A tale of two countries: Nurse practitioners in the United States and China

The growth and impact of advanced nursing practice continues throughout the world, particularly in the United States (USA). Since the first nurse practitioner (NP) programme opened in 1965 at the University of Colorado, advanced practice registered nurses (APRNs) have been highly valued and have become an integral part of the healthcare system in the USA (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). As one of the four types of APRNs, more than 270,000 NPs currently practice in the USA (American Association of Nurse Practitioners, 2019), and can safely provide 75%–93% of primary care services (Maier, Barnes, Aiken, & Busse, 2016). NPs provide a wide range of healthcare services including assessment, diagnosis, management of health problems, prescribing medication and treatments, health education and health promotion, as well as counselling individuals and families (American Association of Nurse Practitioners, 2015; Dunn, 1997). An increasingly large body of evidence demonstrates that NPs deliver quality care comparable and often better than physicians, provide care at lower cost, and are more likely to serve vulnerable populations in the USA—women, non-whites, the poor, uninsured and people with disabilities (Buerhaus et al., 2018; DesRoches, Clarke, Perloff, O'Reilly-Jacob, & Buerhaus, 2017; Perloff, DesRoches, & Buerhaus, 2016). There are over 4.1 million Registered Nurses in China providing healthcare services to 1.4 billion people, about one-fifth of the world's population. Accounting for 43% of all medical workers in China with a doctor-to-nurse ratio of 1:1.14, nurses are now the largest group of the nation's healthcare workforce (National Health Commission of the People's Republic of China, 2019a). However, advanced nursing practice did not emerge in China until the early 2000s. With assistance of the Loma Linda University Medical Center in the USA, Sir Run Run Shaw Hospital in Zhejiang Province implemented China's first two specialty nurses in diabetes and wound/ostomy in the year of 2000 (Wu & Xiao, 2008; Ye, 2001). Since then, subsequent specialty nursing courses have been established across China mainly organized by provincial or municipal health departments and nursing associations, particularly with support from Hong Kong (Wong, 2018; Wu, Li, Li, & Cao, 2017). The first NP educational programme in China was established in Nanjing Drum Tower Hospital thanks to the support of the Johns Hopkins University School of Medicine in 2015 (Li, Chen, Lian, Zhang, & Zhou, 2018). In 2017, Peking University School of Nursing initiated the first master's degree NP programme with recruitment of two students (Peking University School of Nursing, 2017). Shortly after that, in 2019, the first NP in-service training programme co-sponsored by Peking University and the China Medical Board (a Rockefeller-endowed US foundation) was launched, and 20 students from six provinces in China were enrolled (Peking University School of Nursing, 2019). The timing of these two countries’ stories in nursing has been intertwined since the late 19th century, when US nurses Elizabeth McKechnie firstly introduced the Florence Nightingale system of nursing to China in 1884 and Ella Johnson established the first nursing school in China in 1888 (Lin, 1938). Funded by the Rockefeller Foundation, the nursing school of Peking Union Medical College was established in 1920, marking the beginning of higher nursing education in China (Yan, Li, & McDonald, 2014). Anna D. Wolf from the Johns Hopkins Hospital Training School served as its first director (Lin, 1938). The development of NPs in China has also been influenced by professional organizations in the USA where, as noted above, the NP role was first developed and continues to grow. Currently, the USA and China share similar healthcare challenges, such as an aging population with a growing burden of chronic non-communicable diseases, healthcare workforce shortages, uneven distribution of healthcare providers, rising costs in health insurance, all of which is stressing the ability of both nations to delivery needed primary care (Li et al., 2017; Sawin & O'Connor, 2019). Despite the political, economic, societal and cultural differences between the USA and China, NPs are increasingly regarded in both countries as the solution to bridge the healthcare gap (Buerhaus, 2018; Zhan, Shang, Li, & Chen, 2019). In 2018, Peter Buerhaus's landmark report ‘Nurse Practitioners: A Solution to America's Primary Care Crisis’ described evidence of the contributions of NPs from numerous original studies that his research teams have conducted since 2012 (Buerhaus, 2018). This report has recently been translated from English to Chinese by a group of Chinese nursing scholars studying at the Johns Hopkins University School of Nursing. The intent is to not only introduce the emergence, current status and future development of NPs in the USA but also hasten the development of NPs in China. In addition, authors from the Peking University Health Science Center, School of Nursing, and the China Medical Board most recently published a comment in the Lancet entitled ‘Bridging the GP gap: Nurse practitioners in China’ with a Chinese translation included in an appendix that highlights the necessity and feasibility of NPs in meeting China's healthcare challenges (Zhan et al., 2019). The current move to develop the NP role in China is congruent with the first national guide for health promotion, Healthy China 2030 and the corresponding Healthy China Action Plan, that highlight the importance of primary care (National Health Commission of the People's Republic of China, 2019b; Tan, Zhang, & Shao, 2019). Primary care services require multidisciplinary collaborations including doctors (e.g. general practitioners), nurses and other healthcare providers (Li et al., 2017). Challenges such as inadequate training, uneven distribution and ongoing shortage of general practitioners in China (Yang, Han, & Xu, 2019) mirror what was happening half a century ago in the USA when the NP role was created. Nursing experts from the USA and China have taken actions to develop advanced nursing practice (including NPs) in China, such as synthesizing an overview of advanced nursing practice in the USA, Canada, Australia and Hong Kong (Parker & Hill, 2017), as well as providing recommendations pertaining to standards of advanced nursing practice, degree level, pilot projects, clinical tutor-faculty preparation, and strategic directions and corresponding actions (Hill, Parker, Liu, Hu, & Guo, 2017). Obviously, the development of NPs in China should reflect the evidence not only from the USA but also from China itself. More questions and challenges will be encountered in developing greater numbers of NPs in China and assuring they are permitted to provide primary and other specialty care. Some of these challenges may be similar to those in the USA, such as how to remove scope-of-practice restrictions that many states place on NPs (Perloff, Clarke, DesRoches, O'Reilly-Jacob, & Buerhaus, 2019), and primary care physicians’ resistance to allowing NPs to practice fully due to worries or fears about being replaced (Donelan, DesRoches, Dittus, & Buerhaus, 2013). However, it can be anticipated that other obstacles unique to China will emerge. For example, how to assure that NPs who have completed a higher degree are willing to practice in primary care settings that have long been overlooked or even avoided. There is a paucity of evidence demonstrating the feasibility of NPs, as well as cost-effectiveness and quality of care delivered by NPs in China. We know NPs have the potential to contribute to developing China's primary care strategy (Zhan et al., 2019), and we believe the time has come to reflect and share on the experience of the USA in developing this crucial role in China. No conflict of interest has been declared by the authors.

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