China's reliance on lower-paid contract nurses may compromise patient care

Economic and health system reforms in China in recent decades have dramatically reduced the number of traditional hospital nursing jobs, known as "bianzhi" or "iron rice bowl" positions, which are guaranteed for life. Instead, more than half of nursing posts in many Chinese hospitals are now filled with contract-based nurses who do the same work as "bianzhi" for lower pay, fewer benefits and limited job security.

A new study from Columbia University School of Nursing, published in the journal Human Resources for Health, found significantly higher levels of compensation-related dissatisfaction among contract nurses than their "bianzhi" peers. Hospitals with a disproportionate number of contract nurses also had significantly higher levels of patient dissatisfaction, which prior research has linked to lower quality care and worse outcomes.

A research team, led by Columbia Nursing Assistant Professor Jingjing Shang, PhD, RN, investigated the impact of inequitable nurse compensation on patient satisfaction at a representative cross section of 181 Chinese hospitals. The study found that hospitals where contract nurses reported high levels of dissatisfaction with their salary and benefits also had lower quality ratings and were less likely to be recommended by patients. The results suggest a need for more uniform compliance with the China Health Ministry's voluntary regulations requesting that hospitals eliminate two-tiered compensation systems for nurses, Shang says.

"For the best patient outcomes, we really need to have equal pay for equal work," says Shang. "The low rate of job satisfaction among contract nurses puts patients at risk."

Use of contract nurses is expected to increase as China continues its transition to a free market economy and demand for health care increases due to an aging population. The practice has also gained traction over the past decade amid a worsening nursing shortage in China. Nurses hired as "bianzhi" workers still maintain that status, but the majority of new hires are contract nurses, the study reported.

While the average utilization of contract nurses is 51% at hospitals nationwide, the practice varies widely. Some Chinese hospitals use no contract nurses, while others fill more nearly all nursing positions with these lower-paid employees, the study found.

Contract nurses were significantly younger than the "bianzhi" nurses, less likely to be married and have children, had less registered nurse work experience, were less likely to have an advanced nursing degree, and more likely to be male, the study found. Contract nurses surveyed in the study were also significantly more likely than their "bianzhi" peers to express the intention to leave their current job within a year.

"China urgently needs to address the inequalities in nursing compensation to stabilize the nurse workforce and improve the quality of care in hospitals," Shang says.

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