Strengthening actions for caring as a core component of nursing in the People's Republic of China

Nursing has a long and distinguished history in China (Mu, Yao, Cui, Han, & Yang, 2018). However, since the development of the People's Republic of China greater progression in nursing has occurred, with increasing high levels of educational preparation available to nurses up to and including PhD (Kalisch & Liu, 2009). Professional development is ongoing, with desires for increased education and specialism in response to rapidly changing health trends, technological advances and population changes, including a growing population of multi-generational older people significantly dependent on disproportionately smaller numbers of offspring (WHO, 2015). Health care reform is high on political agendas in China (Fang, 2015), and nurses have a recognized key role in this (Mu et al., 2018:373). Nurses in China number more than 4 million, and currently, they are on the cusp of exciting change with the recent establishment of China's first Nursing Union, set up by nine hospitals to spearhead professional development in the face of current challenges (Xinhuanet, 2019). This union was initiated by the Peking Union Medical College Hospital, and aims to improve education among nurses by sharing resources, developing national standards and providing exemplary role models for excellence in practice (Xinhuanet, 2019). At the same time, the Chinese health care system is operating with nursing shortages (Health & Family Planning Commission of the People's Republic of China, 2016 cited in Shao et al., 2018) although the population of Registered Nurses is now increasing. Interestingly, there has been a great emphasis on caring within nursing over the past decade. For example, in 2008 “Nurse Regulations” were issued by the State Council of China, stipulating that nurses should show respect, provide caring and love to patients, and protect their privacy. Since the year 2010, the Ministry of Health started a national project called Quality Care Demonstration Project among public hospitals in China, aimed at improving satisfaction of patients, government and society with health care by improving professional care to patients. The importance of providing human caring in this context was also highly emphasized in the Quality Care Demonstration Project (Ministry of Health of the People's Republic of China, 2010). In 2014, the Ministry of Health and Family Planning Commission also issued a directive that quality assurance mechanisms must also include a measurement and evaluation of human caring. In 2014, the Health and Family Planning Commission of the Peoples' Republic of China also issued the Action Plan for Improving Medical Services (2015) and required that medical institutions should strengthen human caring and thus should improve patients' satisfaction with medical service. The most recent strategic health plan, “Strategic Planning for Healthy China 2030” strengthened the requirement for human caring as a basis for health care and also harmonious doctor–patient relationship. These government regulations requiring implementation of human caring in nursing practice are a driving force for underpinning nursing with a caring philosophy. Indeed, currently there a very big emphasis on developing a caring response within the health professions in China; for example, the Chinese Nursing Development Program (2011–2015) recommended that nursing schools increase the humanities content in their curriculum to strengthen caring consciousness. Increasingly, Chinese nursing scholars have been engaging in research in the field of caring but also in the implementation and development of practical approaches to hands-on nursing that are based on values and philosophies of caring. These scholars believe that implementing nursing that has a strong basis in caring theory and philosophy can have a positive influence on health and the human condition. They describe caring as an “interactive process that usually occurs during moments of shared vulnerability between nurse and patient” (Wolf, Giardino, Osborne, & Ambrose, 1994 cited in Zhang & Liu, 2016). However, despite a clear commitment to nursing that is underpinned by a caring philosophy, curricula in China remain deplete of instruction in this regard (Zhang & Liu, 2016). Nonetheless in some hospitals in China, various measures are taken to provide human caring to patients as well as to colleagues. In Wuhan Union Hospital, for example, Watson's caring science (Watson, 2019) has been implemented since Watson's inaugural visit in 2010. Some hospitals across China now visit this hospital to see this caring model in action. A training programme was developed that includes 13 sessions to train nurses' caring ability, including theoretical learning, activities, reflexive writing and reading articles about human caring. Participants also attend a human caring ward round and sharing human caring stories. The caring theory focuses on nurses to show caring to patients by being polite, communicating person to person with patients for at least 5 min each day, and aiming for caring communication with key questions such as Do you have any discomfort? and Do you have any needs that I need to address? Evaluation forms are used in the hospital to regularly evaluate human caring communication and satisfaction with care (Liu et al., 2016). Coupled with a caring approach to nursing, a caring approach to leadership is also promoted. This replaces a more traditional management style termed rigid management, which has been used by some nursing managers in China (Peng, Liu, & Zeng, 2015:173). Caring leadership behaviours may be exemplified, for example, by celebrating nursing staffs' achievements and celebrating special days, including International Nurses Day. These caring leadership behaviours are becoming more important. While leadership styles and approaches have been studied extensively over the past 50 years, increasingly the notion of the manager's ability to relate in a personal way with staff is gaining increasing credence (Schein & Schein, 2018). For example, Wang et al. (2019) recently found a positive relationship between inclusive leadership style and leaders' innovative behaviours and work engagement. Other studies similarly found links between positive work environments and satisfaction (Liu et al., 2012). In one qualitative study of nurse managers in China, caring leadership was found to promote professional growth (Peng et al., 2015). Simple things like the manager simply remembering and celebrating a nurse's birthday (while on duty) made a big difference to morale. Peng et al. (2015) used Boykin and Schoenhofer's (2001:5) understanding of caring in this context that describes “nursing as caring”. Put simply, personal behaviours of caring, in every circumstance, form the “bedrock” of acting out a caring philosophy. Fundamental to this is the “integrity, wholeness and connectedness of the person” (Boykin & Schoenhofer's, 2001:5). These caring behaviours of leaders are very much linked to caring science (Peng et al., 2015). However, nurse managers often have limited educational backgrounds related to the historical development of nursing in China (Luo, Shen, Lou, He, & Sun, 2016). Indeed, it is postulated “the majority of Chinese managers continue to learn through their failures or work in response to their emotional experiences” (Luo et al., 2016: e88). While limited training of managers is not exclusive to China (Timmins & Adams, 2014), Luo et al. in their qualitative study did reveal that managers certainly learn to adapt on the job by “trial and error” rather than being prepared in advance (2016: e90). Within this context, although there are challenges with nursing resources, much is being done to strengthen the work environment for nurses. Leadership is key in this regard, and Chinese Nursing has a big commitment to the growth and development of nursing leadership, evidenced, for example, by the hosting of regular conferences focused on nursing management. The Chinese Nursing Association, for example, host an annual National Nursing Management Reform and Innovation Forum. (Professor Xinjuan Wu, the Chairperson of the Chinese Nursing Association is proactive in leading on the professionalizing agenda for nurses in China.) From a nursing management perspective, caring within nursing practice is of great concern to both scholars and practicing nurses alike in China (Cheng, Liu, Ke, & Wang, 2019; Guan et al., 2018). The population expanse in Chinese nursing and health care makes their experiences in this regard very relevant for international practice. Caring science and philosophies of caring have much to offer in terms of improving work environments for nursing staff, in addition to improving patient outcomes. The proven result of this humanistic, other centred approach is the development and nourishment of nursing staff and enriching environment that will serve to attract and retain high-calibre staff. Alongside other countries internationally, China now needs to fully explore, and put an evidence base behind, relational leadership styles, such as caring leadership, that will support the workforce and at the same time support and nourish patients in their care. Developing a cohesive philosophy of care has much to offer in terms of aligning nurses' values with managerial targets, which could increase workplace satisfaction (Shao et al., 2018). Only by exploring meaningfully what leadership characteristics and behaviours are required for staff development and improvement, can we know for sure how best to support our workforce into the future and actively support the national and international goals for improvements in quality and safety and effective responses to unprecedented demographic and technological changes for the future.

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