ICUs
 Leaders Fail to anticipate the significant impact of:
 low staffing levels
 deployment and utilization
 excessive workloads

7. Purpose Statement
Explore the perceptions of ICU stakeholders
regarding high nurse workloads in critical care
units in Oman

8. Why Qualitative Case Study?
 Explore a problem and gain further understanding
 Excessive ICU workloads are poorly understood by
Omani healthcare leaders
 Confusion about the severity of the ICU nurse shortage
 Empower and sacrifices personal interests to others

9. Why Qualitative Case Study?
 Prior studies have not measured ICU stakeholder
perceptions about the study problem
 Allowed exploration and understanding of the
reasons contributing to excessive nursing workload
 Data were collected by means of in-depth individual
semi-structured open-ended interviews

10. Research Questions
 RQ 1 – How do stakeholder perceptions differ
regarding the severity of the intensive care unit
nurse shortage in Oman?
 RQ 2 – What factors contribute to excessive nursing
workloads in Oman’s intensive care units?
 RQ 3 - How can Omani healthcare leaders improve
the management of nursing workloads in intensive
care units?

11. Theoretical Framework
 Taylor's Scientific Management Theory
o To replace the “rule-of-thumb”
o To select, train, and develop each employee scientifically, rather
than promoting a worker's self-development.
o To provide continuous supervision and performance appraisal
o To separate the work between supervisors and employees
 Virtually synonymous with maximization of the use of
available nurses in hospital wards or units

12. Population and Geographical Location
 ICU stakeholders representing Royal, Khoula, and Sohar
hospitals
 The population of ICU stakeholders included clinical and
non-clinical workers (nurses, physicians, and hospital
administrators)
 21 ICU stakeholders were interviewed.
 Stratified sampling
 Inclusion and exclusion criteria

13. Data Collection
 Pilot study
o Rustaq Hospital
o A convenience sample of five volunteer healthcare stakeholders
o Fit within the sampling frame and willing to provide timely
feedback on the study’s interview questions.
o Data were not included in the results of the main study

14. Data Collection
 Main study
 Semi-structured open-ended questions
 Face-to face interviews (scheduled for 60 minutes)
 Multiple stakeholders from different hospitals strengthened the
validity of the study’s results.
 Digitally recorded and transcribed for accuracy
 Participants re-read and checked what they said
 Participants were able to provide feedback on a draft copy of
the final case study

15. Data Collection
 Three coders
 After identifying open-ended themes, coders categorized
responses
 Category frequencies were determined.
 A Cronbach’s alpha was computed to determine an inter-rater
reliability score.
 The study’s coding produced a Cronbach alpha of .91 which was
considered reliable

16. Data Analysis
 Pilot study
 Interviews were digitally recorded and transcribed
 Five of the seven pilot study questions were retained without
any phrasing changes
 Two questions were revised for phrasing
 Two new questions were added

17. Results – RQ1
(Severity of the ICU nurse shortage)
 RQ1 was supported: 81% indicating ICUs are
inadequately staffed
 Institutional Perceptions: Sohar Hospital expressed
highest level of concern (100%)
 Role Perceptions: 83% of Hospital Administrators, 78% of
nurses, and 50% of doctors did not believe there was an
adequate number of ICU nurses

18. Results – RQ2
(Factors contributing to nursing workloads in ICUs)
 RQ2 was supported: 74 comments, three main themes
emerged:
 Shortage of ICU nurses
 Shortage of support and resources
 Distractions
 Nurse Turnover:
 Negative working environment
 High workloads
 Unpopular shifts
 Communication, compensation, and hospital policies

19. Results – RQ3
(Suggestions for improving ICU nurse workloads)
 RQ3 was supported
 More experienced ICU nurses
 Increasing the availability of support staff, resources
 Revising hospital policies
 improve pay
 More education and training
 Increase recognition

20. Implications
(Health Vision 2050)
 Nursing and midwifery human resources: the need
for an adequate number of skilled nurses
 Positive practice environments : the importance of
career pathways (promotions, pay increases, and
professional recognition) for nurses.
 Access and quality of education: the importance of
offering multiple and convenient modalities of professional
development programs that includes face-to-face, e-
learning, and distance education

21. Implications
(Health Vision 2050)
 Scaling up capacity of nursing and midwifery: the
need for ICU nurses to be specialized practitioners with a
post-basic certificate
 Strengthening regulatory capacity : the importance of
nurses receiving a minimally acceptable level of education
so they are licensed, certified, and/or baccalaureate trained
nurses.
 Research : the importance of using evidence-based
practices when managing Omani ICUs

22. Limitations
 Self-reported perceptions of 21 stakeholders at three major
hospitals in Oman
 Study participants were limited to health administrators,
doctors, and nurses
 The study’s principal researcher was a senior leader in the
Ministry of Health
 Face-to-face interviews may have influenced the candor and
openness of study participants

23. Further Studies
 Identify the types of ICU nurses required to work
 Conduct an educational needs assessment
 Develop the best career pathways, financial incentives, and
educational programs for nurses in Oman
 Align all workforce initiatives within the framework of the Health
Vision 2050 recommendations

24. Thank
you!