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Research article
A qualitative exploration of nurses leaving nursing practice
in China
Junhong Zhu
1,2
, Sheila Rodgers
3
& Kath M. Melia
3
1
Arthur Labatt Family School of Nursing, University of Western Ontario, London, Ontario, Canada
2
Nursing Studies, School of Medicine, Hangzhou Normal University, Hangzhou, China
3
Nursing Studies, School of Health in Social Science, University of Edinburgh, Edinburgh, UK
Keywords
China, expectations, nursing turnover,
nursing workforce management, power,
shortage, voluntary leaving
Correspondence
Junhong Zhu, e-mail:
junhongzhu66@hotmail.com
Funding
This study is kindly supported by the
Medicine and Health Science Research
Foundation of Zhejiang Province in China
(2010KYA158), the British-Chinese Education
Trust in UK (Chinese Student Award 2011).
Received: 16 June 2014; Accepted: 20
October 2014
doi: 10.1002/nop2.11
Abstract
Aim
This paper reports a theoretical understanding of nurses leaving nursing prac-
tice by exploring the processes of decision-making by registered nurses in China
on exiting clinical care.
Background
The loss of nurses through their voluntarily leaving nursing practice has not
attracted much attention in China. There is a lack of an effective way to under-
stand and communicate nursing workforce mobility in China and worldwide.
Design
This qualitative study draws on the constant comparative method following a
grounded theory approach.
Method
In-depth interviews with 19 nurses who had left nursing practice were theoreti-
cally sampled from one provincial capital city in China during August 2009–
March 2010.
Results
The core category ‘Mismatching Expectations: Individual vs. Organizational’
emerged from leavers’ accounts of their leaving. By illuminating the interrela-
tionship between the core category and the main category ‘Individual Percep-
tion of Power,’ four nursing behaviour patterns were identified: (1) Voluntary
leaving; (2) Passive staying; (3) Adaptive staying and (4) Active staying.
Introduction
In the past three decades, Chinese nurses experienced
rapid economic, social-political and educational changes
in healthcare system reforms. These changes have greatly
impacted their employment decisions. Although nursing
shortage in China is more serious than that in many
other developed countries (WHO 2011, You et al. 2013),
Chinese nurses continue to voluntarily leave nursing prac-
tice. They intend to keep their leaving quiet and personal,
resulting in ineffective communications with policy mak-
ers. The main author initiated her PhD study on nursing
mobility in 2008, when the Chinese pilot health reform
started. This report aims to unfold a theoretical explana-
tion of voluntary departure from the leavers’ perspective.
Background
Historical nursing employment in China
The Chinese government has established dingbian as a staff-
ing legislation in the Chinese healthcare system since 1978.
The staffing requirements in dingbian focus on the numbers
of hospital staff based on the bed size of hospitals and the
ratio of nurses per hospital bed is the only recommended
standard (Ministry of Health of the People’s Republic of
ª2014 The Authors. Nursing Open published by John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution License,
which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
1
China (MHPRC)’s 1978). This differs from most western
countries, where the ratio of patients to nurses based on
daily care ward by ward determines the nursing staffing
(Rafferty et al. 2007, Aiken & Cheung 2008, Conway et al.
2008). From 1979, the Chinese healthcare system gradually
transferred from a planned to a market economy (Ma et al.
2008). Since then, the state subsidy has been cut dramati-
cally, from 30% to less than 7% of total hospital expendi-
ture (Yang 2008).
The Chinese health workforce has slightly increased
and has reached the WHO minimum workforce threshold
since 2006. However, almost all hospitals tend strictly to
limit nursing staff but increase numbers of doctors
(MHPRC 2005, World Health Organization (WHO)
2006, Liang et al. 2007). While China is one of a few
countries that have more doctors than nurses (WHO
2011), the Ministry of Health China (2005) still emphasis-
es dingbian to set up a ratio of per hospital bed to nurses
at 1:04, nevertheless it is 1:1 in OECD countries (Ander-
son et al. 2005). The historical Chinese nursing employ-
ment pattern has resulted in a far more demanding
clinical situation due to the inadequacy of nursing staffing
than in most industrialised countries (Zhu et al. 2014). A
high rate of dissatisfaction and intention to leave nursing
has been reported in different areas nationwide in China
(Sun et al. 2001, Ye et al. 2006, Lu et al. 2007). Neverthe-
less, official statistics is lacking to monitor how many
nurses have actually left nursing practice in China.
Responses to the nursing shortage and
turnover
Nursing shortage is an international problem WHO
2006); however, the literature on nursing shortage is
mainly based on the US, the UK and other industrial-
ized countries. These studies advocate that strategies for
solving the problem include encouraging recruitment
from a broad recruitment base, improving retention,
attracting former nurses back into the profession and
increasing international recruitment from abroad (Aiken
et al. 2001, Shields & Ward 2001, Buchan 2006, Raffer-
ty et al. 2007).
Reducing the turnover tends to be the main concern to
meet the target number of registered nurses in dealing
with the nursing shortage, although Lewis (2002) and
Rafferty et al. (2007) warned that the shortage is not only
merely about numbers but also a matter of how these
numbers are most effectively deployed in the healthcare
system. Most of the literature on nursing turnover uses
the intention of leaving to predict actual turnover by
studying the nurses who are still employed in the profes-
sion and mainly focuses on matching or testing different
theoretical models by quantitative designs (Maertz &
Griffeth 2004, Hayes et al. 2006, Takase et al. 2008).
However, even the most extensive turnover predictive
models have underestimated some important antecedents
as Maertz and Campion (2004) commented. Although the
reasons for the growing shortage of nurses appear similar
everywhere (Tierney 2003), the relevant available compar-
ative studies between China and the developed countries
(Lu et al. 2007, You et al. 2013) have contributed little to
an understanding of the nursing mobility and shortage in
China.
Chinese nurses are facing unique historical, political,
cultural and educational difficulties in trying to solve the
problem of the nursing shortage by retaining nurses.
Compared with the efforts made in most western coun-
tries, Chinese hospital managers are reluctant to admit
that nurses are important to the quality of health care
based on a profit-driven system (Hsiao 2008, Zhu 2010).
The Chinese Nursing Association (CNA) leadership
hopes the backlash of a national nursing shortage and
subsequent negative effects on patient outcomes will
trigger Chinese healthcare reform and will improve the
welfare of Chinese nurses (Xu 2003, Hu et al. 2010).
Nevertheless, the nursing workforce problems were not
considered relevant and important in the current pilot
stage of the new healthcare reform (MHPRC 2009).
Nurses voluntarily leaving nursing practice have a wealth
of experience and what they have to say can help under-
stand the current nursing workforce mobility and reten-
tion problem.
The study
Aim
The aim of the study is to understand why nurses leave
nursing practice by exploring the decision-making process
of registered nurses who have exited clinical care 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 leaving nursing
practice?
Design
The qualitative study draws on the constant comparative
method following a grounded theory approach (Glaser &
Strauss 1967, Glaser 1978). In-depth interviews with 19
nurses who have left nursing practice were theoretically
sampled from one provincial capital city in the east of
China during August 2009–March 2010.
2ª2014 The Authors. Nursing Open published by John Wiley & Sons Ltd.
Nurses leave nursing practice in China J.H. Zhu et al.
Ethical considerations
Ethical approval was granted by Research Ethics Commit-
tee, University of Edinburgh, UK and the provincial
Research Institution of Social Science in China. An
informed choice ensured the participants to voluntarily
join the study and pseudonyms and confidentiality were
preserved against potential harm.
Participants
The participants included leavers with different years of
work experiences in all areas of clinical care (except men-
tal health care) who had voluntarily left their nursing
practice during the past 5 years. The first selection was
carried out on a wide range of leavers according to their
educational and socio-economic background, clinical
practice and leaving experiences. Based on the previous
interview data analysis, the researchers decided who was
the next to talk with, listen to, query or observe based on
a given issue important to the research (Glaser & Strauss
1967). The details of participants selection following the
principle of theoretical sampling in the study have been
discussed elsewhere (Zhu et al. 2014).
Data collection
The interviews were audio-recorded and field notes were
made after each visit or phone call to potential partici-
pants during sampling. Meanwhile, we not only treated
all the relevant literature as secondary data but also
included the data naturally available to the research field,
such as informal conversations or observational notes
made during the research process, relevant nursing poli-
cies, hospital documents, work or personal diaries, news
reports, work contracts.
Data analysis
All interviews were transcribed verbatim and kept in their
original forms for the researcher to check the accuracy of
interpretation and translation during different stages of
analysis and presentation by constantly comparing pieces
of data, back and forward between two languages. Plausi-
ble suggestions were sought in approaching sampling
according to the categories and incidents which emerge
from the data by a constant comparative analysis (Glaser
& Strauss 1967). Refinement of the hypothesis involved
continuously reviewing the core category for internal con-
sistency and logic by looking for negative evidence or
deviant cases until it accounts for all known cases without
exception (Glaser & Strauss 1967, Silverman 2010).
Rigour
For the rigour in all phases of the research process (Zhu
2012), we applied reflexivity to examine the possible bias
throughout the design and conduct of this study, adding
trustworthiness to this study as suggested by Hertz
(1997). The rationale behind presenting the original
descriptive data here is to provide enough evidence to
illustrate the concepts, and the more comprehensive data
could be accessed elsewhere (Zhu 2012). According to
Bryman (2004), who emphasised that enough detail about
Table 1. Summary of the conceptualized categories.
Main categories Subcategories Themes
Mismatched Expectations:
Individual vs. Organizational
Entering nursing with unrealistic expectations ●Choosing nursing with collective expectations
●Restricting realistic expectations of nursing in education
Working in the ideal workplace ●Entering the ideal workplace
●Committing to the organization
●Struggling with a professional identity
Losing confidence in the safety and quality
of health care
●Perceiving the risk in clinical practice
●Recognizing the organizational barriers to safety
●Failing to meet expectations of patients
Individual Perceptions of Power Nursing autonomy vs. medical dominance ●Comparing rewards with doctors
●Struggling with medical dominance
Professional value vs. managerial value ●Emphasising nurses as replaceable labour
●Losing enthusiasm in promotion
●Struggling to meet career progress
Personal freedom vs. organizational control ●Lack of reasonable nursing mobility
●Limited maternity leave and sick leave
ª2014 The Authors. Nursing Open published by John Wiley & Sons Ltd. 3
J.H. Zhu et al. Nurses leave nursing practice in China
findings should be provided to enable readers to deter-
mine applicability and Glaser and Strauss (1967) who
suggested that participants should be able to perceive the
story as a reasonable explanation of what is going on even
if it is not the case that every detail quite fits their cases,
we provided the conceptual categories, the storyline and
the hypothesis of theoretical model to participants, as well
as the clinical nurses and nursing managers, and asked
them to comment on how well the theory seems to fit
their perception.
Findings
This report presents the findings according to the concep-
tualized categories and their subcategories that emerged
from the data analysis (Table 1, Figure 1), which offer
suggestions about what to look for based on reality as it
exists. The core category ‘Mismatched Expectations: Indi-
vidual vs. Organizational’ emerged from the following
three subcategories.
Mismatched expectations: individual vs.
organizational
Entering nursing with unrealistic expectations
This subcategory emerged from the retrospective experi-
ences of participants who explained how different gen-
erations chose nursing studies in the past three decades
from 1978–2008. Students before 1995 received free
nursing education and were more concerned about
reducing the family financial burden. They usually
entered nursing school at the ages of 15–16 and had
better school performance. They constitute the current
main nursing workforce and the majority of nursing
leaders in China. This group of participants were par-
ticularly dissatisfied with the strict learning requirements
of pre- and postregistration nursing education, as they
expected that the time and energy invested in their
nursing education could help their personal and profes-
sional development, while the later self-funded genera-
tion of nurses were more concerned about accessing
health care for their families.
In 1995, Chinese higher educational institutions were
encouraged by the government to receive tuition fees
from the students instead of offering free higher educa-
tion, which was previously fully supported by the govern-
ment. Since then, several strategies have been adopted to
attract more students into different levels of nursing edu-
cation.
First, many participants felt that the reality of being a
nurse was deliberately blurred in the nursing recruitment
process. They enter nursing with a vague idea of the
demands of the job:
The benefits written in the recruitment document sounded
pretty good. It talked about nursing research, nursing edu-
cation and nursing management, but it did not say that
you would work as a clinical nurse. (Rao)
The majority of participants said that they were trans-
ferred into nursing studies without true desire to be
nurses. While different levels of education between the
universities and colleges became fiercely competitive with
a market orientation, Chinese students are required to
accept the pre-condition for getting a university admis-
sion offer ‘I agree to be transferred to other subjects’.
Although nursing is an unwelcome career choice in cur-
rent Chinese society, involuntarily transferring students
into nursing studies from other subjects has been taken
for granted. As a nursing teacher now, Yuan thought that
a lack of proper support for students who involuntarily
entered nursing study has a negative impact on students’
learning attitudes and their leaving the nursing practice
early. She talked about the high ratio of those of leaving
nursing among her previous classmates who graduated
from a top Chinese university:
There were 30 classmates in my class, only 5–6 of them are
still working as nurses, 10 became doctors and the others
became nursing teachers. One of the classmates graduated
with her master’s degree in medicine and went back to work
in nursing, but she soon left and worked abroad. (Yuan)
Leaving
Entering nursing with unrealistic expectations
Working in the ideal workplace
Personal freedom vs. Organizational control
Professional value vs. managerial value
Nursing autonomy vs. Medical dominance
Losing
confidence in
the safety and
quality of health
care
Voluntary
Individual perceptions of power
Passive
Staying
Mismatched Expectations:
Individual vs. Organizational
When individual nurses are aware of high mismatched expectations as well as low perceptions of power
When individual nurses are aware of high mismatched expectations as well as high perceptions of power
Figure 1. The storyline of mismatched expectations towards voluntary leaving.
4ª2014 The Authors. Nursing Open published by John Wiley & Sons Ltd.
Nurses leave nursing practice in China J.H. Zhu et al.
findings should be provided to enable readers to deter-
mine applicability and Glaser and Strauss (1967) who
suggested that participants should be able to perceive the
story as a reasonable explanation of what is going on even
if it is not the case that every detail quite fits their cases,
we provided the conceptual categories, the storyline and
the hypothesis of theoretical model to participants, as well
as the clinical nurses and nursing managers, and asked
them to comment on how well the theory seems to fit
their perception.
Findings
This report presents the findings according to the concep-
tualized categories and their subcategories that emerged
from the data analysis (Table 1, Figure 1), which offer
suggestions about what to look for based on reality as it
exists. The core category ‘Mismatched Expectations: Indi-
vidual vs. Organizational’ emerged from the following
three subcategories.
Mismatched expectations: individual vs.
organizational
Entering nursing with unrealistic expectations
This subcategory emerged from the retrospective experi-
ences of participants who explained how different gen-
erations chose nursing studies in the past three decades
from 1978–2008. Students before 1995 received free
nursing education and were more concerned about
reducing the family financial burden. They usually
entered nursing school at the ages of 15–16 and had
better school performance. They constitute the current
main nursing workforce and the majority of nursing
leaders in China. This group of participants were par-
ticularly dissatisfied with the strict learning requirements
of pre- and postregistration nursing education, as they
expected that the time and energy invested in their
nursing education could help their personal and profes-
sional development, while the later self-funded genera-
tion of nurses were more concerned about accessing
health care for their families.
In 1995, Chinese higher educational institutions were
encouraged by the government to receive tuition fees
from the students instead of offering free higher educa-
tion, which was previously fully supported by the govern-
ment. Since then, several strategies have been adopted to
attract more students into different levels of nursing edu-
cation.
First, many participants felt that the reality of being a
nurse was deliberately blurred in the nursing recruitment
process. They enter nursing with a vague idea of the
demands of the job:
The benefits written in the recruitment document sounded
pretty good. It talked about nursing research, nursing edu-
cation and nursing management, but it did not say that
you would work as a clinical nurse. (Rao)
The majority of participants said that they were trans-
ferred into nursing studies without true desire to be
nurses. While different levels of education between the
universities and colleges became fiercely competitive with
a market orientation, Chinese students are required to
accept the pre-condition for getting a university admis-
sion offer ‘I agree to be transferred to other subjects’.
Although nursing is an unwelcome career choice in cur-
rent Chinese society, involuntarily transferring students
into nursing studies from other subjects has been taken
for granted. As a nursing teacher now, Yuan thought that
a lack of proper support for students who involuntarily
entered nursing study has a negative impact on students’
learning attitudes and their leaving the nursing practice
early. She talked about the high ratio of those of leaving
nursing among her previous classmates who graduated
from a top Chinese university:
There were 30 classmates in my class, only 5–6 of them are
still working as nurses, 10 became doctors and the others
became nursing teachers. One of the classmates graduated
with her master’s degree in medicine and went back to work
in nursing, but she soon left and worked abroad. (Yuan)
Leaving
Entering nursing with unrealistic expectations
Working in the ideal workplace
Personal freedom vs. Organizational control
Professional value vs. managerial value
Nursing autonomy vs. Medical dominance
Losing
confidence in
the safety and
quality of health
care
Voluntary
Individual perceptions of power
Passive
Staying
Mismatched Expectations:
Individual vs. Organizational
When individual nurses are aware of high mismatched expectations as well as low perceptions of power
When individual nurses are aware of high mismatched expectations as well as high perceptions of power
Figure 1. The storyline of mismatched expectations towards voluntary leaving.
4ª2014 The Authors. Nursing Open published by John Wiley & Sons Ltd.
Nurses leave nursing practice in China J.H. Zhu et al.
between nurses and doctors was not as good as stated
earlier’:
Doctors want to make more money!So many patients
received unnecessary IV at midnight...Sometimes I got
very angry...I was scared that I might lose control of carry-
ing out all of the tasks. (Xia)
One of the common complaints about doctors from
nurses was that they had to accept an unnecessarily high
workload due to doctors prescribing excessive medication
and treatment. Although Xia was sympathetic to patients
and angry at doctors, she only linked her leaving to the
workload. These situations have caused an ethical
dilemma for nurses. They generally felt difficulty in deal-
ing with it under medical dominance:
It will put the nurse in a difficult situation. Nursing man-
agers often emphasize that we should not do ‘good deeds’
and we must call doctor if anything happened to patients.
We all need clear awareness of self-protection. No one
dares do the same thing as before. (Chun)
When nurses were afraid of hurting their personal or
work relationship with doctors by taking a stand against
unnecessary treatment, their ability to protect patients’
rights was sorely weakened.
Professional value vs. managerial value
Participants’ leaving experiences confirmed the popular
view among nursing management that individual nurses’
leaving is not a problem for the hospital but for the indi-
viduals:
Actually they did not care to lose nurses; there are plenty
of young nurses available to replace us. (Yun)
All participants were disappointed at the lack of mana-
gerial support for the retention of nurses in clinical prac-
tice. They thought that the nursing managers and hospital
administrators did not value experienced nurses’ work by
considering nurses as replaceable labour.
Meanwhile Chinese nurses are required to pass regular
examinations and spot tests and fulfil publication require-
ments for their career progress, which was expected to
improve the quality of care. However, many participants
thought that meeting these managerial values for nursing
does not ensure that nurses can carry out standard prac-
tice under the heavy workload with the time and staff
constraints.
Personal freedom vs. organizational control
Many participants expressed that there is a lack of reason-
able nursing mobility in the Chinese healthcare system:
Very few nurses could get permission to move in the hospi-
tal. The director of nursing thought that it was a tough task
to transfer nurses between units since there were too many
nurses with similar requests and she was too tired to deal
with such requests every day. Therefore, she decided to
refuse all the requests. My heart sank when I heard that I
had to go back to the ICU from the nursing office, but I
knew that I had to go back. (Bo)
Chinese nurses do not have autonomy to choose the
most compatible nursing practice environment. Mean-
while hospitals also use administrative power and finan-
cial punishment to prevent nurses leaving:
If you ask to leave the hospital within five years, you must
pay 15,000 yuan, or 5000 yuan after you have worked over
5 years, since you breach the contract. The terms are solely
added for the benefit of the hospital....Actually I did not
want to pay the 15,000 yuan penalty for leaving, but my
parents said that I should not offend the hospital, as the
hospital is an influential institution which might negatively
influence my future. (Yan)
Nurses had to accept penalties for leaving, which was
reinforced by the hospital employment contracts. When
the participants lost hope of achieving their individual
expectations, the ideal workplace became a trap for
some nurses who intended to leave but could not afford
the cost of leaving. Meanwhile, threats of firing and
financial punishment have been used by the managers to
limit sick leave and maternity leave. Many complained
that there was a lack of family friendly policies for
nurses in hospitals. Concerning the reality of struggling
with work and family conflicts in the strict maternity
and sick leave regulations, nearly all the participants had
support from their family in their leaving decision to
improve their well-being and quality of family life. The
participants felt more confident than their colleagues
who are unable to empower themselves to leave. Leaving
nursing practice was interpreted by them as a way to
pursue personal freedom.
Discussion
The interrelationship between the ‘Mismatched expecta-
tions: individual vs. organizational’ and ‘Individual per-
ception of power’ was further illuminated through a
cross-tabulation (Figure 2). Glaser (1978:64) suggested
that, when the analyst uses relevant and grounded data-
determined distinctions with logical elaboration in a
cross-tabulation, it ‘helps achieve the goal for theory of
parsimony of concepts, while at the same time richly den-
sifying the theory’; however, caution needs to be raised
that the aim of parsimony of theory may lose some
6ª2014 The Authors. Nursing Open published by John Wiley & Sons Ltd.
Nurses leave nursing practice in China J.H. Zhu et al.
explanatory power in the conceptual categories. We agree
that the importance of study is not to discover a theory,
but to assist in understanding the issues under investiga-
tion (Heath & Cowley 2004). Therefore, the cross-tabula-
tion in this study was used as an analytical device, serving
as a strategy for handling data and understanding the
issues under investigation.
Based on the data-determined ‘high’ and ‘low’ distinc-
tive dimensions of main categories, the cross-tabulation
reduced the continuing nursing career behaviours and
consequences of nursing employment decision into four
typologies, including Voluntary Leaving, Active Staying,
Adaptive Staying and Passive Staying (Figure 2).The
cross-tabulation further suggests following hypotheses to
understand Voluntary Leaving:
●The higher the degree of mismatch between individual
and organizational expectations of nursing recognized
by the nurses and the greater the extent of imbalance
of power the individual nurses perceived, the more
likely it is that the nurses intend to leave the powerless
status of being a clinical nurse in the organization.
●The more difficult it becomes for the nurses to achieve
their individual expectations by exercising nursing
autonomy in their nursing career, the more likely it is
that they actually empower themselves to leave nursing
practice.
It also suggests that nurses chose an active staying in
their nursing career when the individual and organiza-
tional expectations of nursing were more aligned and the
individual nurses were able to exercise nursing autonomy
to achieve their professional values.
The hypotheses developed from this study support the
argument that the reason why nurses entered the profes-
sion should be considered in association with the reasons
why nurses leave (Duffield et al. 2004a,b). Duffield et al.
(2004b) optimistically recommended choosing nursing as
a stepping stone to future careers, since they found that
nurses who were well qualified and skilled were capable
of making the transition to a range of other careers.
However, the Mismatched Expectations model suggests
that the recommendation of Duffield et al. might attract
more students into nursing to ensure the survival of the
educational institution, but it would inevitably increase
unrealistic expectations of nursing when nurses were
inspired to choose nursing as a stepping stone for other
careers. The findings indicate current Chinese nursing en-
rolment and education strategies have not effectively
helped the nursing students to clarify and establish realis-
tic expectations of nursing.
When ‘mismatched expectations: individual vs. organi-
zation’ emerged as the core category from the data, it
was noteworthy that there is little consensus in current
literature on how expectations are best defined from
sociological, psychological, organizational and nursing
perspectives. The definition of ‘role expectation’ pro-
vided by Biddle (1979:256) makes a useful starting point
to examine the expectations of nursing both for individ-
uals and organizations: ‘expectations that are structured
for the roles of position within a social system.’ Never-
theless, ‘mismatched expectation: individual vs. organiza-
tional’ in this study is beyond a static concept of role
expectations or professional expectations of being a
nurse within a broad educational, economic and social
context in China.
The two subcategories ‘entering nursing with unrealis-
tic expectations’ and ‘working in the ideal workplace’
coincide with the two main concepts of pre-entry expec-
tations and postentry experiences in the Met Expecta-
tions model developed by Porter and Steers (1973).
Mismatched
expectations:
individual
Vs.
organizational
High
High
Individual perceptions of power
by choosing to leave nursing
practice
by accepting nursing as just a
job for life
by learning rules and focusing
on tasks for “fitting in”
by pursuing nursing as a life
career
Voluntary leaving Passive staying
Adaptive stayingActive staying
Low
Low
Figure 2. Mismatched expectations model.
ª2014 The Authors. Nursing Open published by John Wiley & Sons Ltd. 7
J.H. Zhu et al. Nurses leave nursing practice in China
between nurses and doctors was not as good as stated
earlier’:
Doctors want to make more money!So many patients
received unnecessary IV at midnight...Sometimes I got
very angry...I was scared that I might lose control of carry-
ing out all of the tasks. (Xia)
One of the common complaints about doctors from
nurses was that they had to accept an unnecessarily high
workload due to doctors prescribing excessive medication
and treatment. Although Xia was sympathetic to patients
and angry at doctors, she only linked her leaving to the
workload. These situations have caused an ethical
dilemma for nurses. They generally felt difficulty in deal-
ing with it under medical dominance:
It will put the nurse in a difficult situation. Nursing man-
agers often emphasize that we should not do ‘good deeds’
and we must call doctor if anything happened to patients.
We all need clear awareness of self-protection. No one
dares do the same thing as before. (Chun)
When nurses were afraid of hurting their personal or
work relationship with doctors by taking a stand against
unnecessary treatment, their ability to protect patients’
rights was sorely weakened.
Professional value vs. managerial value
Participants’ leaving experiences confirmed the popular
view among nursing management that individual nurses’
leaving is not a problem for the hospital but for the indi-
viduals:
Actually they did not care to lose nurses; there are plenty
of young nurses available to replace us. (Yun)
All participants were disappointed at the lack of mana-
gerial support for the retention of nurses in clinical prac-
tice. They thought that the nursing managers and hospital
administrators did not value experienced nurses’ work by
considering nurses as replaceable labour.
Meanwhile Chinese nurses are required to pass regular
examinations and spot tests and fulfil publication require-
ments for their career progress, which was expected to
improve the quality of care. However, many participants
thought that meeting these managerial values for nursing
does not ensure that nurses can carry out standard prac-
tice under the heavy workload with the time and staff
constraints.
Personal freedom vs. organizational control
Many participants expressed that there is a lack of reason-
able nursing mobility in the Chinese healthcare system:
Very few nurses could get permission to move in the hospi-
tal. The director of nursing thought that it was a tough task
to transfer nurses between units since there were too many
nurses with similar requests and she was too tired to deal
with such requests every day. Therefore, she decided to
refuse all the requests. My heart sank when I heard that I
had to go back to the ICU from the nursing office, but I
knew that I had to go back. (Bo)
Chinese nurses do not have autonomy to choose the
most compatible nursing practice environment. Mean-
while hospitals also use administrative power and finan-
cial punishment to prevent nurses leaving:
If you ask to leave the hospital within five years, you must
pay 15,000 yuan, or 5000 yuan after you have worked over
5 years, since you breach the contract. The terms are solely
added for the benefit of the hospital....Actually I did not
want to pay the 15,000 yuan penalty for leaving, but my
parents said that I should not offend the hospital, as the
hospital is an influential institution which might negatively
influence my future. (Yan)
Nurses had to accept penalties for leaving, which was
reinforced by the hospital employment contracts. When
the participants lost hope of achieving their individual
expectations, the ideal workplace became a trap for
some nurses who intended to leave but could not afford
the cost of leaving. Meanwhile, threats of firing and
financial punishment have been used by the managers to
limit sick leave and maternity leave. Many complained
that there was a lack of family friendly policies for
nurses in hospitals. Concerning the reality of struggling
with work and family conflicts in the strict maternity
and sick leave regulations, nearly all the participants had
support from their family in their leaving decision to
improve their well-being and quality of family life. The
participants felt more confident than their colleagues
who are unable to empower themselves to leave. Leaving
nursing practice was interpreted by them as a way to
pursue personal freedom.
Discussion
The interrelationship between the ‘Mismatched expecta-
tions: individual vs. organizational’ and ‘Individual per-
ception of power’ was further illuminated through a
cross-tabulation (Figure 2). Glaser (1978:64) suggested
that, when the analyst uses relevant and grounded data-
determined distinctions with logical elaboration in a
cross-tabulation, it ‘helps achieve the goal for theory of
parsimony of concepts, while at the same time richly den-
sifying the theory’; however, caution needs to be raised
that the aim of parsimony of theory may lose some
6ª2014 The Authors. Nursing Open published by John Wiley & Sons Ltd.
Nurses leave nursing practice in China J.H. Zhu et al.
The extent of individual perception of power might still
be low when nurses continue to practise over time. When
they realise a high degree of mismatched expectations
between individuals and the organization over their prac-
tice under medical dominance without managerial and
organizational support, they compromise their individual
expectations of nursing to meet the organizational expec-
tations and accept nursing just as a job for life. The evi-
dence indicates that the nurses with lower perception of
power do not have the freedom to leave nursing practice,
but loose enthusiasm and commitment in their nursing
career. In this way, they are engaging in the passive stay-
ing behaviour pattern.
It is understandable that the low rate of nurses’ volun-
tarily leaving nursing practice could be temporary under
the current Chinese organizational control both from
educational and hospital settings. However, nurses’ per-
sonal freedom will likely increase in the future due to
demographical, financial, educational and social changes
in China, which means if nurses are unable to exercise
nursing autonomy to achieve essential nursing values,
they are more likely to challenge the mismatched expecta-
tions and pursue freedom by leaving nursing. Therefore,
if the policy makers and the hospital managers still take
organizational control for granted without effective inter-
vention, the rate of voluntary leaving may dramatically
increase.
Conclusion
The study indicates that ineffective nursing employment
may not only occur when experienced nurses choose vol-
untary leaving but also happens when they resort to pas-
sive staying and when novices continue an adaptive
staying mode and act towards patients with a dehuman-
ized attitude. The Mismatched Expectations model sug-
gests that the higher the degree of mismatch that the
nurses recognised between individual and organizational
expectations of nursing and the more difficult it becomes
for the nurses to achieve their individual expectations by
exercising nursing autonomy with managerial and organi-
zational support in a nursing career, the more likely it is
that they empower themselves to leave nursing practice.
This study is restricted by the reality of the difficulty in
expanding the data collection from different populations
and settings following the theoretical sampling in a time
limited PhD project. Nevertheless, the theoretical perspec-
tive may contribute to the international debate on effec-
tive retention strategies towards effective nursing
workforce management. The hypotheses and suggestions
warrant verification and readily modification in nursing
workforce management in different healthcare systems by
further research.
Conflict of interest
The authors declare that there is no conflict of interest
with the funders.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/ethical_1author.html)]:
●substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
●drafting the article or revising it critically for impor-
tant intellectual content.
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