Shanghai, one of the largest cities in mainland China, is in the east coast of Asia. With a population of more than 18 million, the healthcare system and medical institution of Shanghai are responding to a heavy load of patients. Because nursing staff shortage is common in either Western or Eastern countries, now, Shanghai is experiencing a shortage of 13,300 nursing staff. This article is focused on the nursing system and the composition of nursing staff in Shanghai.
Shanghai, located on the east coast of Asia, is one of the largest cities in mainland China. With a population of more than 18 million, the city has a total area of 6,340 m2. There are 518 public and private medical agencies in Shanghai, including 37 large hospitals or tertiary hospitals, 161 district hospitals or secondary hospitals, and 320 community healthcare centers or primary hospitals. There are 2 kinds of hospitals: general hospital, which covers all kinds of medical divisions, and special hospital, which specializes in one kind of organ system or disease. Patients are free to select medical agencies based on the acuity of their illness, their preference, and the cost of treatment.
Nursing Education and Types of Nursing Staff
Early in 1921, the undergraduate nursing program was started in the Medical College of Peking University; later, because of the world war, the university-based education of nurses was stopped. After the establishment of the People's Republic of China (PRC), since 1952, nationwide secondary level of nursing education has prosperously developed. After a proposal on "promoting higher nursing education" was submitted to the National People's Congress in 1979, diploma-nursing programs in universities was started 1 year later, which includes 3 years of occupational education in community colleges. In 1983, undergraduate nursing programs, which varied from 4 to 5 years, in medical universities were again started. The master's degree program, usually consisting of 3 years of education and research in nursing, was started at Peking University in 1992 and the first PhD nursing program was started in the Second Military Medical University in 2003.
There are 5 levels of nursing: certified nursing assistant, registered nurse (RN), head nurse, nurse superintendent, and nursing director or chief nurse executive. In Mainland China, there are 4 professional levels of nursing staff: junior RN, senior RN, nurse in charge, and professor nurse. The Nurses' Law, published in Mainland China in 2008, requires that all clinical nursing staff be certified as RNs. Nursing staff can design their career ladders according their practicing performances and educational background.
Nursing Composition
The World Health Organization, China statistics indicate that nurse-to-patient and nurse-to-physician ratios are much less than the world average. In 2001, the physician-to-nurse ratio in Mainland China was 1:0.61 and 1:0.86 in Shanghai, whereas 1:2 to 1:4 is the best ratio between physicians and nurses reported by the World Bank in 1993. There are only 38,700 nursing staff in Shanghai in the 2007 Nursing Human Resources Survey; this results in roughly 1 nurse per 465 people or 2.15 nurses per 1,000 people, which is severely not enough because the Health Administration Ministry of the PRC declared that nurse-to-bed ratio should not be less than 0.6:1 in hospitals.
The nursing staff in Shanghai is composed primarily of certificate-prepared (76%) and diploma-prepared (22%) nurses, with 2% holding a bachelor's or master's degree and less than 1% having a PhD degree. Nurses' educational preparation varies by hospital type; nurses with higher educational level are prone to seek jobs in large or tertiary hospitals. The percentages (rounded off) of nursing staff are composed of junior RNs (43%), senior RNs (44%), nurse in charge (12%),and associate professor or professor nurses (0.5%). The distribution of nurses by professional title varies between different hospital types, but there are more nursing experts in large hospitals than in district hospital or community healthcare centers.
The average age of nurses in Shanghai is approximately 26 years, with 84% of nurses between 20 and 30 years of age. Nearly all nurses are women; only 0.18% are men. In China, some vocations that still seem to be not appropriate for a certain sex, like nursing, is not for men. Nursing has been an occupation in China for more than a century, since the birth of the first Western hospital in the 19th century. Although its concepts and contents keep evolving, male nurses have consistently accounted for a very tiny proportion of the whole profession, even in a cosmopolitan city like Shanghai.
Salary, Social Status, and Job Satisfaction
The average annual salary of nursing staff is 27,000 CNY (US$3,953.44), which is lower than the average annual income of 28,000 CNY in Shanghai. A total of 65% of nurses think that they have a relatively lower social status than other professionals do. With heavy workload, low level of salary, and low level of social status, nursing staff's attitude toward the job showed that 66% of them are dissatisfied with their jobs. Most of them think that the input and output of their efforts in working are not directly related. This results in a great challenge for nursing administrators in Shanghai to retain their nursing staff. For example, in Changhai hospital, one of the largest Shanghai hospitals, with 1,800 beds, nearly 200 nurses left their jobs last year, which was almost 15% of the total nursing staff. This induced a lot of rigorous problems related to patient health and safety.
Clinical Nurse Specialist
The specialization of nursing is leading to better care and safety of patients. Shanghai is one of the first cities in Mainland China to begin a clinical nursing specialist credentialing system since 2002, especially in intensive care, skin care, ambulance care, and pain management. There are many clinical nursing training centers in different large hospitals certificated by the Shanghai Nurse Association, and every year, selected nurses from different hospitals are sent to the training center to gain more knowledge and skills to improve their nursing expertise. For example, Changhai hospital is the training center for intensive care and ambulance care in Shanghai. After training and assessment, a certain proportion of nurses earned the honor of clinical nurse specialists, who then become experts in their specialty clinical area in their hospitals.
Discussion
Because the composition or RN mix is a crucial factor that influences nursing quality and patient safety, and because in China, with 20 years of development of patient-centered care, nursing has changed a lot, the care needs of patients has become complex and detailed, patient acuity and the use of sophisticated technology have increased, and the length of stay has decreased at the same time. These factors require nursing specialization and higher RN staffing levels to meet the huge demand. Heavy workload and shortage of nursing staff result in decreased care quality, which poses a great challenge to nursing administrators in Shanghai hospitals.
How to restructure nursing staff composition is now a vital concern for the Shanghai Municipal Health Bureau and administration departments of different university nursing schools. Clinical nursing managers need to pay more attention to staff retention and provide a visible professional career ladder to their staff. As sufficient nursing staff are developed with a scientific ratio of clinical specialist and experienced RNs, better nursing quality and increased patient safety will be gained.