Expert suggestion: Accelerate the implementation of the medical nursing staff system. Some nursing staff have poor professional skills, and their fees have become a heavy burden for some families. Living in the ward, hospital, nurse, nurse, patient, hospital, and nursing staff

[Editor's note]

On January 7th last year, the Legal Daily published an article titled "Why do we still need to hire caregivers when everyone has been sent to the hospital?", which attracted widespread attention from society. For over a year, there have been frequent discussions between readers and journalists on this topic. It is widely believed that this is a practical issue involving a large number of families. We support the cancellation of caregivers and the replacement of caregivers by nurses responsible for patient care or the establishment of assistant nurses in hospitals.

The nursing work of medical institutions is related to the quality of medical care and patient safety, as well as the physical health and medical experience of the people. In 2010, the former Ministry of Health issued a notice requiring the gradual resolution of the problem of relying on patients' family members or self hired caregivers to undertake patient care, and reducing the burden on patients' families. In August 2020, the General Office of the National Health Commission issued a notice on further strengthening the nursing work of medical institutions, proposing that when nursing resources are insufficient, medical institutions can hire a certain number of qualified and trained medical nurses according to actual needs, and strengthen standardized management according to requirements.

The reporter conducted a further investigation into the issue of waste storage of caregivers.

Wearing a hospital uniform with a white background and a blue pattern, Li Wenchang, a 75 year old resident of Shunyi District, Beijing, lay on a hospital bed about one meter wide, covered in white bedding and sheets. Due to illness, Li Wenchang was unable to move. Beside him, a middle-aged caregiver dressed in black is busy taking care of his daily life, sometimes feeding him and sometimes changing his diapers.

This is a scene seen by a reporter from the Legal Daily in early June of this year when he walked into the orthopedic ward of a tertiary hospital in Beijing. At this moment, Li Wenchang is queuing up in the ward to undergo surgery. The caregiver was hired by his son Li Mingxuan with money.

In Li Mingxuan's view, taking care of his father is a caring caregiver, but he still feels unhappy: "In the past three months, my father has been hospitalized in several hospitals for about 70 days. After being reimbursed by medical insurance, he paid more than 10000 yuan for medical expenses, which is higher than medical expenses. He paid more than 17000 yuan, which is a significant burden for our family."

The Li family's experience is not an exception. The reporter learned from the interview that due to the insufficient number of nurses in China, except for some special wards such as infectious disease wards where the daily care of patients is undertaken by nurses, when patients in ordinary wards need daily care, it is mainly undertaken by family members or self hired caregivers. Some hospitals cooperate with third-party organizations to provide caregivers; Some hospitals do not have relevant cooperation, and family members have to find their own caregivers. The sources of caregivers include caregiver service companies, housekeeping companies, and individual caregivers. The market-oriented cost of caregivers usually ranges from two to three hundred yuan or even higher per day.

The interviewed experts believe that in the situation where it is difficult to replenish nursing resources in a timely manner, implementing the medical nurse system is always a solution to solve the problem of patient hospitalization and accompanying care. In the future, supporting systems should be introduced as soon as possible to solve the problem of payment for nursing services, establish a mechanism for sharing nursing costs among all parties, accelerate the exploration of establishing a medical nurse system, and reduce the burden on patients and their families.

The patient is hospitalized and unable to take care of themselves

Helpless to pay for self hired caregivers

Let's start from this year's Spring Festival period. At that time, Li Wenchang felt unwell, especially with difficulty urinating. Considering the cost of going to the hospital for medical treatment and the busy work of the child, he has been enduring it. In early March, he discovered that he had started urinating blood and realized the severity of the problem before telling his son about his condition.

Li Mingxuan quickly put down his work and sent his father to a tertiary hospital near his home. After diagnosis, it was found that Li Wenchang had a tumor in his prostate. The doctor suggests transferring to another hospital for treatment. After transferring to another tertiary hospital in Beijing, the doctor's examination concluded that based on the location and condition of the tumor, surgery is not necessary for the time being. Instead, taking medication at home can suppress the development of the tumor.

To Li Mingxuan's surprise, during his father's treatment at home, he had another problem with his lumbar spine and could only lie in bed, unable to take care of himself. On March 31st, Li Mingxuan sent his father back to B Hospital for treatment. Due to having to go to work and unable to take care of his father, Li Mingxuan, on the recommendation of the ward nurse, hired a caregiver to take care of his father 24 hours a day for a one-on-one service of 240 yuan. My father stayed in the ward for 20 days.

Li Mingxuan told reporters that this caregiver does not belong to the hospital, but belongs to a domestic service company that has cooperation with the hospital, and the hospital itself does not have caregivers.

It is worth noting that according to the medical documents provided by Li Mingxuan, his father was hospitalized for 20 days and paid over 18000 yuan in medical expenses to B Hospital, including 520 yuan for nursing expenses, which is 26 yuan per day. During the same period of hospitalization, he paid a caregiver fee of 4800 yuan, which is more than 9 times the hospital's nursing fee.

During his hospitalization at Hospital B, the doctor conducted CT and MRI examinations and found shadows in the fourth and fifth segments of his lumbar spine, suspecting that the tumor had bone metastasis. Li Wenchang was transferred to another tertiary hospital for 17 days of inpatient examination and treatment. Considering that the other party is taking care of the patient with great care and that he does not have the time or energy, Li Mingxuan decided to continue hiring this caregiver at the same cost.

Fortunately, after lumbar puncture biopsy, it was diagnosed with bone tuberculosis. However, due to the inability of this hospital to undergo surgical treatment, on May 9th, Li Wenchang was transferred to the current A hospital to wait for surgery, and was still taken care of by this caregiver.

Li Wenchang was infected with COVID-19 while waiting for the operation, and the doctor ordered him to go home for observation and treatment until he turned negative. During hospitalization, I paid over 470 yuan in nursing fees to the hospital, totaling over 33 yuan per day. In early June, after turning negative, Li Wenchang returned to Hospital A and waited in line for surgery.

"Since March 31st, this caregiver has been accompanying my father. As of June 9th, we have paid more than 17000 yuan in caregiver fees. This amount of money far exceeds the medical expenses we paid ourselves after being reimbursed by medical insurance." Li Mingxuan said, "During my father's hospitalization, he had already paid the caregiver fees to the hospital. Why do I have to hire a caregiver and bear such a large amount of caregiver fees?"

Wang Xia, a resident of Haidian District in Beijing, not only feels that the cost of caregivers is "too expensive", but also dissatisfied with the hospital's "forced recommendation" of caregivers. In April this year, she rode an electric bike to work and was hit by a car at the intersection, resulting in a broken leg bone. After the surgery at a tertiary hospital in Beijing, I hired a caregiver for 5 days. If the patient is hospitalized in this hospital and cannot take care of themselves after the surgery, the hospital requires the patient to hire a caregiver from a third-party organization that has cooperation with the hospital. We are not allowed to hire caregivers ourselves, nor are we allowed to be accompanied by family members.

The cost of caregivers is 200 yuan per day for "one to many" and 320 yuan per day for "one to one". "I chose a 'one-on-one' one, and in addition to the nursing fee, I also need to pay a daily nursing fee of 25 yuan to the hospital," said Wang Xia.

While paying nursing fees to hospitals, there are also many people who feel it is unreasonable to pay a large amount of caregiver fees. In mid April this year, Mr. Xu, a resident of Tangshan City, Hebei Province, in his thirties, went to a local hospital for treatment and hospitalization due to cerebral hemorrhage. After the surgery, he hired a "one-on-one" caregiver for 340 yuan per day. This means that he needs to pay over 10000 yuan in monthly caregiver fees, which is a heavy burden for my family. It is understood that in 2022, the average monthly salary of urban non private unit employees in Tangshan City was over 7700 yuan, while the average monthly salary of private unit employees was over 4300 yuan.

The payment receipt provided by Mr. Xu to the reporter shows that he also needs to pay a nursing fee of 15 yuan to the hospital every day.

According to data uploaded by patients on a certain social media platform, the "one-on-one" nursing fees in various regions are mostly two to three hundred yuan per day, and there are also three to four hundred yuan per day. In general, if hospitalized for one month due to illness, in addition to paying nursing fees normally, the expenditure on caregiver fees is mostly between 6000 yuan and 9000 yuan.

The entry threshold for caregivers is low

The training was not conducted in a standardized manner

During the interview, many patients and their families complained to the reporter that they paid a lot of money to hire a nurse, but the professionalism and professional ethics of the other side left people speechless.

At the beginning of last year, when reporters interviewed Beijing resident Xiao Hua, she was complaining about her grandmother's abuse by caregivers during her hospitalization. When interviewed again recently, she told reporters that her grandmother had passed away, and "the experience before her death has become a permanent pain in the hearts of her family.".

Xiao Hua recalled that her grandmother was sent to a tertiary hospital in Beijing for emergency treatment due to illness. After the first aid is completed, the elderly person is kept in the hospital for observation. Originally, family members were not planning to find caregivers, but the hospital did not allow family members to accompany them, stating that the hospital had cooperative caregivers who could provide accompanying services.

I didn't stay in the hospital for a few days, and my grandmother was clamoring to be discharged. "Xiao Hua said that the caregiver was particularly cruel to her, disliked her for being overweight, and even used a lot of force to help her turn over. He even hit her hard," Xiao Hua said, looking at Grandma's arms bruised and bruised. The whole family was very angry and quickly took videos and photos to negotiate with the hospital. The hospital provided the phone number of the caregiver's company and asked the family to negotiate directly with the other party.

"We haven't found any explanation yet," Xiao Hua said.

Similar incidents have also been exposed. In early May 2022, a caregiver from the inpatient department of a community health service center in Huangpu District, Shanghai, assaulted an elderly patient. After the incident, the relevant local departments issued a notice stating that the involved caregivers were suspended from work; The domestic service company it belongs to carries out rectification work in accordance with the requirements of the competent department.

Compared to this, the insufficient nursing ability of caregivers is a more common problem.

Song Jiaming, who has been working as a nurse in a tertiary hospital in Tianjin for more than 10 years, told reporters that many caregivers lack professional nursing knowledge. For example, there are strict requirements for patients to turn over after surgery, and some caregivers do not understand. If patients request to turn over, it may cause wound rupture, and in severe cases, a second surgery may be required.

"Nurses often come into contact with patients' blood, secretions, excreta, etc., making them relatively susceptible to infection by various pathogenic microorganisms, making them a high-risk group for infectious diseases. However, they generally lack awareness of hospital infections and their harmfulness, increasing the risk of cross infection within hospitals," said Song Jiaming.

The journalist's interview found that the lack of nursing ability and poor professional competence among caregivers are closely related to their low entry barriers and non-standard training.

As a job seeker, the reporter dialed the online recruitment hotline for caregivers and learned that some caregiver platforms have very broad recruitment requirements for caregivers, with no restrictions on education or relevant experience. It is best to be in their forties or fifties and be able to work hard.

For example, when the reporter saw that a nurse platform was targeted as a delivery nurse for a Beijing hospital, he called the hospital. The other party said that the nurse candidates were generally under 55 years old, both men and women, regardless of registered residence. After signing the contract, they could apply for health certificates in Beijing, and after completing 200 class hours of online training, they could be issued a nurse certificate. After taking up their jobs, their monthly income was more than 6000 yuan. The platform charges a service fee of several hundred yuan and a fee of 300 yuan for obtaining a caregiver certificate every year.

And caregivers who have received training say that many of the training is just a formality.

A caregiver said that the domestic service company provided training to them before they started working, and the training format was to have them watch video lectures; The caregiver also said that the housekeeping company sent her a book about nursing to read, which is considered training.

"If there is no systematic professional learning and training, there are significant risks and hidden dangers in carrying out nursing work," said Song Jiaming.

Insufficient hospital nurse resources

Long term existence of huge gaps

Several patients and their families suggested in interviews with reporters that since the hospital has collected nursing fees, it should take on the daily care work of patients. If the hospital feels that the nursing fees are too low, it can appropriately increase the nursing fee standards; If hospitalization requires additional payment for living care, it is also hoped that this money will be handed over to the hospital for management personnel to carry out living care, which is more professional and reassuring.

In fact, according to the Notice on Strengthening Clinical Nursing Work in Hospitals issued by the former Ministry of Health in 2010, nurses should fully fulfill their obligations and complete clinical nursing work in accordance with nurse regulations and nurse rules, including closely observing the vital signs and changes in the patient's condition; Correctly implement treatment, medication, and nursing measures, and observe and understand patient reactions; Provide daily care and assistance to patients who cannot take care of themselves.

However, in reality, the reporter learned through interviews that, except for some special wards such as infectious disease wards, the daily care of patients is undertaken by nurses. For patients in other wards who require daily care, it is mainly undertaken by relatives or caregivers. Some hospitals cooperate with third-party caregivers, who provide paid living care services; Some hospitals do not have relevant cooperation, and family members have to find their own caregivers. The sources of caregivers include caregiver service companies, housekeeping companies, and individual caregivers.

As a nurse with over 10 years of experience, Song Jiaming is well aware of the responsibilities of nurses, but there are too few nurses in the department to be busy at all.

At 8:00 am on June 2nd, Song Jiaming finally got off the night shift. She started working at 5:30 pm the previous day. That night, there were nearly 40 hospitalized patients and only two on duty nurses. "I didn't have time to move around the ward," he said.

Song Jiaming has been working 10 to 11 night shifts per month for many years. In her opinion, if it weren't for patients hiring caregivers to help, the department would need to add more nurses to be busy.

Her department has 53 beds and treats thousands of patients who require surgery every year, with only 12 nurses and head nurses. According to the requirements of the national health regulatory department, the bed to bed ratio should not be less than 1:0.4, and their department did not meet the standards.

Chen Qian, who works at a tertiary hospital in Beijing, believes that even if the bed to bed ratio in the ward meets the standard, nurses cannot be busy. Chen Qian is 26 years old this year. There are a total of 22 beds in a certain department of the hospital where she works, with a maximum of 10 nurses.

"There are seventeen or eighteen patients in the ward all year round, and when I work night shifts, I often get busy," she said. She works night shifts from 4:30 pm on the first day to 7:30 am the next day. After taking over the shift, first transfer to the ward, then distribute medication to the patient according to the doctor's instructions, focusing on medication for patients with special needs, such as sleeping pills, hypoglycemic drugs, etc. Next, write nursing records. After these tasks are completed, it is almost late at night, and it is necessary to patrol the ward on time to prevent unexpected situations from happening.

In contrast, in the eyes of some patients and their families, nurses do nothing except administer fluids, dispense medication, and measure body temperature. Ms. Lin, a resident of Beijing, said that during her hospitalization, nurses were rarely seen in the ward. It seemed that apart from intravenous infusion and temperature measurement, everything else had nothing to do with it. "Is it a shortage of nurses, or are nurses simply unwilling to take on the patient's daily care work?"?

A interviewed nurse explained that the focus of nursing work is to observe the condition, carry out various operations, and care for critically ill patients. However, there are also some daily care, including guiding and assisting patients and their families in operations, such as explaining feeding precautions to choking patients and their families; Explain the importance and precautions of turning over to disabled patients and their families, and assist their families in turning over the patient.

"What is nursing? Do patients and their families consider the health education provided by nurses to be nursing? I think so, but most patients and their families have insufficient understanding of nursing and believe that nurses can only provide practical care for them." This interviewee said.

In addition, what patients cannot see is that, on the one hand, China has entered an aging society, and the number of clinical elderly people has increased, with an increase in dementia, disability, and severe elderly people. Clinical nurses often pay more attention to the condition of critically ill patients; On the other hand, the number of nurses in our country is indeed too small.

In May 2021, the General Office of the State Council issued the "Opinions on Promoting the High Quality Development of Public Hospitals", proposing to increase the number of nurses and gradually achieve an overall healthcare ratio of around 1:2 in public hospitals.

By the end of 2022, the total number of registered nurses in China exceeded 5.2 million, with approximately 3.7 registered nurses per thousand population.

According to a professor from the School of Nursing at Peking University, according to the indicators in the Opinion, there is a shortage of over 3.5 million registered nurses among professional nursing staff in medical institutions in China.

Yao Huaifang, a member of the Anhui Provincial Committee of the Chinese People's Political Consultative Conference and chief physician of the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, said that the hospital's current nursing resources are difficult to meet the needs of patients, and nurses are still unable to cope with medical care, let alone let nurses take on the responsibility of caring for patients. According to the requirements of the national health regulatory department, the ratio of hospital beds to nurses should not be less than 1:0.4. That is, if a ward has 40 beds, the number of nurses should not be less than 16. However, many hospitals now have nurses equipped below this number. During her research, she found that some hospitals have dozens of patients in their wards, with only two nurses on night shifts. "Nurses cannot run over and sometimes even dare not admit new patients.".

In Yao Huaifang's view, the main reason for the current shortage of nursing resources is: insufficient number of nursing staff in hospitals; Nurses have low salaries, heavy workloads, night shifts, and a high probability of medical disputes. Sometimes, they are not respected by patients and their families, making it difficult to attract young people to engage in the nursing profession; Nurses suffer from a serious lack of pursuit of professional skills and a sense of professional honor, with a portion of nurses leaving nursing positions every year.

Hospitals can be equipped with caregivers

Unified scheduling and allocation of work

Before hospital nursing resources are replenished, the key to breaking through lies in medical caregivers.

In August 2020, the General Office of the National Health Commission issued a notice on further strengthening the nursing work of medical institutions. Nurses should take solid measures in diet care, skin care, pipeline care, etc. based on the patient's condition and self-care ability, and consolidate the quality of basic nursing care.

The reporter noticed that according to this notice, medical institutions can hire a certain number of trained and qualified medical nurses according to actual needs, and strengthen standardized management as required. At the same time, it is necessary to establish a management system for medical nursing staff, clarify their job responsibilities and professional rules, conduct regular training and service quality supervision and assessment, and standardize service behavior. Medical caregivers should provide daily care and supportive activities to patients under the guidance of medical staff.

This means that when the number of nurses is insufficient, not only can family members hire caregivers to fill the vacancies, but medical institutions can also directly equip medical caregivers.

In April 2022, the National Health Commission issued the "National Development Plan for Nursing", which proposed to "establish a management system for medical nursing staff" and "explore the establishment and development of a professional team of medical nursing staff" in addressing nursing shortcomings and weaknesses.

In the view of the interviewed experts, it is necessary to establish a management system for medical caregivers in the current situation of insufficient nursing resources and difficulty in accompanying patients. Its positive significance is to alleviate the two difficulties of nurses being unable to bear the burden of patient life care and patient family members being physically and mentally exhausted as caregivers in the short term.

Professor Wang Yue from the School of Medical Humanities at Peking University told reporters that it is feasible and a good way for medical institutions to establish a team of medical nursing staff. This can change the model of overall nursing solely carried out by nurses in hospitals, and increase the number of nursing staff at two levels: nurses and nursing staff. In fact, this has improved the bed to nurse ratio of medical institutions and increased nursing resources.

An associate professor at a nursing vocational college in a certain province said in an interview with reporters that with government financial support, establishing a medical nursing staff team and recruiting and training medical nursing staff can help solve the employment difficulties of college graduates, including nursing students. After entering nursing positions through training, they can help optimize the structure of nursing staff in medical institutions, enrich clinical nursing staff, provide better care for patients, and improve patient satisfaction with hospitalization.

The wish is beautiful, but the reality is that, except for a few places, the medical nurse system has not been established yet, and it is still the caregivers who actually fill the gap in nurse resources.

In Yao Huaifang's view, there are many reasons behind it: on the one hand, if medical care and life care cannot be clearly separated, the responsibilities of nurses and medical caregivers will be difficult to distinguish clearly; On the other hand, after medical caregivers are included in the hospital management system, if they need to be included in the medical insurance expenditure category, the corresponding medical insurance expenditure will also increase. Based on the current medical insurance situation, it is difficult to fully support the expenses of medical care and life care. Furthermore, where the nursing staff team comes from is also a question.

The associate professor of a nursing vocational college in a certain province mentioned above believes that from the perspective of hospital management, most hospitals belong to differential funding units. Considering their own operational issues, most hospitals will purchase large medical equipment with medical income, resulting in a decrease in investment in nursing work, which leads to hospitals being unwilling to pay for medical nurses due to interest constraints.

In her opinion, from the perspective of supporting systems, the nursing fees charged by hospitals currently include not only daily care, but also nursing observation of patient vital signs, bed sheet replacement, patient transportation, disease observation, health education, etc. The standards are very low and insufficient to compensate for the labor costs of nurses. At the same time, the national medical insurance system is also an obstacle to the implementation of the medical nurse system in hospitals, and the payment of medical nurse fees is not within the scope of medical insurance reimbursement.

Local exploration of "no companionship"

National promotion will take some time

In August 2022, Fujian began organizing and implementing pilot projects for "unaccompanied" wards in public hospitals.

The Fujian Provincial Health Commission and the Department of Human Resources and Social Security jointly issued the "Fujian Province" Pilot Work Plan for "No Accompanying" Wards, proposing to carry out pilot work for "No Accompanying" Wards throughout the province based on the principle of finance, medical insurance, and patients each bearing a little burden, forming a nursing staff team composed of nurses and caregivers. The Fujian Provincial Health Commission has also organized experts to formulate and issue the "Fujian Province" Ward Service Standards for "No Accompanying" Wards.

According to the Work Plan and Service Standards, "no accompanying" does not mean that there is no accompanying person, but rather that nursing staff who have undergone standardized training provide 24-hour continuous and uninterrupted life care services for hospitalized patients. Nurses, under the guidance and management of nurses, provide accompanying and life care services in a "one to many" mode based on the patient's condition and needs.

In addition, nursing staff are uniformly hired and managed by the hospital, and a nursing staff management organization is established by the hospital to be responsible for the daily affairs management of nursing staff. Explore the establishment of a pricing mechanism for "unaccompanied" services in accordance with the service methods and standards, and standardize the charging behavior related to "unaccompanied" services.

In the view of the professors from the School of Nursing at Peking University mentioned earlier, the most core of the pilot program in Fujian Province is to explore the establishment of a service price mechanism for "unaccompanied" wards, in order to ensure that nursing services in "unaccompanied" wards can operate in a long-term and healthy manner. It is feasible for Fujian to follow the principle of finance, medical insurance, and patients each bearing a portion, reducing the burden of hospitalization on the general public. "It cannot be solely borne by finance, medical insurance, or the general public.".

Yao Huaifang believes that managing nursing staff in a hospital undoubtedly increases the difficulty and scope of hospital management. However, due to their ability to standardize management and assume responsibility, they can provide more peace of mind for patient families than third-party nursing institutions or scattered social caregivers. Moreover, professional and skilled caregivers are better able to take care of patients in a reasonable and scientific manner, which is conducive to patient recovery.

"From the perspective of reform trends, the nursing staff system in hospitals should be standardized, professionalized, and specialized. Nursing fees should be standardized, and nursing staff should be certified professionals after vocational training," said Yao Huaifang.

But she also pointed out that there are still many obstacles that need to be overcome in promoting the reform of "unaccompanied" wards: currently, medical insurance has not clearly defined the scope of reimbursement for life care and medical care. How can it be standardized in the future? Has the pricing department issued relevant regulations regarding the cost standards for daily care? Before setting up nursing staff majors in vocational high schools and technical schools, it was difficult for hospitals to recruit professional nursing staff with basic technical skills. What should we do? If nursing staff are included in the unified management of hospitals, how is the nature of their work clearly defined, whether they are hired by society or belong to the staffing of hospital staff, and whether the country has established corresponding rules and regulations?

"After the hospital increases the management of nursing staff, it requires significant investment in financial, material, and human resources. Can local finance provide strong support like Fujian Province? Before implementing the plan, each department needs to conduct in-depth research to form a complete and implementable plan." Yao Huaifang said.

As mentioned by the associate professor of a nursing vocational college in a certain province, it is worth paying attention to whether the finance can support some economically underdeveloped areas. She called for the establishment of an independent human resource management system and salary system for nurses based on the "nurse+medical nurse" model, clarifying the entry threshold and career promotion space for the nursing staff. At the same time, the medical insurance system should also be reformed accordingly, including some nursing fees in the scope of medical insurance payment.