A U.S. healthcare executive s recent visit to China By Richard F. Peisch Richard F. Peisch is the founder and president of MDP, Inc., a medical revenue cycle management company headquartered in Boston. In June of 2011, MDP executives travelled to China to review the health care system there. Our mission was equal parts sales, market research and tourism. We visited Shanghai, Hong Kong, Xian and Beijing and in Shanghai we were granted full access to and a tour of the Fudan University Cancer Hospital, one of China s leading cancer hospitals. While at the hospital, we were informed about the number of staff, the number of beds, the different departments and the types of care the hospital provides. We learned that, among other staffing, of the 498 nurses on their staff, only 4 had Masters Degrees and only 113 had college degrees. While this level of nurses education may seem low by U.S. standards, the number with college degrees was a huge increase over the national average in China (23% versus 5%). Since Fudan has a nursing staff of 498 and a total of 1090 beds, it gives the hospital a nurse-to-bed ratio of.46 which is very low when compared to international standards for nursing. We asked ourselves, if this is the nurse/bed ratio in one of the toprated hospitals in all of China, does this mean there is a nursing shortage in China? One nurse offered an explanation for the possible nursing shortage. While she acknowledged that there was a shortage of nurses, she described how, in Chinese hospitals, there are many normal workers who provide care. She insisted that the US does not have a true equivalent for a normal worker but described the position as being similar to a nurse s assistant. In America, patients expect that basic treatment should be provided by a medical professional, either a doctor or a nurse. But in China, there is no expectation that the person who brings patients medicine or blankets has to have a medical degree. She described how, when people in the US catch a cold, they take Advil or Tylenol and sleep it off but people in China go to a hospital and get an IV. This means that Chinese hospitals have a lot of patients who do not need intensive care so having fewer nurses and more normal workers is acceptable. It is unclear just how many normal workers are in China but our source estimated that there are an equal number of normal workers as nurses. According to this perspective, even though there is a slight shortage of nursing staff, the shortage of true nurses is more dramatic by international standards. We decided to investigate those international standards and look at some data and previous research on the issue in an attempt to determine the level of the nursing shortage in China. According to the World Health Organization (WHO), in order for a health care system to run efficiently and meet the population s primary care needs, there must be a minimum of two nurses per 1,000 individuals. In China, a country with a population of 1.3 billion, there was only 1 nurse per 1,000 individuals in 2006 (compared with 9.37
nurses per 1,000 individuals in the US). With a current nursing population of approximately 1.3 million, China will need to train and employ at least 1 million more nurses to uphold the WHO standard and millions more to reach the standards of other developed nations. It appears that this overwhelming shortage has arisen for two complex political and social factors. The first factor is the underdevelopment of the nursing profession due to a lack of higher education. The second is the structure of the Chinese health care system which dissuades the hiring of nurses, overworks and underpays nurses, and concentrates nurses in large, urban hospitals. In recognition of some of these problems, the Chinese government announced some major health care reforms in 2009. Addressing the nursing shortage will be a major test of the efficacy of those reforms and will ultimately improve population health in China. The profession of nursing did not exist in China until the 1840 s when Western-style medicine was introduced and the first school of nursing opened its doors in 1888. Before nursing became a legitimate profession, the sick were provided treatment by doctors and the majority of nursing was done by family members along with barefoot doctors. These were grass-roots doctors who received basic medical and paramedical training (six months to a year and a half from a local hospital) and worked in rural villages promoting hygiene, illness prevention and family planning. Although the concept of having a stranger provide the care intended as a family member s duty was foreign to Chinese society, the nursing profession grew in the early and mid-1900s. In 1967-1997, however, the anti-intellectual Cultural Revolution halted nursing education (and many other forms of education) altogether. Though nursing education was revived in 1983, the lapse left by the Cultural Revolution left a 30 year gap in education, training, and development of the profession. Today, there are several different forms of nursing education. 93% of all nurses are trained in 3-year programs (following 9 years of primary and secondary schooling). These include diploma programs and a few associate degree programs. Those entering diploma programs are typically 15-16 years old while those entering associate degree programs are typically 18 years old. Those in any 3-year program must take a licensing exam to become Registered Nurses (RN). However, the US recognizes a distinction in the degrees in that, if a Chinese nurse was to attempt to gain employment in the US, a nurse with a diploma would not be eligible to take the NCLEX (the US RN licensing exam) before further training, while a nurse with an associate degree would be eligible. An alternative route to an RN degree, reintroduced in 1983, is the 5-year baccalaureate program (also known as the Bachelor s degree program). In terms of curriculum, the RN degrees in China are similar to the RN degrees in the US. The biggest difference is that Chinese nurses are also trained in traditional Chinese medicine which emphasizes holistic care as a means of restoring balance and harmony between people and their surroundings.
In 1992, the first Masters of Science in Nursing program was introduced at Beijing Medical University. An even more recent development is the formation of Doctoral Programs in Nursing. In 2006, there were five doctoral programs, including one that was developed by Johns Hopkins in collaboration with Peking Union Medical College in Beijing. Though much progress has been made in the past decade with regards to advancing nursing education, China is still behind many other developed nations in terms of how many nurses there are with higher-level degrees. Degree Type: Number of Programs in China Percentage with the degree (China): Number of Programs in the US Percentage with the degree (US): Diploma 400 70 73 16 Associate Degree 250 23 938 36 Baccalaureate 179 5 585 35 Masters of Science 30 <1 448 13 (All higher degrees) Doctoral 5 <1 103 Included in 13 Other (accelerated baccalaureate, postmasters, DNP) 0 0 630 Accelerated Bac. included in Bac. (35). Post-MA and DNP included in higher degree (13) Total 864 100 2,777 100 Because the majority of nurses in China only hold diplomas or associate degrees, they are restricted in the types of care they can provide. Additionally, because so many nurses do not hold higher degrees in China, the profession as a whole is not seen as prestigious as it is seen in the US and this lack of higher education devalues the profession in China. While the advancement of nursing education is crucial to mitigating the nursing shortage, the problem is, in many respects, symptomatic of larger financing and organizational issues in the Chinese health care system. Hospitals are reluctant to hire nurses for a variety of reasons, one of which is that they view nurses as incapable of bringing in as much revenue as a physician due to their lack of training and professional prestige. Doctors are hired over nurses because they can prescribe expensive medications
and order expensive treatments. Hospitals need to generate revenue as the government cut back how much it funded hospitals and covered health insurance. In fact, in 2003 45% of the urban population and 79% of the rural population had to pay for care totally out-of pocket. Also in 2006, 49.3% of health care expenses came from patients, 32.6% came from social health expenditure, and 18.1% came from the government. Though new reforms will increase coverage and government provision of care, Chinese hospitals still prefer to hire doctors over nurses. Because of this, there is rising nurse unemployment in China, specifically in urban areas. In 2004, the Ministry of Health predicted that there would be 1.036 million vacancies to be filled in Chinese hospitals by 2015. It is obvious how few nurses are being employed when one compares the nurse-to-doctor and the nurse-to-bed ratio in China to that in the US. Nurse-to-Doctor Ratio Nurse-to-Bed Ratio China 1:1.38 US 4:1 1.25 Being that there are only.38 nurses per bed in the average Chinese hospital (and only.46 nurses per bed in the leading cancer institute we visited), nurses are severely overworked. Nurses are also severely underpaid by hospitals, making around $200/month in rural areas and up to $799/month in urban areas. A physician s salary in China is not much different from a nurse s salary but Chinese doctors can make extra money by receiving commissions from hospitals based on their prescription drug sales, cuts of the operations, and red envelope money from patients seeking better care. Nurses Salary (Dollars per Month) Doctor s Salary (Dollars per Month) China 200 (rural) -799 (urban) 300 (GP) -800 (specialist) US 3,666 (RN) 6,700 (Doctoral) 8,000 (non-specialist) 18,000 (surgeon) Additionally, some hospitals will even demote nurses to temporary status so as to avoid providing certain benefits or higher salaries. These problems not only dissuade many individuals from pursuing a career in nursing but also encourage nurses to leave the field and even the country. The Chinese government actually encourages nurses to seek international work; a stance that may alleviate nursing shortages in other countries such as the US but exacerbates the nursing shortage in China.
In its organization, the Chinese medical system also encourages nurses to seek work only in certain regions of the country; primarily, urban areas in Eastern China. In the 1980s, the Chinese government dismantled many of its rural people s communes and eliminated the rural cooperative medical system. The Ministry of Health began pooling the majority of its resources into large, urban hospitals: 80% of the funds were allocated to such hospitals even though 70% of the Chinese population lives in rural villages. Not only did this cause patients to bypass rural clinics in favor of urban hospitals, but it caused nurses (and physicians) to pool in Eastern China s cities because they had more developed economies than those in Western China. Rural Nursing Density Urban Nursing Density Percentage of Nurses Working in Eastern China Percentage of Nurses Working in Western China 5.5 RNs/10,000 individuals 18.8 RNs/10,000 individuals 75% 25% It is difficult to recruit physicians and nurses to rural areas because the lifestyle is less attractive, including the fact that nurses worry they will be paid even less in rural clinics. Because of this, there are ample nursing jobs in rural clinics and unemployment in cities. This skewed concentration of nurses in urban, Eastern hospitals leads to an enormous discrepancy in quality and quantity of care provided in rural populations. In 2009 the Chinese Government announced a plan for health care reform (New Rural Co-operative Medical Care System). The reforms are an attempt to alleviate many the problems mentioned previously and bring affordable health insurance to 90% of the population by 2010. In 2004, nursing was recognized by the Chinese government as being a highly valuable profession which required a high level of training. This came after the SARS epidemic in 2003 in which the International Committee of the Red Cross, recognized the bravery and the value of Chinese nurses. In 2005, the government proposed the Nursing Development Plan in China and on January 28, 2010, Premier Wen Jiabao signed the Nursing Act to increase nursing education, raise salaries, and lessen the patient load of most nurses. There is also a general effort to eliminate the diploma programs to encourage nurses to seek higher education. Other advocates for improvements in the nursing profession are unions and the Chinese Nursing Association (established in 1909). In China, each company has its own labor union so, for example, Fudan Hospital would have a labor union for all of its health care personnel. Because of this, each union can advocate for improved conditions in its own hospital but not for the nursing profession as a whole. The Chinese Nursing Association is an advocate for the advancement of the profession. One of its major goals is trying to get nurses more involved in research. The Association recently stated that it
hopes the newly improved health care system will incorporate nurses as part of the solution to inefficiencies in cost and operations. Many lessons have been drawn from China s experience As part of the current refocusing on primary care, new efforts by nursing education include training more nurses in community medicine (something they currently don t have much training in because the majority of their work is done in hospitals). The new rural health workers (potentially including nurses) would, as the barefoot doctors did, operate highly subsidized primary care and preventative medicine clinics in rural areas. Nurses will also play a role in the advancement of primary care, a highly emphasized component of the 2009 reforms.