May 26, 2017 05:31 PM

Poor Pay, Rising Violence Leads to Acute Nursing Shortage

Nurse Li Ying helps patients replace their intravenous drips in the ward of a community health service center, in Minhang, Shanghai, China, on May 12. Poor pay and violence have led to a shortage of nurses in China. Photo: IC
Nurse Li Ying helps patients replace their intravenous drips in the ward of a community health service center, in Minhang, Shanghai, China, on May 12. Poor pay and violence have led to a shortage of nurses in China. Photo: IC

(Xian) – When nurse Gao Lei’s mother was battling cancer, Gao says she was too busy taking care of other patients and hardly had time to stay by her mother’s side, until her mother died in the same hospital where Gao worked.

“I could have requested leave, but I was too ashamed to do so,” said Gao, who works for Xian Gaoxin Hospital, a major private healthcare provider in Shaanxi province.

“When I’m away, my colleagues have to take on my share of work. Everyone is overstretched to a point to which they often can’t squeeze even a little time out to eat, drink water or even go to the bathroom.”

According to government estimates, China’s hospitals need more than one million new nurses by 2020 as the country grapples with demands from an aging population and a growing middle-class. But overwork, poor pay and rising violence at the workplace – mostly from angry patients – have led to an exodus of nursing staff in recent years.

One in 10 registered nurses left the health sector before they hit retirement age in 2015, the latest year for which attrition data is available. A survey that year found that 58.7% of the nurses “felt like quitting,” said professor Fang Pengqian from Huazhong University of Science and Technology, who led the study.

But the nursing sector has long been ignored by the government, which has dragged its feet for years on introducing laws that can address these issues, without offering reasons for the delays.

Gao says she often works 12-hour shifts, six days a week. She not only has to care for inpatients and assist doctors during surgery, but also urge patients to pay their medical bills on time, push cleaning staff to empty the trash bins and fix TV sets in the ward.

Crippling Shortage

Gao is one of the 3.5 million registered nurses in China, where there were just over two nurses for each 1,000 patients in 2016. In comparison, The U.S. and Japan each had 11 nurses per 1,000 patients in 2014, according to data from the World Bank.


With a population of 1.38 billion, China needs at least 640,000 nurses to reach the World Health Organization (WHO) standard of three nurses per 1,000 people, according to a Caixin calculation based on figures released by the National Health and Family Planning Commission earlier this month.

But instead of recruiting new staff, hospitals were pushing more patients onto their existing nursing pool. About 63.5% nurses and 55% doctors surveyed nationwide said it was common practice to add extra beds to wards with no additional support for the nursing staff, according to a 2015 study by the China Nurses Association.

Government data also show that China’s doctor-to-nurse ratio was 1:1.45 in 2016, well below the World Bank’s standard of at least two nurses to assist a physician.

A major obstacle to pushing up this ratio is the low nursing services fee stipulated by the government. Both public and private hospitals must follow a set of standards issued by provincial governments when charging patients for medical services. The daily fee for the highest level of nursing care in top-level hospitals in Beijing was only 25 yuan (less than $4). This was just one-fourth of the daily nursing cost of 96 yuan in the city in 2015, according to an article in Health Development Outlook magazine published by Peking University.

Compared to this, the government's upper limit on charges for services offered by doctors, including consultation fees, were much higher. This has prompted hospitals to hire more doctors, while squeezing salaries and benefits for nurses.

More than 76% of nurses across the country earned less than 5,000 yuan per month, which was less than the average monthly pay of 5,600 yuan in smaller, second-tier cities in China, according to a joint survey in May by China Social Welfare Foundation, Xinhua News Agency, Nurses Concern Foundation and online health services provider Less than 4.5% of nurses nationwide earned more than 8,000 yuan per month, it found.

In Xian, the capital of Shaanxi province in central China, Gao and most of her colleagues with five years of experience or less earned 2,400 yuan a month. Things worsened in the smaller neighboring city of Xianyang. Through a series of interviews, Caixin found that the largest maternity and children’s hospital there paid most of its nurses, with up to seven years of experience, a little over 1,000 yuan per month. This fell below the city’s minimum wage of 1,680 yuan.

‘Kicked’ on the Job

In addition to poor pay and long work hours, nurses have witnessed an increase in incidents of workplace violence, mostly from disgruntled patients and their families.

In April, a mother kicked a nurse to the ground for allegedly failing to correctly insert a needle into her dehydrated son’s arm. The incident at a hospital in Nanjing led to a heated debate on Chinese social media about workplace safety for nurses. CCTV footage from the hospital showed the nurse withdrawing the needle as soon as she stood up.

The debate came at a time when the nursing community was already on edge after another high-profile incident. A man was arrested in southern China in July for allegedly assaulting a pregnant nurse because he was angry over the care she was giving his son. In that case, in Hainan province, the man had become violent after the nurse asked him to turn off his son’s saline drip while she carried out another duty, local media reported.

Two out of five nurses in the country had experienced physical violence or verbal abuse from patients or their families in the past year, the May survey found.

Some patients were verbally abusive and called nurses names because they were angry that the treatment or medical checks were overpriced, Gao said.

It was common to see nurses with black and blue arms, she added. Some minimally conscious patients would forcefully kick and strike them, and some conscious ones would pinch them on purpose when the treatment was painful, she said.

The study in May also found that more than 51% of nurses nationwide had suffered psychological trauma.

“Symptoms of depression are common among us,” Gao said. These have been exacerbated by a decline in society’s recognition and respect for nurses’ contributions over the past two decades, the study indicated.

Forty-year-old head nurse Hu’s face lights up when she talks about how her patients used to treat her in the 1980s. “Many recovered patients came from afar on their tractors to the hospital just to say thank you. Many brought eggs from their farms or insoles for our shoes that they had made themselves,” said Hu, who only gave her last name.

Gao recalled a similar experience in 1999, when her patients always remembered her name and greeted her warmly on the streets. “But nowadays, patients will not greet you outside the hospital even after you’ve saved their lives,” she said.

The May survey polled 51,406 nurses nationwide and found that 90% of respondents didn’t feel respected by the public and 92% felt a nurse’s standing in society had deteriorated over time.

This dramatic change in patients’ attitudes toward medical staff is a side effect of China’s healthcare reform. In 2000, Beijing started encouraging all hospitals to generate revenue to fill holes in their budgets after government subsidies were gradually phased out in the 1990s. Nearly half the country’s public hospitals have been privatized since then.

With the government subsidy covering only 8% of their expenses, public hospitals turned to selling drugs at huge markups and tied part of doctors’ benefits packages to profits earned from medicine sales.

This has led to widespread complaints by patients, who say doctors were overprescribing drugs and tests to push up hospital profits.

The latest wave of reforms aims to ease government controls on hospitals by giving them more leeway to decide on fees for medical services to boost revenue instead of relying on drug sales.

Provincial governments have published a new set of standards on the maximum prices hospitals can charge, including a cap on nursing fees.

For example, in Shaanxi province, the government raised the upper limit for top-grade nursing care in big hospitals to 36 yuan per day from 24 yuan, a hospital source from Xian said.

“Most hospitals have already pushed up their charges to the maximum limit,” according to the source, who wished to remain anonymous. But as the new limits have taken effect on April 8, it is too early to say how the changes can help improve nurses’ working conditions and salaries.

No Legal Cover

The nursing community has been clamoring for a law to protect them from workplace violence, according to Li Xiuhua, a member of the Chinese People’s Political Consultative Conference (CPPCC), the country’s top political advisory body, who has advocated for such a law over the past four years.

China has two regulations concerning nurses, introduced in 1993 and 2008, but they only outline the registration procedure for nurses and their job responsibilities. They don’t address issues of mental or physical harm while on duty.

Lawmakers have delayed introducing a law to address issues of pay and workplace safety for nurses because the nursing profession has been neglected in Chinese society, said Zhou Yan, a professor of public administration at the South University of Political Science & Law, in a recent interview with healthcare magazine China Hospital CEO.

The country also lacks a grading system that classifies nurses based on their years of experience or level of expertise and stipulates corresponding salaries and benefits, similar to that in U.S. hospitals.

“Many people think nurses are merely assistants to doctors, and have postponed the law with excuses like ‘the timing is not right’,” said Zhou.

The central government’s policy agenda for the 2016 to 2020 period requires hospitals to raise nurses’ salaries, but it doesn’t say whether the government would increase subsidies to cover the extra expenses.

The government also wants to ensure that the country meets the WHO standard of having more than three nurses per 1,000 people by 2020.

To achieve this goal, China needs to raise its number of registered nurses to 4.45 million in 2020 from 3.24 million in 2015. But if current working conditions persist, hospitals will struggle to attract and retain qualified nurses.

“All the nurses I know feel underpaid, underappreciated and overworked,” said Gao. “If I could choose again, I would never become a nurse.”

Contact reporter Song Shiqing (

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