Journal of Nursing Management, 2014, 22, 423–432

The impact of safety and quality of health care on Chinese

nursing career decision-making

1 2
JUNHONG ZHU BSc, MSc, PhD, RN , SHEILA RODGERS BSc, MSc, PhD, RN and KATH M. MELIA B. Nurs
3
(Manc), PhD
1
Lecturer, Nursing Studies, School of Medicine, Hangzhou Normal University, Hangzhou, PR China, 2Senior
Lecturer and 3Professor, Nursing Studies, School of Health in Social Science, University of Edinburgh, UK

Correspondence (2014) Journal of Nursing Management 22,

ZHU J.H., RODGERS S. & MELIA K.M.
Junhong Zhu 423–432.
Hangzhou Normal University The impact of safety and quality of health care on Chinese nursing career
No 16 Xuelin Road decision-making
Xiasha
Hangzhou 310012 Aim The aim of the study was to understand why nurses leave nursing practice in
China China by exploring the process from recruitment to final exit. This report
E-mail: junhongzhu66@hotmail. examines the impact of safety and quality of health care on nursing career
com
decision-making from the leavers’ perspective.
Background The nursing shortage in China is more serious than in most
developed countries, but the loss of nurses through voluntarily leaving nursing
practice has not attracted much attention.
Method This qualitative study draws on a grounded theory approach. In-depth
interviews with 19 nurses who have left nursing practice and were theoretically
sampled from one provincial capital city in Mainland China.
Finding ‘Loss of confidence in the safety and quality of health care’ became one of the
main categories from all leavers’ accounts of their decision to leave nursing practice. It
emerged from three themes ‘Perceiving risk in clinical practice’, ‘Recognising
organisational barriers to safety’ and ‘Failing to meet expectations of patients’.
Discussion The findings indicate that the essential work value of nursing to the
leavers is the safety and quality of care for their patients. When nurses perceived
that they could not fulfil this essential work value in their nursing practice, some of
them could not accept the compromise to their value of nursing and left voluntarily
to get away from the physical and mental stress. However, some nurses had to stay
and accept the limitations on the safety and quality of health care.
Conclusion The study suggests that well-qualified nurses voluntarily leaving nursing
practice is a danger signal for patients and hospitals, and has caused deterioration in
nursing morale for both current and potential nursing workforces. It suggests that
safety and quality of health care could be improved when individual nurses are
empowered to exercise nursing autonomy with organisational and managerial support.
Implications for nursing management The priority retention strategies need to
remove organisational barriers to the safety and quality of health care. Under the
current nursing shortage, Chinese hospital managers might consider recruiting
nurses and care assistants of different educational levels, which would effectively
improve nursing team work and support nurses’ to stay and actively achieve their
work values for the safety and quality of health care.
Keywords: China, nursing, quality, safety, voluntary leaving, work value

Accepted for publication: 10 June 2013

DOI: 10.1111/jonm.12140
ª 2013 John Wiley & Sons Ltd 423
J.H. Zhu et al.
Introduction
The World Health Organization (WHO) warns that
nursing shortages are directly influencing the quality
of health services and patients’ mortality and
advocates that every country, poor or rich, should
have a strategic national workforce plan (World
Health Organization 2006). However, although the
nursing shortage in China is more serious than in
many other developed countries, the loss of nurses
who voluntarily leave nursing practice has not
attracted much attention in Chinese society. Chinese
nurses continue to leave clinical care but are used to
keeping quiet individually. Chinese nurses who have
voluntarily left nursing practice have a rich experi-
ence that covers their whole career process from
recruitment to final exit. What they have to say
about their career decision making can help to expli-
cate nursing workforce problems to policy makers
and hospital managers.
Background
Nursing shortage
Nursing shortage is a worldwide problem (World
Health Organization 2006) and is defined as an imbal-
ance between the nursing requirements and the nurses
actually available (Zurn et al. 2002). An overview of
the nursing workforce imbalance worldwide has been
provided by the World Health Statistics (World
Health Organization 2008, 2011). The USA has the
biggest registered pool of nurses, and a relatively high
number of other health workers, compared with that
of other countries. Despite this the shortage of nurses
is still estimated to be about one million by 2015
(Aiken & Cheung 2008). Although the Chinese health
workforce has slightly increased and exceeded the
WHO minimum workforce threshold since 2006
(World Health Organization 2006), China is one of
the few countries in the world with more doctors than
nurses and this gap continues, although the Chinese
government has declared it will try to control the ratio
of doctors to nurses to 1:1 by 2012 (MHPRC 2005).
This raises questions about public investment in
training and deployment to achieve the most cost-
effective health service (World Health Organization
2006). Currently, the Chinese public are greatly dis-
satisfied with the high cost and low quality of health
care (Hsiao 2008, Ma et al. 2008). However, the
nursing shortage and workforce problems were not
considered to be a relevant and important issue in the
424
new Chinese health care reform, which was launched
in 2008 (MHPRC 2009).
Lewis (2002) further suggests that the shortage is
not merely about numbers but also a matter of how
these numbers are most effectively deployed in the
health-care system. In reality, there is a shortage of
nurses willing to work under the present conditions
(Buchan 2006). The International Council of Nurses
(ICN) provided an overview of unemployment and
under-employment of the available nursing workforce
worldwide (Spetz 2011). In mainland China, there is a
high rate (over 70%) of nurses with an intention to
leave nursing in different areas nationwide (Sun et al.
2001, Ye et al. 2006, Lu et al. 2007). Meanwhile,
consistent evidence shows that about 9–15% of quali-
fied nurses, while working in Chinese hospitals, are
not employed as nurses (Yang & Chen 2004, Liu
et al. 2005). These inactive nurses have exacerbated
the shortage in China. A high nurse turnover rate not
only has a negative impact on the quality of care, but
also affects the morale of nurses and reduces their
productivity (Shields & Ward 2001).
Nursing turnover
The majority of research contributing to nurse
turnover uses the intention of leaving to predict
actual turnover, and mainly focuses on nurses who are
still employed in the profession (Hayes et al. 2006).
Maertz and Griffeth (2004) also comment that turn-
over studies focus on matching or testing different the-
oretical models by quantitative research design, but
even the most extensive turnover prediction models
have underestimated some important antecedents. A
retrospective approach has some advantages as the
whole leaving process can be examined in a relatively
holistic way (Morrell et al. 2008). Although a few
studies focus on individuals who have left nursing
(Duffield et al. 2004a,b), self-reported accounts fail to
explicate the motivation behind individuals’ unique
circumstances or link them with decision processes
(Maertz & Campion 2004). Takase et al. (2008) sug-
gest that the discrepancy between intention and the
actual behaviour of leaving and the validity and reli-
ability of studies needs further exploration in different
social–cultural contexts.
Many Chinese nurse researchers have adopted the
concepts of ‘job satisfaction’, ‘organisational and
professional commitment’, ‘turnover’ and ‘intention to
leave’ to understand nursing turnover (Sun et al.
2001, Liu et al. 2005, , Lu et al. 2007). However, a
common methodological limitation of these studies is
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 423–432
 Safety and quality of health care on Chinese nursing career decisions
that they mainly use questionnaires to carry out
quantitative surveys using previously identified
concepts based on Western realities. The concepts
and indicators lack significance and meaning in
understanding nursing mobility and shortage in a
Chinese context. These studies failed to portray mean-
ingful, subjective experiences and perspectives of the
Chinese nurses’ leaving. There was little opportunity
for Chinese nurses to explain their work and life with
relevance to their reasons for leaving in their own
words, which left the problems they encountered
without raising a collective awareness for the policy
makers.
The study
Aim
The aim of the study was to understand why nurses
leave nursing practice by exploring their career deci-
sion process from entering to exiting nursing practice
in China. The research questions focus on:
● How do leavers describe their experiences of being
a clinical nurse during their entering, practising and
leaving nursing practice?
● How do they explain their reasons for their leaving
nursing practice in China?
Design
A qualitative study design was based on symbolic
interactionism by drawing upon the grounded theory
approach (Glaser & Strauss 1967, Glaser 1978),
particularly the constant comparative method and
the flexible process towards data collection following
the principle of theoretical sampling. In-depth inter-
views with nurses who left clinical care were chosen
as the most effective method to collect data. We agree
with the view of Finlay and Gough (2003) that subjec-
tivity in research can be transformed from a problem
into an opportunity through reflexivity. Throughout
the design and conduct of this study, reflexivity
has been applied to examine possible bias, which
adds to the credibility and trustworthiness of the
study.
Participants
The research site was a provincial capital city in the
east of China, which is regarded as one of the
most attractive Chinese cities to work in. However,
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 423–432
the terms and conditions of employment for nurses in
this city are not substantially different from cities
elsewhere in China. Participants were registered nurses
who worked in all areas of clinical care, including sur-
gical, medical, intensive care, paediatric, geriatric, and
obstetric and gynaecological units and had left nursing
practice in the last five years. The procedure of identi-
fying the 19 interview participants was guided by the
principle of theoretical sampling (Glaser & Strauss
1967).
Ethical considerations
Ethical approval was granted from the Research
Ethics Committee of the University of Edinburgh. The
study did not use organisational gatekeepers to iden-
tify the potential participants from the local Health
authority. The leavers were approached directly.
Data collection
A persistent concern in field work is to determine who
the researcher needs to talk with, listen to, query or
observe about a given issue important to the research
(Glaser & Strauss 1967). Participants were identified
through personal contacts, through snowballing tech-
niques and through the recommendations of other
colleagues. According to the principles of theoretical
sampling, the criteria selected for the next interviewee
always followed data analysis of the previous inter-
view. There were three stages of sampling. The first
stage included six participants and focused on select-
ing as wide a range of participants as possible accord-
ing to their educational background, clinical practice
and leaving experiences. As the data analysis
progressed, ‘choosing ideal workplace’ and ‘the safety
of health care’ emerged as analytical categories. The
category ‘choosing the ideal workplace’ indicated that
grade three hospitals were initially regarded by
participants as the ideal workplace, where the most
well-qualified nurses were recruited (Zhu 2012). At
that time, the Vice Minister of Health announced a
concern that grade three hospitals accounted for the
highest rate of accidents (Ma 2010). A decision was
made to narrow down and focus on the leavers from
grade three hospitals only. The second stage of
sampling included eight participants who left these
hospitals. In order to gather data until each category
was saturated, the third stage of sampling extended to
five further participants who had left clinical care but
were still working in the hospital in non-nursing
positions.
425
J.H. Zhu et al.

In another incident, as a new team leader, Bo

Data analysis blamed herself for causing suffering to a patient when
The constant comparative analytic process was fol- an unexpected extubation required the patient to
lowed as outlined by Glaser and Strauss (1967) and undergo a second operation:
Glaser (1978). Focusing on generating ideas that fitted
‘Oh, I was extremely sad. Every change of the
and worked, the data was given considerable attention
patient’s condition in the future would be related
through open coding, selective coding and theoretical
to me… I must take responsibility for it as the
coding and utilised the program NVIVO 8 (QSR Interna-
team leader… In the first three years, I really
tional Pty Ltd, Doncaster, Victoria, Australia) to facili-
wanted to be a good nurse… After the incident,
tate the analysis. Emergent themes and categories were
there is still some fear and pressure inside. …I
not only validated by participants in ongoing concur-
did not feel confident. I like to do every detail of
rent analysis, but also through the constant comparison
the job for patients, but, if I pay too much atten-
with the literature. Further verification occurred
tion to the small thing, I could not finish the
through discussion following presentation of the find-
tasks on time… I began to wonder whether nurs-
ings at conferences and informal communication.
ing was a suitable career for me’.
(Bo)
Findings When the incident happened during her duty as a
This paper reports a perhaps surprising finding. ‘Loss of team leader, Bo lost confidence in her capability to be
confidence in patient safety and quality of care’ emerged a good nurse and gave up her nursing career.
as one main category from both experienced and inexpe- Other participants did not mention that they
rienced nurses’ accounts of their leaving nursing prac- had encountered an accident during their practice.
tice, which consisted of three themes: perceiving risk in However, safety issues were raised by the majority of
clinical practice, recognising organisational barriers to participants.
safety and failing to meet expectations of patients.
‘As the only member of staff in the haemodialy-
sis ward I was responsible for two to three
Perceiving risk in clinical practice patients from 7:30 am to 9 pm. If emergencies
arose, I could not cope with more than one at
Two participants had experienced adverse events
the same time. …Yes, I thought such practice
before they left clinical care. The analysis compares
actually put the patient’s life in danger… it
their personal encounters with other participants’
should be identified as malpractice. …I felt that
views towards the clinical risk in their workplace.
all the hard work I had done was just for com-
In one incident, the identity labels of two babies
pleting tasks, but not for individual patients.
were wrongly replaced when Yun and a colleague
That is not enough… I was very nervous in
were routinely bathing 40 newborns. After this experi-
such situations. It is a kind of powerless feeling.
ence, Yun lost confidence in ensuring the safety of
I could not stay until my health status got
patients and began to question the value of staying in
worse’.
a nursing career:
(Ling)
‘If the accident had not happened, I would work
Ling was confident in her capability after 18 years
hard as usual. I have worked for 14 years with
of nursing practice, but safety concerns made her
complete trust from my colleagues. Everything
nervous. This eventually compounded her decision to
had been fine before this accident. I had never
leave because she worried that her health would
thought that it would happen to me… I should
become worse with work stress.
not make a mistake like this to bring harm to
Like Ling, the majority of participants were quite
the patients’ families, myself, the unit, and the
confident in their professional capabilities and believed
hospital. After you have experienced such an
that they could make a difference to patient care by
accident, it affects your confidence. The accident
doing a good job. However, some of them expressed
could not be avoided by individual efforts in
sympathy for colleagues who experienced accidents.
such busy environment. I felt that there was no
value in being a nurse’. ‘Actually, when a person is exhausted, it is very
(Yun) easy to make a mistake. The danger is obvious.

ª 2013 John Wiley & Sons Ltd

426 Journal of Nursing Management, 2014, 22, 423–432
 Safety and quality of health care on Chinese nursing career decisions
It is not only me; lots of nurses could give you
lots of evidence. …such as accidents, mistakes
and conflicts between nurses and patients, do
you believe that tired staff can work effectively?
…I had no quality of life when I was a nurse’.
(Qun)
Nurses were the last line of defence for patient
safety within the hospital. However, they could easily
become scapegoats when things went wrong, because
there was a lack of proper risk management. With
nursing shortages, a state of fatigue has negatively
influenced the quality of care and well-being of nurses.
Leaving nursing was regarded by participants as a
way to escape from the high risk and low quality of
the health-care work environment.
Participants with less than three years’ experience
did not directly comment on safety issues in their
practice. However, safety issues were indirectly illus-
trated by their experiences of being evaluated as ‘a
good nurse’ in the early stages of nursing practice.
As a newly qualified nurse, Li was seen as a good
worker by the head nurse because she was a quick
learner and could work independently:
‘The head nurse said she needed to choose a
good nurse from our new recruits as a pair of
quick hands due to the shortage of staff. …after
two days, the head nurse let me take all the
responsibility independently, but sometimes I felt
I did not do well, especially I did not know how
to use the ventilator. …I needed to take arterial
blood from patients, but I did not know how.
They just let you practice by yourself on the
patients. Then I always failed. Eventually, the
head nurse did it with me once. After then I
could do it by myself. She was pleased that I
could learn more quickly than she originally
expected of me’.
(Li)
When inexperienced nurses lack proper supervision
and managerial support, they might make mistakes,
which inevitably puts patients at risk. As a new nurse,
Yan described an incident in her practice:
‘A patient needed to continue the intravenous
drip, but the fee information notes arrived at the
bedside saying that his account had no money.
The hospital policy is that he only could con-
tinue the treatment if he had enough money, so
the IV was removed. He put money into his
account, and then I gave the injection to him
again. The patient accused me of not letting him
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 423–432
finish the IV as he would have paid immediately.
It was useless to explain the hospital policy, but
I have no way of changing it ’.
(Yan)
It appeared that less experienced nurses tended to
carry out tasks by passively following the require-
ments of the hospital. The cost of overlooking educa-
tional and supervisory investment for new recruits
may have a negative impact on the quality and safety
of health care.
The majority of leavers were worried about safety
and quality issues. It was surprising then that the
group of nurses who were still working in the hospi-
tals in non-nursing roles rarely cited safety issues as a
contributory factor to them leaving clinical practice,
like other participants, although they also talked
about their work stress. However, these participants
reported that one of their current tasks in the hospi-
tals was personally accompanying their relatives or
friends to hospital appointments in order to ensure
that nothing goes wrong. This evidence further indi-
cates low confidence in the safety and quality of
health care. The views on patient safety of those who
were still working in the hospitals in non-nursing roles
could be interpreted as a tolerant attitude towards
accidents within the hospital.
Recognising organisational barriers to safety
Despite their concerns, participants felt that they did
not have enough confidence to challenge the organisa-
tional barriers to safety and quality of health care.
Yun interpreted her formal punishment as benign
because it exempted her from an official accident
report:
‘I was really lucky. It was an accident according
to the law. The hospital leaders were actually
nice to me and only regarded it as a “serious
mistake” with a financial punishment, which I
thought was benign for me’.
(Yun)
However, in addition to financial punishment, the
‘public self-criticising conference’ gave her further
moral punishment:
‘We were required to make a statement of self-
criticism in front of all staff at the hospital-level
conference. I must be terribly unlike a human
being in those terrible days. …I could not sleep
well and recall the experiences of more than
10 years clinical care and asked myself what I
427
J.H. Zhu et al.
originally expected and wanted in life again and
again. …I felt that I would make more sacrifices
if I stayed in nursing. What about the rewards of
more sacrifices? …In addition, some head nurse
or nurses from other units like to belittle you in
public. So I did not know if there was any signif-
icant meaning to work there’.
(Yun)
The tradition of public criticism implicitly encour-
aged belittlement and isolated possible collegial sup-
port among nurse managers and colleagues. The blame
culture seemed to humiliate Yun and undermined her
self-esteem.
Self-criticism within a blame culture also did not
lead to an open discussion of managing the risks in
Bo’s case. There was a lack of official record-keeping
and effective organisational intervention strategies to
follow up adverse events. This prevents health staff,
organisations and the health care-system from learning
from mistakes.
‘We had more than 10 beds. All patients were
cared for by a nurse based on one-to-one in day
shifts. Five nurses worked on night shifts accord-
ing to the schedule. …I was the group leader, the
second nurse was less experienced, the third one
was a beginner and the last one was a nursing stu-
dent. I was under great pressure to work as a team
leader on night shifts. I had to take care of every-
one including patients and staff… very tired’.
(Bo)
Unqualified nursing staff were counted in the staffing
numbers to meet the legal ratio, which caused addi-
tional stress for the team leader. However, Bo was
regarded as an unqualified team leader because of the
incident. It seemed that both the participant and the
head nurse lacked a clear awareness of the relationship
between the staffing policy and safety of practice.
Many nurses cited incidents where the individual
staff and institutions tend to cover up adverse events
before the patients and their relatives knew of it.
Nurses characterised the system as being closed and
concealing:
‘A nurse should help patients resolve their prob-
lems, but here you must be consistent with the
hospital. When we entered the unit, we were
told that the benefit of the hospital is absolutely
the priority and we should keep all information
within the unit as confidential… Although I have
left the hospital now, I might apply for a non-
nursing job in a health institution which might
428
need their reference. The hospital is powerful; I
did not want to get into trouble’.
(Yan)
Yan asked me to turn off the recording when she
talked about significant differences in the mortality rate
of patients. As a new nurse, although Yan showed sym-
pathy for the patients, she tended to keep quiet in order
to avoid getting in to trouble. The power of the hospital
over the individual nurse was well recognised. Qun con-
firmed that nurses were required to toe the line with
hospitals in risk management:
‘The hospitals currently pay great attention to
self-protection. When something goes wrong, all
of us must be quiet or keep the nursing record
consistent with our leaders’.
(Qun)
The hospitals sought to protect their reputations by
limiting what nurses might say and by modifying writ-
ten records; however, such actions may compromise
patients’ rights.
Rao was a nursing teacher who was involved in
teaching safety and risk management in a nursing
college. She stated that neither nursing education nor
clinical practice experiences could empower nurses to
deal with risk management effectively. Owing to the
lack of a transparent reporting system for adverse
events nurses also did not have the opportunity to
learn from the mistakes. The nurses in this study
reported that some colleagues wanted to leave nursing
practice but had to stay in the job and tended to
become passively tolerant of the current situation and
obedient to their direct managers.
There was also a lack of effective monitoring by the
health authority in the current Chinese health care sys-
tem. Xue did not think the current style of evaluation
from the health authority would improve the quality
of health service:
‘The external supervision from the health
authority could not make a very objective evalu-
ation. It can be secretly made up. For example,
if the provincial health bureau comes to evaluate
the clinical quality of health care today, the hos-
pital would arrange more staff… Sometimes the
hospitals let us require patients’ cooperation by
giving positive feedback in filling in the patient’s
satisfaction questionnaires for the evaluation’.
(Xue)
The evidence has shown that when the work envi-
ronment could not support nurses in ensuring the
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Journal of Nursing Management, 2014, 22, 423–432
 Safety and quality of health care on Chinese nursing career decisions
quality and safety of patient care, the more capable
nurses seemed more likely to choose to leave nursing
rather than stay in nursing for life because they felt
they could not cope with failing to meet the expecta-
tions of patients.
Failing to meet the expectations of patients
Most participants who left nursing could not tolerate
the risks to patient care and poor quality of care.
‘Maybe as staff we might be tolerant (to the mis-
take), but how could people be tolerant if the
mistake or accident happened to yourself or
close friends?’
(Xue)
The majority of participants tended to blame them-
selves or colleagues when the quality of health care
was compromised.
‘I do think there are some problems with the
quality of nurses. Many nurses are passive in
work… They did parts of the work but ignored
some of them, especially when it is difficult to
finish everything well. Therefore, some problems
are transferred and have an effect on patients
now’.
(Ling)
Nurses had to focus on finishing the task rather
than being concerned with individual patients’ needs.
Participants seemed to think that some nurses did
patients a disservice by simply accepting poor quality
of care as the norm and passively staying in the job.
Chinese patients have been regarded as customers
by hospital administrators because they pay increasing
amounts of money for their care. Nurses were
required to provide different standards of health ser-
vice for different patients in the same public hospital.
Some patients paid more for a ‘VIP’ service and there-
fore had higher expectations.
‘Sometimes if the patients’ family are well off,
they would like to pay more for better service,
but we still need to care for so many other
patients. Most patients’ requirements could not
be met well. …Then they blame us. The hospital
managers did not protect me even if the conflict
was caused by a hospital regulation. They still
asked me to make apologies to the patient. I told
myself that I would never ever make such an
apology again in my life’.
(Yang)
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Journal of Nursing Management, 2014, 22, 423–432
Participants not only felt frustrated in treating the
patients differently but also felt disappointed that they
had to become scapegoats and take the blame even
though they worked hard and tried their best for
patients. The participants generally lost their sense of
pride as a nurse when they could not meet the expec-
tations of patients.
Discussion
The findings of the study are perhaps surprising in that
all participants, both experienced and inexperienced
nurses, had lost confidence in the safety and quality of
care. The data indicates that under a blame culture,
whether the participants personally experienced
adverse incidents or witnessed their colleagues’ suffer-
ing after they encountered accidents, they all worried
that they might be involved in an incident; yet the safety
of patients was perceived as being out of their individ-
ual control. There was also a lack of risk management
and support in the organisation. Awareness of the high
risk in clinical practice and of the organisational barri-
ers to safety has caused ethical dilemmas for Chinese
nurses. Leaving nursing practice was regarded by many
participants as a way to escape the stress and to avoid
being involved in possible incidents.
The relationship between staffing and safety has been
well documented (Aiken et al. 2001, Aiken & Cheung
2008, Duffield et al. 2011). In China, unreliable nurse
staffing statistics provided by the hospitals have already
caused concern to the government (MHPRC 2010). In
order to improve safety, frequent assessment and moni-
toring were organised. Some participants pointed out
that the inspection strategies might protect the organi-
sation rather than protect patients. Many participants
doubted whether the bureaucratic inspection approach
could effectively identify the organisational barriers to
safety and quality of care.
Compared with the more experienced participants,
those who had worked for less than 3 years did not
directly comment on the safety issues in their practice.
However, the safety issues were indirectly illustrated by
their experiences of being evaluated as ‘a good nurse’ in
the early stages of their nursing practice. The organisa-
tional criteria of being a ‘good nurse’ were emphasised
for new nurses: the sooner they got used to doing the job
independently, the better the evaluation from head
nurses and colleagues. Nurses felt they had tried their
best in practice as a new nurse and wished to be recogni-
sed as a good staff member. The evidence from the study
demonstrates that without proper and timely supervision
and support, some new nurses might act towards
429
J.H. Zhu et al.
patients with a dehumanised manner in order to ‘fit in’
with the organisational rules. Melia (1987) found that
some nurses adopted ‘fitting in’ as their future caring
style and in a later study, Attree et al. (2008) found that
students’ feelings of being vulnerable and their need to
‘fit in’ made them feel unable to challenge unsafe prac-
tice. The similar need to ‘fit in’ was perceived by newly
qualified nurses in this study. These participants
described how they suppressed their scared and anxious
feelings and distanced themselves from what they knew
that they were expected to do from their training. This
resulted in a dehumanised attitude towards patients in
their daily practice. The findings support Maben and her
colleagues’ (2006) advocacy that clinical supervision and
mentorship is the key to retention of the nurses. Never-
theless, our study shows that the majority of leavers
themselves were well qualified and experienced clinical
supervisors. When this group of participants felt they
could not ensure the safety and quality of care, they felt
ashamed to work as a nurse and lost the motivation to
stay in a nursing career. The findings further indicate
that effective retention might not be achieved simply by
emphasising the responsibility of individual supervisors
and mentorship without proper organisational support.
The relationship between nurses’ educational qualifi-
cations and perception of safety is well supported in the
literature (Clarke 1999, Aiken et al. 2003, Hart 2005,
Kruger et al. 2006). Kruger et al. (2006) identified that
personal competence is a critical determinant of patient
safety. Aiken et al. (2003) studied the relationship
between hospital nurses’ educational levels and surgical
patient mortality. They found that, with higher propor-
tions of nurses educated at bachelor level or above, sur-
gical patients experienced lower mortality and failure
to rescue rates. The findings of this study indicate that
even though the grade three hospitals recruited the best-
educated and well-qualified nurses, they were not effec-
tively employed to use those capabilities. By solely em-
phasising improving the educational level of nurses but
failing to provide specific educational interventions for
safety and quality issues, Chinese nursing might become
what Davies (1995) called a ‘high intake and high wast-
age model’.
In a study of patient safety, Smith et al.(2009) state
that a caring nurse is more than willing to promote
patient safety, while McGrath found:
‘It is often those with a powerful sense of com-
mitment to caring for others who find the
strength to leave nursing and seek satisfaction in
other fields of work’.
(McGrath 2006, p.3)
430
McGrath has not fully explained why nurses who
are committed to caring seek satisfaction in other
careers. The notion of caring was not principally men-
tioned by nurses in this study. Many participants in
this study said that they left clinical practice because
they had tried their best, but had lost confidence in
the safety and quality of patient care. The study
suggests that the decision to leave is determined
neither by the individual commitment to caring nor
safety, but it is an interactive decision-making process
that depends heavily on whether the individual and
organisational expectations of nursing care are aligned
with regard to the safety and quality of health care.
‘Patient safety as first priority’ was highly acknowl-
edged by health-care management, which gains their
organisations a good reputation in society (Jones &
Redman 2000). However, the findings of this study
suggest that the priority of patient safety in Chinese
grade three hospitals is not a result of managerial
strategies. The Chinese health-care system has gradu-
ally transferred from a planned to a market economy
since 1979 (Hsiao 2008). The ‘goal displacement’
which is described by Etzioni (1964) provides a useful
start to understanding the organisational expectations
of nursing in these Chinese hospitals:
‘It arises when an organisation displaces its goal –
that is, substitutes for its legitimate goal some
other goal for which it was not created, for which
resources were not allocated to it, and which it is
not known to serve. …The mildest and most
common form of displacement is the process by
which an organisation reverses the priority
between its goals and means in a way that makes
the means a goal and the goals a means’.
(Etzioni 1964, p. 10)
It could be argued that such ‘goal displacement’ hap-
pened when Chinese hospitals’ prime expectation
became to achieve the highest profit rather than focus
on health-care outcomes (Pei et al. 2002, Hsiao 2008).
Merton (1968) notes that an extreme case of goal dis-
placement occurs when the employees never come to a
decision of their own making because they are more
concerned about following organisational rules, and
this occupies their entire attention. This study demon-
strates that it may be detrimental for patient care if the
nurse takes the organisational expectations for granted
and ignores professional judgement.
We are aware of the great concern for patients’
safety and quality of care which has been raised in the
Mid-Staffordshire NHS Public Inquiry from 2005 to
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 423–432
 Safety and quality of health care on Chinese nursing career decisions
2013 (Francis 2013). Our findings highlight the
lessons which have been learnt from the Mid Stafford-
shire NHS investigation, as Francis (2010) suggests: ‘It
is the individual experiences that lie behind statistics
and benchmarks and action plans that really matter,
and that is what must never be forgotten, when poli-
cies are being made and implemented’. Our study
echoes the view of this Public Inquiry that the despon-
dent nurse might struggle for safety and quality of
health care, but loses hope for change through their
individual efforts without organisational and manage-
rial support. The participants in our study gave up
their individual efforts by leaving nursing practice
because they lost the confidence in patient safety.
The safety issues that occurred within the Chinese
health-care system, as well as in the British health-care
system, have warned that powerless nurses are ineffec-
tive nurses, which is worth policy makers careful
concern.
Conclusion and implications for nursing
management
The study suggests that well-qualified nurses voluntar-
ily leaving to get away from the physical and mental
stress in nursing practice is a danger signal for both
patients and hospitals in China. The problems encoun-
tered and created by nurses leaving continue to have a
negative impact on the morale of nursing and the
safety and quality of health care. As Buchan (2006)
advocates, nursing shortage is a health system problem
that undermines health system effectiveness and
requires health system solutions. For the effectiveness
of the Chinese health-care system, there is an urgent
need for the hospital managers and policy makers to
concentrate on empowering nurses to exercise nursing
autonomy by providing educational, organisational
and managerial support. The findings suggest that
Chinese nurses need to be encouraged to be involved
in open discussion and reporting of adverse incidents
as a learning process without fearing blame. In the
current nursing shortage, Chinese hospital managers
might consider recruiting different educational levels
of nurses and care assistants, which would effectively
improve nursing team work and support nurses’ active
stay to achieve their work values in patient safety. We
hope that what the leavers’ experienced and thought
should be of great concern to the Chinese government
when new health-care reform strategies, which aim to
improve the safety and quality of health care, and
reduce the individual patient’s cost, are being made
and implemented (MHPRC 2009).
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2014, 22, 423–432
Acknowledgement
The main author thanks the anonymous reviewers, as
well Professor Rosemary Mander for the great supports
as first year PhD supervisor. This study was also kindly
supported by the Hangzhou Normal University.
Source of funding
This study was funded by the Medicine and Health Sci-
ence Research Foundation of Zhejiang Province in China
(2010KYA 158), the British-Chinese Education Trust in
UK (Chinese Student Award 2011). The authors declare
that there is no conflict of interest with the funders.
Ethical approval
The study has approved by my PhD study review
board in the School of Health in Social Science,
Edinburgh University, and has received the ethical
approval from the school research commitment on
29th July, 2009.
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