COMMENTARY

China's Nursing Shortage

Marilyn W. Edmunds, PhD, CRNP

Disclosures

July 09, 2010

Nursing Shortage in China: State, Causes, and Strategy

Yun H, Jie S, Anli J
Nurs Outlook. 2010;58:122-128

Article Summary

Written by a nursing faculty group in Shanghai, this article describes the nursing shortage in China. With a population of 1.3 billion people, China has 1.65 million nurses. However, the country needs 5 million more nurses to meet the global standard for a nursing labor force. Demand far outstrips availability.

Yun and colleagues explain in frank terms some of the causes of the nursing shortage in China. A major factor is that nurses are assigned to the nursing field rather choosing it for a career. Most nurses work extremely long hours doing hard work for which they are paid a very low salary. "The average salary for entry-level nurses in some Chinese urban hospitals is equivalent to that of a janitor," write the authors. Nurses might be responsible for more than 30 patients at once. Nurses employed as regular hospital workers have the highest salaries and some vacation benefits. However, part-time workers can be paid only half the salary of regular workers; to save money, many hospitals have reclassified their nurses as part-time workers. Conditions in the rural areas are even more strained, with even larger nursing shortages and lower salaries. Consequently, the status of nurses is also very low. Nurses are neither very respected nor valued except in some military hospitals where they have developed some clinical treatment skills.

Where possible, Chinese nurses try to emigrate to other countries, where they might make 30%-50% higher salaries, as well as develop greater knowledge and skills and earn more respect. Thus, China is a donor of nurses to other parts of the world.

This article discusses some of the solutions that China has implemented to address its nursing shortage. The strategies include:

  • Improving the healthcare system;

  • Improving work cultures for increased retention through policy and regulation;

  • Making greater investments in nursing education to build sustainable nursing education infrastructures; and

  • Enhancing the image of the nursing profession.

Viewpoint

China is a unique country with many unique problems. Chinese traditional medicine still flourishes and guides diagnostic and treatment decisions in many hospitals. Scientific or western medicine is implemented with varying degrees of skill. In many situations, Chinese traditional medicine contradicts what western medicine practitioners would recommend. The lack of technologic diagnostic and treatment equipment and standard medications and a shortage of money dictate limitations on what medicine can do in healthcare. For example, performing a culture before giving an antibiotic may not even be considered.

Ninety percent of China's nurses are prepared in what are called associate degree programs but are usually the equivalent of high school level programs. The students are individuals who are not eligible for college. Many of these nurses have knowledge and skills equivalent to those of nurses' aids or technicians in the United States. About 7% hold what is called a diploma in nursing. Only 2%-3% have college degrees, most of these at the bachelor of science level. Graduate education is in its infancy.

In a country with twice as many physicians as nurses, and with a relatively low level of knowledge and skill among its nurses, it is usually a physician at the patient's bedside when the patient is very ill. Under these conditions, it will be very difficult for the role of the nurse to grow until the foundational nursing programs are at a higher level. Even then, it will be difficult for nursing to develop to its potential if the profession must fight to remove physicians from the bedside.

China is a country in which very few patients have private insurance. There is no system of primary care -- anyone who is ill must go to the hospital. Physician salaries are no longer always covered by the government, and physicians in hospitals have to generate their own salaries. That commonly leads to provision of services, such as an intravenous infusion for every patient, which brings in money but may not be appropriate care.

An unanticipated consequence of the 1-child policy is that the only child must be responsible for the health and daily care of both parents and perhaps more than 1 set of grandparents. The 1-child policy has therefore eroded the traditional family's ability to care for its elderly members. No healthcare system for these older individuals is in place: no geriatricians, no geriatric nurse practitioners, no nursing homes, and no assisted-living centers. The government is only now beginning to understand that they must create a system to care for the many parents who lack children to support them.

Nurses could make significant contributions to the healthcare of the Chinese people. In a communist society, big changes in redirection of resources and policy could quickly result in big changes in the education and use of nurses. During a time of war, nurses are seen as important resources. However, when no war is being fought, something else must capture the attention of policy makers so they develop a vision of how nurses could make a difference in Chinese healthcare.

Abstract

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