Moving on performance responsibility: an institutional ethnographic study of nurses’ experiences with quality indicators in the transforming healthcare system of Saudi Arabia

OBJECTIVE: To explore how nurses working in Saudi–affiliated health-care settings experience and negotiate quality indicators within the context of health system transformation in Saudi Arabia. METHODS: This qualitative institutional ethnographic study was conducted in tertiary teaching hospitals and primary health-care centres in Riyadh. Purposive sampling recruited 22 registered nurses from medical, surgical, critical care, emergency, oncology, obstetric, paediatric, and primary care units. Data were generated through semi-structured interviews, non-participant observations of quality-related activities, and collection of institutional texts, including policies, key performance indicator definitions, dashboards, and audit tools. Data were analysed using institutional ethnographic principles supported by NVivo 14 to map how nurses’ everyday work is coordinated by quality indicators and associated texts. RESULTS: Four interrelated themes were identified: “Caring Through Numbers: Making Quality Visible,” describing how nurses translate bedside care into indicator fields and documentation; “Carrying the Score: Performance Responsibility on Nurses’ Shoulders,” highlighting how unit-level indicator results are experienced as personal and collective judgments of nursing performance; “Working Around the System: Navigating Constraints and Contradictions,” capturing pragmatic adaptations and quiet resistance to indicator demands; and “Reclaiming Professional Voice in Quality Work,” showing how nurses use indicators as learning tools and call for shared responsibility and system support. CONCLUSION: Quality indicators in Saudi university settings function as ruling texts that shape nurses’ priorities, accountability, and sense of professional agency. Transforming dashboards into instruments for quality improvement requires co-design with nurses, realistic targets, and organisational investment in staffing, education, and supportive digital infrastructure. CLINICAL TRIAL: Not applicable.