Vol.7, No.2 July 2001
Editorial | Contents
Nursing education: the Chinese perspective
Refereed Article
Author
Tina Tse
Senior Lecturer
Curtin University Western Australia
Email: tset@nursing.curtin.edu.au; Fax: 61 (08) 9266 7485
Key words: Nursing education, China
Abstract
This paper reports the directions and concerns pertaining to nursing education in China and comparison was drawn between China and her Western counterparts. A review of all papers submitted by nurse leaders and academics of China to the 1st Sino-Hong Kong Nursing Education Conference and a selection of Western journal publications on nursing education found one of the main foci of concerns in nursing education was innovative undergraduate program development. In contrary to their Western counterparts, there was a lacking of enthusiasm in discussion on preparing students on nursing research at undergraduate level and issues related to professionalism among the Chinese academics. However, their main challenge ahead is to prepare students who come from the one-child-families at a level of maturity consistent with the responsibilities of nursing. Overall, there was a concerting effort worldwide to promote nursing education according to the recommendations made by the WHO.
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Introduction
Philosophical changes in nursing and health care practice have stimulated nurse leaders to constantly explore different strategies to prepare students to professionally, intellectually and psychologically function as competent nurses. Many of them have already demonstrated their commitments to promote nursing education that is relevant to the socio-economic-political structure of the community and reflects the commitment to the principles of the recommendations made by the World Health Organization (WHO) Global Advisory Group on nursing education in 1992. A key part of the recommendations in relation to the advancement of basic nursing education is for WHO and signatory countries to continuously support the development of innovative nursing educational programs. The direction of curricula of such programs is toward future care needs and priority health problems. The main foci of the program are on the development of critical thinking and caring attitude of the students. In order to achieve these objectives, students entering nursing programs should have a good basic education and have reached a level of maturity consistent with the responsibilities of the work.
The outcomes of the WHO Global Advisory Group meetings on nursing education offer a vision and focus for preparing nurses to meet challenges of the 21st century. However, its recommendations are not the end, it is the beginning and the key point is on how the aspirations will be translated into reality and action. Although at times curriculum review is reactive it is required to follow the direction of its professional body such as National League for Nursing in the United States or government body such as Ministry of Education in Taiwan (Story et al. 1990). Often nurses are pro-active in responding to changes in health policy and health needs by ongoing evaluation and modification of curriculum and teaching strategies. As Salvage (1993) clearly pointed out, implementation of the recommendations should be guided by local circumstances such as resources and health care needs. Literature indicates that nurse leaders are well on the way to develop, implement and evaluate innovative nursing education programs to meet health care challenges of the new millennium (Cloutterbuck & Cherry, 1998; Spitzer, 1998; Pleasance & Sweeney, 1994). International nursing community also engages in exploring commonalities and differences in preparing nurses to meet the diverse needs of health consumers. A number of cross-cultural comparison of nursing education conducted among countries in Central and Eastern Europe (Welch, 1995), Asia, America, Africa and Europe (French et al. 1996), and China and America (Story et al. 1990) has been published in major nursing journals. Such comparison encourages nurses to be more aware of the global approach to nursing education instead of limiting their interest on local issues. Indeed, an exchange of ideas on teaching-learning experiences, either at nursing conferences or through nursing journals, would promote studentís learning outcomes, consequently, better standard of care and professional image.
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Purpose of the study
The 1st Sino - Hong Kong Nursing Education Conference was held in Hong Kong in late 1996 and the conference papers/ abstracts covered a board range of issues related to nursing education in China and Hong Kong. China is one of the signatories of the WHO. As indicated by the conference papers/ abstracts, there is concerting efforts among the Chinese nurse leaders and academics to advocate advancement in nursing. As nursing education in China has only been re-established in early 1980s, comparatively little is known about the recent development of Chinese nursing education and it is of interest to the nursing community to have an overview of the nursing education in China. The aims of this study were twofold: [1] to highlight concerns expressed by delegates and papers/ abstracts submitted to the conference about nursing education in China, and [2] to compare foci of nursing education in China and her overseas counterparts.Nursing education in China
The author assumes that readers are familiar with the background of nursing education in English speaking countries, but not their Chinese counterparts, hence a brief description of nursing education in China is provided for reference.
Nursing education in China follows the guidelines stipulated by the Ministry of Education. The guidelines stress that nurses should have good general education foundation, knowledge in basic medical sciences and clinical medicine, health promotion knowledge, nursing studies and skills, and they should be able to synthesis knowledge and skills in different clinical health care settings (including rural areas where medical support is inadequate). It also states that nurses should have a healthy body and mind.
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Basic nursing education
Junior school graduates can enrol in a fee paying three-year (approximately 152 study weeks) basic nursing education program at a health school. The ratio of theoretical and clinical component is 1.0 : 1.3. First year syllabus include: language, English, politics, physical education, mathematics, physics, chemistry, biochemistry, anatomy and embryology, physiology, immunology, micro-biology, behavioral science, basic Chinese medicine and acupuncture, and fundamental nursing. Second year syllabus focuses more on nursing and include medical nursing, surgical nursing, paediatric nursing, gynaecological nursing, pathology, pharmacology and some of the first year subjects (except science subjects). Clinical nursing practice is introduced in the second year and majored in the final year. Other nursing specialty areas such as ENT nursing, infectious nursing and preventive medicine and health promotion are taught in the final year. Annually there are approximately 40 000 students graduated with nursing certificate from about 510 health schools in China (Chiu & Lee, 1996, Chan & Wong 1999).
Diploma programs
Since 1980, there are 65 nursing schools that are affiliated with tertiary institution that offer nursing education at diploma level to students who had graduated from senior secondary schools and nurses who graduated from the basic nursing program and wish to advance their nursing qualification. However, only a small number of certificate nurses are admitted to the program because they are required to pass the university entrance examination. Depending on the students’ education/ professional background, it usually takes 2-3 years for them to complete the diploma program. Each year approximately 4000 graduates from the diploma program enter the workforce and work as professional nurse or senior nurse (Chan et al., 1999)
Baccalaureate degree programs address a higher level of learning and students are prepared to take on leadership role in health care settings. After 10 years of turmoil, a result of the Cultural Revolution, nursing education at university level was re-established and the first group of the first baccalaureate degree program graduated in 1988 (Davies et al. 1992). Approximately 400-500 students graduate from 15 medical science universities each year. There are 3 major theoretical modules in the 5-year degree program: foundation unit (30%), medical foundation unit (30%) and professional unit (40%) as well as a clinical component. The ratio of theoretical and clinical components is estimated to be 1.0 : 0.8. Theoretical component include nursing philosophy, ethics, nursing diagnosis and nursing research. Clinical nursing, in addition to those offered at the diploma or certificate levels, include other specialty areas such as mental health/ psychiatric nursing, dermatology and neurology nursing.
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Review Process
Sample
All 345 abstracts and conference papers submitted to the Conference from China (excluding those from Hong Kong) and all journal articles on nursing education published in three major nursing journals in Australia (The Australia Journal of Advance Nursing, Spring 1995 to Autumn 1996), Britain (Nurse Education Today 2/1995 to 6/1996) and United States (Journal of Nursing Education 1/1995 to 6/1996) during the same time as from the Conference first call of papers to the conclusion of the Conference were included in the study.
Analysis
A content analysis approach was used to guide the review process and the analysis was conducted by a team of nurse academics. Based on the content of the articles, a table to encompass all possible codes and categories was developed. In order to minimise ambiguity and ensure coding consistency among the team members, the meaning of each code and category was clearly defined. At the beginning and the end of the analysis process, 10% of randomly selected papers was analysed by each team member, entries to categories were compared and discrepancies were discussed. The final agreement in classifying responses among the members was 93% which is considered satisfactory.
Results and discussion
An analysis of content of the articles identified some common features as well as differences in directions and concerns in nursing education. It was found that the Chinese nurse leaders and academics focused on basic and post-graduate nursing education, advanced specialisation programs, teaching-learning strategies and quality assurance (Table 1). Comparing to their overseas counterparts, they were less concerned with promotion of nursing research and issues related to professionalisation (Table 2).
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The review found that there is a concerting effort globally to develop and implement different teaching-learning strategies to promote the cognitive and psycho-motor domains of nursing practice. It was reported that student learning outcomes were enhanced by using innovative teaching approaches such as experiential learning and reflective practice; and technological advancement also promoted studentsí learning opportunities and academic achievement. In comparison, the affective domain of nursing practice received lesser attention and only a small number of the reviewed papers discussed on promotion of studentsí attitudes towards nursing and strategies related to improving quality of care.
A number of discussions were held on the preparation of student to take on challenges in providing care for their patients, a phenomenon unique to the Chinese. Apparently, the one-child-family policy in China has become a pressing issue as more and more students entering nursing education programs are from one-child families (Chiu et al. 1996). Social research has demonstrated that parental preference for number and gender of children has a certain impact on children’s behavioural patterns (Shen & Wang, 1995; Tao, Tseng & Qiu et al., 1988; Yu, 1985) and children without siblings tend to manifest problems in areas related to emotions and maturity (Tao, Qiu & Li et al. 1995). Not surprisingly, Chinese nurse leaders and academics were concerned about life experiences and maturity of being the only child in the family which might effect the level of maturity consistent with the responsibilities of nursing. Furthermore, it is deemed their responsibility to develop the students’ ability to function as a competent nurse, professionally, intellectually and psychologically. Indeed it imposes a challenge for them to find ways to help their students to develop a higher level of maturity and meet the health needs of the patients.
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A voluminous of reviewed articles addresses directions and development of basic nursing education. In most parts of Australia, Britain and United State of America, the nursing education has been transferred to universities. In China, progress has been made to transfer nursing education to universities and a majority of nursing education programs is still conducted at health schools, yet, as reflected by the conference papers, many of the academics were enthusiastic about promoting nursing education to a high level of preparation. However, there is a shortage of nurses in China to meet the immediate demands of health services, it may not be possible to transfer tens of thousands of nursing students to universities in the near future. Nursing education at health schools will continue to play an important role in preparing nurses to meet the health needs of the community. Yet the curriculum of such program do not address nursing research and foster the culture of evidence based practice. Thus it is not surprising that there was a lack of discussion on promotion of nursing research at the Conference.
Attention was placed on post-graduate education for nurses. In view of the expanding and more specialised roles of nurses, there is a global trend towards role-specialisation and courses have been implemented to promote such development. One unique feature found amongst the conference papers was on the development of advanced specialisation nursing courses in Traditional Chinese medicine (TCM). TCM has played a very important role in the field of medicine in China over thousands of years, with the introduction of Western medicine in the last century, extensive work has been done in attempting to integrate the TCM and Western medicine in health care practices. TCM is one of the foundation core units in the nursing education curriculum, and many nurses have specialised in TCM nursing after attending post-basic advanced specialisation courses in TCM Nursing.
Discussions on professionalization was a popular discussion topic amongst the papers published in the British and United State of America journals, but this phenomenon was not found among the conference papers. A plausible explanation could be that nursing in China has already been officially recognised as a profession. In the Chinese health care system everyone has a specific role to play, their status in the society is marginally different and variation in salary is not significant. A nurse may not become the hospital director but she/he can hold the position as a deputy director or other important position. For example, many other health professionals such as doctors or psychologists are employed as full time teaching staff at the faculty of nursing led by a nurse academic. In other words, political-social environment plays an important role in shaping the community attitudes toward nursing and their view on nursing as a profession.
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Conclusion
The first university nursing education program in China commenced in 1922, 6 years after the first degree program was implemented in the United States (Davies et al. 1992). Nursing education in China has been greatly disadvantaged by turmoils caused by World Wars, civil war and the Cultural Revolution. Since the late 80s, nursing education in China has undergone the transition of transferring certificate nursing program to university based diploma and degree programs, this process may take a few decades to complete. Nevertheless, Chinese nursing leaders and academics, similar to their overseas counterparts, have committed themselves to the recommendations made by the WHO (1992) and strive to develop different teaching-learning strategies to promote the cognitive, psycho-motor and affective domains of nursing practice, and the development of innovative nursing education programs addresses the future care needs and health problems of the local community. Yet, the biggest challenge for and unique to the Chinese nurse leaders and academics is to prepare students who come from the over-protective one-child families at a level of maturity consistent with the responsibilities of the work. In view of the global tendency for small family unit, it will be interesting to see how this problem can be addressed.
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List of Reference
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French, P. Anderson, J. Burnard, P., Holmes, C., Mashaba, G., Wong, T. & Zit B. H. 1996). International comparison of baccalaureate nursing degrees: collaboration in qualitative analysis. Journal of Advanced Nursing, 23 (3): 594 - 602.
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