Inl. J. Nun. Stud. Vol. 15. pp. 129.134. Pergamon Pres Ltd., 1978. Printed in Great Britain.
0020-1878/78/0801-0129$02.00/0
China’s nurses: redefining roles to improve health RICHARD
GARFIELD,
R.N., B.A.
254 S. Farragut Sweet, Philadelphia, Pennsylvania 19139, U.S.A.
Since its birth in 1949, the People’s Republic of China has hosted a small but steady number of foreign visitors interested in the health field. Not until 1976, to my knowledge, had a group primarily composed of nurses from overseas spent 22 days travelling throughout the country to observe developments in the nursing profession. In all, our group visited more than 30 health institutions, including hospitals, nursing schools, clinics, offices of the government health ministry at all levels, and research centers. This article will report on observations and interviews collected in those 22 days, with the assistance of a team of interpreters. It is supplemented by the study of materials on health and nursing published either for internal Chinese or international audiences. Much of what we saw looked similar to nursing practice in the U.S.A. Basic training takes 2 yr throughout the country, with additional training of ‘X-1% yr for specialties like anesthesia, physical therapy, or radiology. Nurses staff hospitals on three 8-hr rotations/day, count narcotics and report to the oncoming staff before leaving. Further, we were repeatedly told that nurses do nursing work, and doctors are responsible for the medical duties. Thus, it appeared that nursing practice in China was quite similar to that in the West. In fact, many of the recent developments in Chinese nursing have altered the nature of the profession in that country. The style and content of nursing education has changed greatly in the last 30 yr. Where once students learned primarily by the didactic classroom method, now they spend most of their time doing small group projects, rural and community health rotations, and independent study. Various instructors, only some of them nurses, teach in the predominantly hospital-based schools. The principle guiding educational practice is that teachers teach students, students teach students, and students teach teachers. In other words, the whole school is an educational community of equal partners. Knowledge of value, it is thought, comes from direct experience. Theoretical knowledge must develop from practical experience and not vice versa, so students are encouraged to question and reform the tenets and content of educational practice. As Chairman Mao Tse Tung wrote, “Reading is learning, but applying is also learning, and the more important kind of learning at that”.“’ Similarly, testing methods have changed in the last 10 yr. To speed up reform, Mao Tse 129
130
RICHARD GARFIELD
Tung stated, “Examinations at present are like tackling enemies. They are surprise attacks . . . nothing but a method of testing official stereotyped writing. I disapprove of them and advocate . . . for example, if twenty questions are set and the students can answer ten of them well, they may score 100 marks. But if their answers are unimaginative and contain no original ideas, even though they are able to give correct answers to all twenty questions, they are given 50 or 60 marks . . . Why should one learn by rote? We can try this 3).(2) At present, examinations are primarily open book, and the evaluation of preparation for graduation is undertaken by students and teachers alike through judgement of clinical skill and theoretical knowledge. The prime responsibility for these evaluations rests on the teachers, but student input by way of self-evaluation, peer rev.iew, and evaluation of teachers appears considerable. There were no unified national standards for graduation from nursing schools, but such standardization is now being developed. Basic medical education has also changed. ‘Open door education’, as the Chinese call it, has been developed: examination methods have been reformed, learning through practical work has become more important than voluminous book reading, and teamwork between students and teachers has been promoted. In addition, basic medical education has been reduced to 4 yr in duration. V)For both doctors and nurses, then, most learning is carried out through continuing education activities. In their basic education, medical students are taught basic nursing skills and nursing students learn to perform diagnostic procedures and treat common diseases. Thus, while nursing and medicine remain independent professions, the rigid borders between them have been obscured through educational reform. In practice, the distinction between nursing and medical work has also been reduced, though not eliminated. Nurses, for instance, independently prescribe some drugs, order blood tests and take blood samples, administer oriental medical therapies like acupuncture, and perform physical therapy. Doctors commonly assist in washing patients, giving medicines, and performing similar duties commonly considered in the nursing realm. A leading pediatrician in Peking put it succintly when he said, “If I am examining a young patient and he happens to defecate, I feel proud and happy to clean him myself. Before the cultural revolution (1966-1970), I would have thought it undignified and demeaning to do such work. Now I realize that in this way I serve my patients more fully.” He went on, “In this way, relations between doctors and nurses no longer contain a character of split and competition between seniors and juniors, but of cooperation between coworkers with a common task-to serve the patients wholeheartedly ” .c4)The differences between doctors and nurses are seen as technical ones-differences between background knowledge and tasks performed. These differences do not connote the great differences in power and status present in the west between nurses and doctors. “Doctors and nurses have relations of equality: the only difference is their experience, which is not the same”.(*) Health work in China did not always have this characteristic. Nursing, like modern health practice as a whole, was imported by missionaries from the United States and Britain at the beginning of the 20th century. (6)As late as 1949 when the communists took over the country following a long civil war, the majority of health institutions were run by foreign missionaries. Nurses functioned strictly as the handmaidens of doctors in these hospitals, and had little or no role outside of them.“) Major changes occurred after 1949. First, all health institutions run by foreigners were
CHINA’S NURSES: REDEFINING
ROLES TO MPRO
VE HEAL TH
131
nationalized and those run by the Chinese were organized into group practices. Widespread expansion of facilities, the number of nurses and doctors, and educational institutions followed. In 10 yr, the number of nurses increased from about 13,000 to over 100,000.@’As a result of this rapid expansion many nurses were undertrained. Their coordination, status improvement and technical upgrading posed considerable problems in the 1960’~.(~) In addition, the ‘Great Leap Forward’ period (1958-1961) started to change the overall orientation of health work. The goal of health work increasingly was to serve the needs of the common people by providing primary care and preventive services to the vast rural areas of the country rather than highly technical curative services to the urban elite. At the same time, major efforts to improve the status of women in China occurred. Little more than slaves in traditional Chinese society, the promulgation of new marriage and property laws, and a widespread educational campaign to back them up, freed women to participate actively in shaping their country. Many women went into medicine (more than half of the doctors today are women) and nurses took initiative for the first time in redefining the nature of health work. Nurses were in the forefront of the effort to transfer skilled staff to rural areas and practice @rimary care among the peasant farmers.“‘) The pride, skill and experience gained at this time seems to have gone far in promoting the widespread changes in health worker relations which occurred 5 yr later in the cultural revolution. Many of these changes have already been mentioned. One would assume that doctors and even nurses, trained by the old methods and used to a strict hierarchy and large division of labor, would resist such changes. Indeed they did. Nursing and medical schools throughout the country had to be closed for several years to restructure curricula and debate educational philosophy. The health ministry also closed, and only the most necessary tasks were handled by a functional technical staff. While disrupting the health system temporarily, this forced health institutions to deal with the questions of roles, relations, and goals in a decentralized manner, based on local needs and conditions. By 1968, several main trends were apparent. First, the rigid separation of the work of doctors and nurses was considered to be detrimental to the health program and had to be broken down. Second, the management of health institutions, like all institutions in China, had to be controlled by the workers themselves. In this way, unnecessary bureaucracy could be eliminated, class differences could be reduced, and health work could be carried out more effectively. To deal with the first problem, in some hospitals nurses took over from the physicians for a time. They attempted to do all the medical work and have the doctors do all the nursing. Without the requisite skill, knowledge, and role expectations, neither group could function and the patients suffered. (‘I)Furthermore, it was seen that a reversal of the dominating groups failed to promote initiative and release creativity. It was just like the previous hierarchy. This narrow ideal of progress was critized and soon done away with.(12’ Instead, promoting teamwork and upgrading the technical and social roles of nurses changes the relations between nurses and doctors. “In our idea of division of labor, there is a fixing of responsibility and there is an interchange so help can be given to one another. Our society does not break down relationships with barriers”.(‘3) This new system has a number of important ramifications in the work life of a nurse. First, nurses take an active part in making patient care decisions. Nurses in many hospitals
132
RICHARD
GARFIELD
accompany physicians on rounds in the morning, and are integral participants in patient care conferences. They can do a better job of patient teaching, since they are more informed in medical matters relating to each patient. More education of the medical and nursing staff can go on, since all staff have experience and knowledge to teach each other. The work can be more satisfying, since working more closely allows for the development of more supportive relationships. Finally, greater flexibility occurs, for staff with different tasks can fill in for or assist one another. Gone is the exclusive power formerly held by doctors to make patient care decisions. Also gone are the administrative and financial prerogatives formerly held by doctors. The nationalization of health services in the 1960’s did away with private practice for doctors, and all health workers now earn a salary determined by job category, productivity, attitude and seniority. Doctors earn salaries about 10% higher than most nurses in our limited survey, and a number of senior nurses earned more than doctors. This is very different from the United States, where doctors incomes are more than three times those of nurses on the average. The administrative prerogatives of doctors were part of the larger problem of health center management. tiureacratic management of hospitals, under the control of government and doctors, was eliminated during the cultural revolution by the establishment of ‘revolutionary committees’ of health worker representatives. Health workers of all types elect peers to a committee which runs the hospitals until the next election in 2 or 3 yr. The nomination and election process for new committee members works in the following way: doctors and nurses in each ward meet to discuss the makeup of the present revolutionary committee, and recommend other exemplary workers and effective leaders. They send their recommendations for a new committee to the present revolutionary committee. That committee proposes changes at a general meeting of the hospital staff. The proposal can be approved right on the spot, or the ward staff can go back and discuss it. If several units are dissatisfied with the proposal, the committee goes back and makes a new proposal for examination. This back and forth process can go on several times before agreement on the committee’s makeup is reached. Every half year, with or without an election, the ward units examine the actions of the revolutionary committee, suggest changes, and sometimes even remove poor leaders from the committee. Similar democratic decision-making processes are used to set hospital policy, establish 1 and 5 yr plans, and determine funding priorities. “Here there is no trace of the former hierarchy. There was one here before the cultural revolution, but it was a senseless hierarchy, and we destroyed it. There was a hospital chief and a committee of hospital administrators composed of professors and specialists, men who had not transformed their conception of the world”.(14) The new system gives health workers a sense that the hospital and the health work it performs is their responsibility. The task of improving the work thus requires their initiative and energy. The revolutionary committee system of management has problems, too. Prime among these are a chronic underrepresentation of women and the difficulty of carrying through long term projects with a changing leadership. The Chinese feel, however, that in spite of these limitations, there has been a great improvement. All this, however, is not considered enough to restrict elitist tendencies among health professionals. Additionally, all administrative staff and doctors spend one day a week doing manual labor-cleaning the grounds, fixing food, or whatever else most needs to be done. Usually wards are cleaned from top to bottom one day a week by the doctors,
CHINA 5 NURSES: REDEFINING ROLES TO IMPROVE HEALTH
133
nurses, and able patients in that unit. In addition, since rural areas still have poorer health services than urban areas, all health professionals rotate to rural areas for one in 3 or 4 yr.(15)It is considered that the shortage of medical personnel is a short term problem, but the danger of privileged classes in the society losing their contact with the common people is very real and must be prevented in the short and long term. The rigid separation of medical and nursing practice is reduced over time by two other characteristics of the health system. First, nurses often become doctors. Unlike the United States where to do so would mean starting at the beginning of the medical school, it is done (after at least 5 yr of work) through a 1 or 2 yr additional course.(‘@ So common is this technical promotion of nurses to doctors in China that foreign nurses of middle age are often assumed to be doctors in their home countries. “Why not,” goes the logic, “for who make a better doctor than an intelligent, experienced nurse?” Second in reducing the distinction between medical and nursing practice is the ‘barefoot doctor’, a rural paramedical practitioner trained through a series of short internships during the slack agricultural season. The barefoot doctor forms the backbone of the primary care network in rural agriculture communes. (“) He or she works half-time like the other farmers, and is paid from the surplus grain produced by his work group. His role combines medical and nursing skills, as he is the main health resource for miles around. As the barefoot doctors increase in numbers and their training upgrade is improved, it is seen that they will supercede both doctors and nurses in importance as the core of the nation’s health practitioners. The restructuring of health worker relations has significantly redefined the nature of health work in China, and promoted the achievement of several national goals. These include the provision for primary and preventive health services, decentralization of decision making and management, promotion of worker control over all institutions, development of close relations between health workers and the public, and reduction of class differences inherited from the past. None of this is simple, and none of the Chinese developments have occurred without determination and great effort. (la)At present, thechinese face many questions about how to further develop these new systems. (lg)To us, it seemed a dynamic, constructive, and effective method.
Acknowledgement-The author wishes to gratefully acknowledge the assistance of Margret Stanley, Harold Wildes and Catherine Winkler in the preparation of this article.
References 1. Current Background translation series, no. 888, August 22, 1969. Taken from Mao Tse Tung (1956). Problems of Strategy in China’s Revolutionary War. 2. Current Background, op cit. Mao Tse Tung (1964): Talks at Spring Forum Festival. 3. Berger, A. (1973). Medical Education in China. Eastern Horizon 12(l). , 4. Quoted from comments by Chief of Pediatrics, Friendship Hospital, Peking, Dr. Thu, 8 November, 1976. 5. Maccioni. M. (1975). Daily Life in Revolutionav China. p. 278. Monthly Review Press, New York. 6. Bowers, J. Z. and Purcell, E. F. (1974). Medicine and Society in China. Josiah Macy Foundation, New York. 7. Chou Yung-gun (1963). China reconstructs. Nursing in New China 12(l). 8. Orleans, L. (1961). Professional Manpower and Education in Communist China. U.S. Government Printing Office, Washington.
134 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
RICHARD GARFIELD Hsinhua (New China News Agency) Release no. 1335, p. 14,7/24/56. Selden, M. (1972). Health Pat Bulletin No. 47, Chinese Health System. Quoted from comments by nurses at Friendship, Kiangsu Traditional, and Canton No. 1 Hospital. Survey of China Mainland Press No. 702, p. 89, translation of Hung-ch’i (Red Flag), No. 3,2 March, 1971. Quoted from comments by Ma Hai-teh, American dermatologist and long time resident of China, 10 November, 1976. Maccioni, M., op cit., p. 276. Horn, J. S. (1%9). Away with All Pests, Monthly Review Press, New York. Joint Publications Research Service translation No. 36,889, Chen Chung-jen, (1966). Promoting nurses to doctors. J.. Nurs. 1.56. Side& V. W. and Side& R. (1973). Serve thePeople. Chapter 3. Beacon Press, Boston. Yang, L. (1977). Achievements in public health work must not be negated. Peking Rev. No. 24,21. Ta Kung Pao (1977). Old and FuoungScientists Determined to Modernize China. An editorial. No. 577. 13 July, 1977, p. 1. (Received 9 September 1977; acceptedforpublication
26 January 1978)
0020-1878/78/0801-0129$02.00/0
China’s nurses: redefining roles to improve health RICHARD
GARFIELD,
R.N., B.A.
254 S. Farragut Sweet, Philadelphia, Pennsylvania 19139, U.S.A.
Since its birth in 1949, the People’s Republic of China has hosted a small but steady number of foreign visitors interested in the health field. Not until 1976, to my knowledge, had a group primarily composed of nurses from overseas spent 22 days travelling throughout the country to observe developments in the nursing profession. In all, our group visited more than 30 health institutions, including hospitals, nursing schools, clinics, offices of the government health ministry at all levels, and research centers. This article will report on observations and interviews collected in those 22 days, with the assistance of a team of interpreters. It is supplemented by the study of materials on health and nursing published either for internal Chinese or international audiences. Much of what we saw looked similar to nursing practice in the U.S.A. Basic training takes 2 yr throughout the country, with additional training of ‘X-1% yr for specialties like anesthesia, physical therapy, or radiology. Nurses staff hospitals on three 8-hr rotations/day, count narcotics and report to the oncoming staff before leaving. Further, we were repeatedly told that nurses do nursing work, and doctors are responsible for the medical duties. Thus, it appeared that nursing practice in China was quite similar to that in the West. In fact, many of the recent developments in Chinese nursing have altered the nature of the profession in that country. The style and content of nursing education has changed greatly in the last 30 yr. Where once students learned primarily by the didactic classroom method, now they spend most of their time doing small group projects, rural and community health rotations, and independent study. Various instructors, only some of them nurses, teach in the predominantly hospital-based schools. The principle guiding educational practice is that teachers teach students, students teach students, and students teach teachers. In other words, the whole school is an educational community of equal partners. Knowledge of value, it is thought, comes from direct experience. Theoretical knowledge must develop from practical experience and not vice versa, so students are encouraged to question and reform the tenets and content of educational practice. As Chairman Mao Tse Tung wrote, “Reading is learning, but applying is also learning, and the more important kind of learning at that”.“’ Similarly, testing methods have changed in the last 10 yr. To speed up reform, Mao Tse 129
130
RICHARD GARFIELD
Tung stated, “Examinations at present are like tackling enemies. They are surprise attacks . . . nothing but a method of testing official stereotyped writing. I disapprove of them and advocate . . . for example, if twenty questions are set and the students can answer ten of them well, they may score 100 marks. But if their answers are unimaginative and contain no original ideas, even though they are able to give correct answers to all twenty questions, they are given 50 or 60 marks . . . Why should one learn by rote? We can try this 3).(2) At present, examinations are primarily open book, and the evaluation of preparation for graduation is undertaken by students and teachers alike through judgement of clinical skill and theoretical knowledge. The prime responsibility for these evaluations rests on the teachers, but student input by way of self-evaluation, peer rev.iew, and evaluation of teachers appears considerable. There were no unified national standards for graduation from nursing schools, but such standardization is now being developed. Basic medical education has also changed. ‘Open door education’, as the Chinese call it, has been developed: examination methods have been reformed, learning through practical work has become more important than voluminous book reading, and teamwork between students and teachers has been promoted. In addition, basic medical education has been reduced to 4 yr in duration. V)For both doctors and nurses, then, most learning is carried out through continuing education activities. In their basic education, medical students are taught basic nursing skills and nursing students learn to perform diagnostic procedures and treat common diseases. Thus, while nursing and medicine remain independent professions, the rigid borders between them have been obscured through educational reform. In practice, the distinction between nursing and medical work has also been reduced, though not eliminated. Nurses, for instance, independently prescribe some drugs, order blood tests and take blood samples, administer oriental medical therapies like acupuncture, and perform physical therapy. Doctors commonly assist in washing patients, giving medicines, and performing similar duties commonly considered in the nursing realm. A leading pediatrician in Peking put it succintly when he said, “If I am examining a young patient and he happens to defecate, I feel proud and happy to clean him myself. Before the cultural revolution (1966-1970), I would have thought it undignified and demeaning to do such work. Now I realize that in this way I serve my patients more fully.” He went on, “In this way, relations between doctors and nurses no longer contain a character of split and competition between seniors and juniors, but of cooperation between coworkers with a common task-to serve the patients wholeheartedly ” .c4)The differences between doctors and nurses are seen as technical ones-differences between background knowledge and tasks performed. These differences do not connote the great differences in power and status present in the west between nurses and doctors. “Doctors and nurses have relations of equality: the only difference is their experience, which is not the same”.(*) Health work in China did not always have this characteristic. Nursing, like modern health practice as a whole, was imported by missionaries from the United States and Britain at the beginning of the 20th century. (6)As late as 1949 when the communists took over the country following a long civil war, the majority of health institutions were run by foreign missionaries. Nurses functioned strictly as the handmaidens of doctors in these hospitals, and had little or no role outside of them.“) Major changes occurred after 1949. First, all health institutions run by foreigners were
CHINA’S NURSES: REDEFINING
ROLES TO MPRO
VE HEAL TH
131
nationalized and those run by the Chinese were organized into group practices. Widespread expansion of facilities, the number of nurses and doctors, and educational institutions followed. In 10 yr, the number of nurses increased from about 13,000 to over 100,000.@’As a result of this rapid expansion many nurses were undertrained. Their coordination, status improvement and technical upgrading posed considerable problems in the 1960’~.(~) In addition, the ‘Great Leap Forward’ period (1958-1961) started to change the overall orientation of health work. The goal of health work increasingly was to serve the needs of the common people by providing primary care and preventive services to the vast rural areas of the country rather than highly technical curative services to the urban elite. At the same time, major efforts to improve the status of women in China occurred. Little more than slaves in traditional Chinese society, the promulgation of new marriage and property laws, and a widespread educational campaign to back them up, freed women to participate actively in shaping their country. Many women went into medicine (more than half of the doctors today are women) and nurses took initiative for the first time in redefining the nature of health work. Nurses were in the forefront of the effort to transfer skilled staff to rural areas and practice @rimary care among the peasant farmers.“‘) The pride, skill and experience gained at this time seems to have gone far in promoting the widespread changes in health worker relations which occurred 5 yr later in the cultural revolution. Many of these changes have already been mentioned. One would assume that doctors and even nurses, trained by the old methods and used to a strict hierarchy and large division of labor, would resist such changes. Indeed they did. Nursing and medical schools throughout the country had to be closed for several years to restructure curricula and debate educational philosophy. The health ministry also closed, and only the most necessary tasks were handled by a functional technical staff. While disrupting the health system temporarily, this forced health institutions to deal with the questions of roles, relations, and goals in a decentralized manner, based on local needs and conditions. By 1968, several main trends were apparent. First, the rigid separation of the work of doctors and nurses was considered to be detrimental to the health program and had to be broken down. Second, the management of health institutions, like all institutions in China, had to be controlled by the workers themselves. In this way, unnecessary bureaucracy could be eliminated, class differences could be reduced, and health work could be carried out more effectively. To deal with the first problem, in some hospitals nurses took over from the physicians for a time. They attempted to do all the medical work and have the doctors do all the nursing. Without the requisite skill, knowledge, and role expectations, neither group could function and the patients suffered. (‘I)Furthermore, it was seen that a reversal of the dominating groups failed to promote initiative and release creativity. It was just like the previous hierarchy. This narrow ideal of progress was critized and soon done away with.(12’ Instead, promoting teamwork and upgrading the technical and social roles of nurses changes the relations between nurses and doctors. “In our idea of division of labor, there is a fixing of responsibility and there is an interchange so help can be given to one another. Our society does not break down relationships with barriers”.(‘3) This new system has a number of important ramifications in the work life of a nurse. First, nurses take an active part in making patient care decisions. Nurses in many hospitals
132
RICHARD
GARFIELD
accompany physicians on rounds in the morning, and are integral participants in patient care conferences. They can do a better job of patient teaching, since they are more informed in medical matters relating to each patient. More education of the medical and nursing staff can go on, since all staff have experience and knowledge to teach each other. The work can be more satisfying, since working more closely allows for the development of more supportive relationships. Finally, greater flexibility occurs, for staff with different tasks can fill in for or assist one another. Gone is the exclusive power formerly held by doctors to make patient care decisions. Also gone are the administrative and financial prerogatives formerly held by doctors. The nationalization of health services in the 1960’s did away with private practice for doctors, and all health workers now earn a salary determined by job category, productivity, attitude and seniority. Doctors earn salaries about 10% higher than most nurses in our limited survey, and a number of senior nurses earned more than doctors. This is very different from the United States, where doctors incomes are more than three times those of nurses on the average. The administrative prerogatives of doctors were part of the larger problem of health center management. tiureacratic management of hospitals, under the control of government and doctors, was eliminated during the cultural revolution by the establishment of ‘revolutionary committees’ of health worker representatives. Health workers of all types elect peers to a committee which runs the hospitals until the next election in 2 or 3 yr. The nomination and election process for new committee members works in the following way: doctors and nurses in each ward meet to discuss the makeup of the present revolutionary committee, and recommend other exemplary workers and effective leaders. They send their recommendations for a new committee to the present revolutionary committee. That committee proposes changes at a general meeting of the hospital staff. The proposal can be approved right on the spot, or the ward staff can go back and discuss it. If several units are dissatisfied with the proposal, the committee goes back and makes a new proposal for examination. This back and forth process can go on several times before agreement on the committee’s makeup is reached. Every half year, with or without an election, the ward units examine the actions of the revolutionary committee, suggest changes, and sometimes even remove poor leaders from the committee. Similar democratic decision-making processes are used to set hospital policy, establish 1 and 5 yr plans, and determine funding priorities. “Here there is no trace of the former hierarchy. There was one here before the cultural revolution, but it was a senseless hierarchy, and we destroyed it. There was a hospital chief and a committee of hospital administrators composed of professors and specialists, men who had not transformed their conception of the world”.(14) The new system gives health workers a sense that the hospital and the health work it performs is their responsibility. The task of improving the work thus requires their initiative and energy. The revolutionary committee system of management has problems, too. Prime among these are a chronic underrepresentation of women and the difficulty of carrying through long term projects with a changing leadership. The Chinese feel, however, that in spite of these limitations, there has been a great improvement. All this, however, is not considered enough to restrict elitist tendencies among health professionals. Additionally, all administrative staff and doctors spend one day a week doing manual labor-cleaning the grounds, fixing food, or whatever else most needs to be done. Usually wards are cleaned from top to bottom one day a week by the doctors,
CHINA 5 NURSES: REDEFINING ROLES TO IMPROVE HEALTH
133
nurses, and able patients in that unit. In addition, since rural areas still have poorer health services than urban areas, all health professionals rotate to rural areas for one in 3 or 4 yr.(15)It is considered that the shortage of medical personnel is a short term problem, but the danger of privileged classes in the society losing their contact with the common people is very real and must be prevented in the short and long term. The rigid separation of medical and nursing practice is reduced over time by two other characteristics of the health system. First, nurses often become doctors. Unlike the United States where to do so would mean starting at the beginning of the medical school, it is done (after at least 5 yr of work) through a 1 or 2 yr additional course.(‘@ So common is this technical promotion of nurses to doctors in China that foreign nurses of middle age are often assumed to be doctors in their home countries. “Why not,” goes the logic, “for who make a better doctor than an intelligent, experienced nurse?” Second in reducing the distinction between medical and nursing practice is the ‘barefoot doctor’, a rural paramedical practitioner trained through a series of short internships during the slack agricultural season. The barefoot doctor forms the backbone of the primary care network in rural agriculture communes. (“) He or she works half-time like the other farmers, and is paid from the surplus grain produced by his work group. His role combines medical and nursing skills, as he is the main health resource for miles around. As the barefoot doctors increase in numbers and their training upgrade is improved, it is seen that they will supercede both doctors and nurses in importance as the core of the nation’s health practitioners. The restructuring of health worker relations has significantly redefined the nature of health work in China, and promoted the achievement of several national goals. These include the provision for primary and preventive health services, decentralization of decision making and management, promotion of worker control over all institutions, development of close relations between health workers and the public, and reduction of class differences inherited from the past. None of this is simple, and none of the Chinese developments have occurred without determination and great effort. (la)At present, thechinese face many questions about how to further develop these new systems. (lg)To us, it seemed a dynamic, constructive, and effective method.
Acknowledgement-The author wishes to gratefully acknowledge the assistance of Margret Stanley, Harold Wildes and Catherine Winkler in the preparation of this article.
References 1. Current Background translation series, no. 888, August 22, 1969. Taken from Mao Tse Tung (1956). Problems of Strategy in China’s Revolutionary War. 2. Current Background, op cit. Mao Tse Tung (1964): Talks at Spring Forum Festival. 3. Berger, A. (1973). Medical Education in China. Eastern Horizon 12(l). , 4. Quoted from comments by Chief of Pediatrics, Friendship Hospital, Peking, Dr. Thu, 8 November, 1976. 5. Maccioni. M. (1975). Daily Life in Revolutionav China. p. 278. Monthly Review Press, New York. 6. Bowers, J. Z. and Purcell, E. F. (1974). Medicine and Society in China. Josiah Macy Foundation, New York. 7. Chou Yung-gun (1963). China reconstructs. Nursing in New China 12(l). 8. Orleans, L. (1961). Professional Manpower and Education in Communist China. U.S. Government Printing Office, Washington.
134 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
RICHARD GARFIELD Hsinhua (New China News Agency) Release no. 1335, p. 14,7/24/56. Selden, M. (1972). Health Pat Bulletin No. 47, Chinese Health System. Quoted from comments by nurses at Friendship, Kiangsu Traditional, and Canton No. 1 Hospital. Survey of China Mainland Press No. 702, p. 89, translation of Hung-ch’i (Red Flag), No. 3,2 March, 1971. Quoted from comments by Ma Hai-teh, American dermatologist and long time resident of China, 10 November, 1976. Maccioni, M., op cit., p. 276. Horn, J. S. (1%9). Away with All Pests, Monthly Review Press, New York. Joint Publications Research Service translation No. 36,889, Chen Chung-jen, (1966). Promoting nurses to doctors. J.. Nurs. 1.56. Side& V. W. and Side& R. (1973). Serve thePeople. Chapter 3. Beacon Press, Boston. Yang, L. (1977). Achievements in public health work must not be negated. Peking Rev. No. 24,21. Ta Kung Pao (1977). Old and FuoungScientists Determined to Modernize China. An editorial. No. 577. 13 July, 1977, p. 1. (Received 9 September 1977; acceptedforpublication
26 January 1978)
