Can Education Resolve Nursing Shortage in China?

Abstract

The paper aims to understand how the Chinese nursing education and recruitment policy impacts nurses to leave nursing practice. There is a lack of feasible strategies to maintain a sustainable effective nursing workforce with an increasing trend of nurses' leaving clinical care. In its efforts to resolve the nursing shortage, the Chinese government currently emphasizes expanding nursing education while controlling staffing ratios. This qualitative research design was based on the framework of symbolic interactionism. The in-depth interviews with 19 nurses who have left the nursing practice were theoretically sampled from one provincial capital city in China. The core category "Mismatched Expectations: Individual vs. Organization" emerged from five subcategories, which illustrates how the mismatched individual and organizational expectations of nursing were created through nurses educational and employment processes within the Chinese health care system. When the individual and organizational expectations of nursing are highly mismatched, there is a risk that highly educated nurses will leave nursing practice. Students should be enabled to have realistic expectations of nursing, and new graduates need sufficient supports to adapt to the health care environment without losing their vision of nursing for future.

Full text

Athens Journal of Health
September 2015
177
Can Education Resolve Nursing
Shortage in China?
By Junhong Zhu

Sheila Rodgers†
Kath M. Melia‡
The paper aims to understand how the Chinese nursing education and recruitment
policy impacts nurses to leave nursing practice. There is a lack of feasible strategies
to maintain a sustainable effective nursing workforce with an increasing trend of
nurses' leaving clinical care. In its efforts to resolve the nursing shortage, the Chinese
government currently emphasizes expanding nursing education while controlling
staffing ratios. This qualitative research design was based on the framework of
symbolic interactionism. The in-depth interviews with 19 nurses who have left the
nursing practice were theoretically sampled from one provincial capital city in China.
The core category "Mismatched Expectations: Individual vs. Organization" emerged
from five subcategories, which illustrates how the mismatched individual and
organizational expectations of nursing were created through nurses educational and
employment processes within the Chinese health care system. When the individual and
organizational expectations of nursing are highly mismatched, there is a risk that
highly educated nurses will leave nursing practice. Students should be enabled to have
realistic expectations of nursing, and new graduates need sufficient supports to adapt
to the health care environment without losing their vision of nursing for future.
Key words: China, Nursing education, Nursing shortage, Recruitment.
Background
A high rate of nursing turnover has incurred great educational and human
resources wastage (Kotecha 2002, Lavoie-Tremblay et al. 2008, Pellico et al.
2009). It is presumed that the educators and hospital managers have a common
awareness that retention of staff is an important issue and that they wish to
manage turnover effectively (Hayes et al. 2006). There is no sound evidence to
prove whether the educators and hospital managers in developing countries
have a similar awareness or the motivation to retain qualified nurses (Dovlo
2005, Gill 2011, Xu 2003), which may be a particular concern in China. The
Chinese government uses expansion of nursing education in order to solve the
nursing shortage, but has shifted from government supported free education to
students' self-funded education as the consequence of the national higher
education reforms (MHPRC 2005). The enrolment of students in higher levels
of nursing education shows an increasing trend from 2001 to 2014 (Table 1 and
Postdoctoral Associate, Arthur Labatt Family School of Nursing, University of Western
London, Ontario, Canada.
†Head of Nursing Studies, School of Health in Social Science, University of Edinburgh, UK.
‡Professor, Nursing Studies, School of Health in Social Science, University of Edinburgh, UK.

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Table 2). The government declared that 51.3% of clinical nurses already have
an associate degree or a higher degree and expected those ratios would
continue increasing to 60% by 2015 (MHPRC 2011). However, an increasing
loss of Chinese nurses after graduation has been mentioned (Anand et al. 2008,
Fang 2007, Xu 2003).
Table 1. Multilevel Nursing Education and Nursing Workforce in China
Types of programme
Age of
entry
Years of
study
Percentage of
the workforce in
2005
Percentage of all
the workforce in
2013
Diploma
15-16
3
85-95%
51%
Associate degree
18
3
4-8%
38%
Bachelor degree
18
4-5
6%
11%
Postgraduate education
(Master and Doctorate Degree)
<35
3
n/a
n/a
Source: MHPRC 2005, ICN 2013.
Table 2. Chinese Nursing School Recruitment
Types of
programme
2001
2005
2010
2013
Number
%
Number
%
Number
%
Number
%
Diploma
75,000
71%
88,000
62%
82,200
50%
488,779
71%
Associate
degree
25,000
23%
38,200
27%
49,200
30%
161,038
23%
Bachelor
degree
6,500
6%
15,100
11%
32,000
20%
42,878
6%
Total
<106,500
100%
141,300
100%
164,300
100%
692,695
100%
Source: MHPRC 2005, ICN 2013.
In 1978, the Chinese government established dingbian as a staffing
legislation in the national health care system (MHPRC 1978). The standards of
dingbian focus on the numbers of all types of hospital staff per bed based on
the size of the hospitals and the ratio of doctors to nurses is stipulated (Table
3). It is different from the current international nursing staffing policy in most
western countries, which focuses on the number of patients per nurse based on
the work-unit (Aiken and Cheung 2008, Conway et al. 2008, Rafferty et al.
2007). From 1979, the Chinese health-care system gradually transferred from a
planned to a market economy (Hsiao 2008). Since then, the State subsidy has
been cut annually, from 30% to less than 7% of total hospital expenditure
(Blumenthal and Hsiao 2005). Due to a lack of valid monitoring mechanisms
in Chinese hospitals (Ma et al. 2008, Wu 1997), the hospital managers are
reluctant to admit that nurses are important to the quality and safety of care
based on a profit motive driver (Hsiao 2008, Zhu et al. 2014). Consequently,
controlling the ratio of nursing staff became the main strategy used by the
hospital managers to achieve cost efficiency. There is a lack of feasible
strategies to retain and attract nurses back to nursing in China (Fang 2007, Zhu
2010, Zhu et al.2015).

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September 2015
179
Table 3. The Discrepancy between Dingbian and Actual Staffing in Chinese
Health System
The ratio of
staffing
(numbers of
all health
staff/ beds)
Hospital size
(number of beds)
Average
ratio of
nurses/beds
Ratio of
doctors/
nurses
Sources
<300
300-500
>500
Dingbian
1.30-
1.40:1
1.40-
1.50:1
1.60-
1.70:1
0.4:1
1:1.5-2.0
MHPRC 1978
Actual ratio
of staffing
(Zhejiang
Province )
1.32:1
1.33:1
1.53:1
<0.4:1
>1: 1.5
Liang et al.
2007
Actual ratio
of staffing
(Nationwide)
n/a
n/a
n/a
0.33:1
1:2.28 (1952)
1:1.09 (2001)
1:0.68 (2003)
1:1.16 (2011)
1:1.03 (2014)
MHPRC 2005
MHPRC 2011
WHO 2014
The Study
Aim The study aims to explore how nursing education and employment policy
impacts on Chinese nurses' career decision making. The research questions
focus on: how do the nurses who leave nursing describe their experiences
through the processes of nursing education and recruitment, and are education
issues part of the reason for their leaving nursing practice in China?
Design
A qualitative study design was based on symbolic interactionism (Blumer
1969, Glaser and Strauss 1967). The key premises of symbolic interactionism
provide an interpretative view of sociology which emphasizes understanding
the actions of participants in their active experience and the ways in which
their actions arise from and reflect back their experience (Blumer 1969). The
theoretical framework of symbolic interactionism supports in-depth interviews
with nurses who left clinical care as the best way to collect data (Zhu 2012).
Participants and Research Setting
The research site is located in one provincial capital city in the east of
China. The interview participants include 19 nurses who have worked in all
areas of clinical care apart from mental health care, and have left their nursing
practice in the last 5 years. The rationale of setting the leaving period at a
maximum of 5 years allows participants enough time and space to make sense
of their actions as an outsider looking back from their current position at their
nursing career decision-making process when the consequences of their
departure have become apparent.

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Ethical Considerations
Ethical approval has been granted from the Research Ethics Committee of
Edinburgh University. We did not use organizational gatekeepers to identify
the potential participants from the Chinese Health authority, since we believe
that nurses who left their nursing practice are professionals, have the
knowledge and ability to understand the nature of the study and can participant
the study based on informed consent without organizational approvals.
Data Collection
Each in-depth formal interview lasted 2 to 3 hours on average. The
selection criteria for the next interviewee always followed the previous
interview analysis in the field, which was guided by the principle of theoretical
sampling (Glaser and Strauss 1967, Silverman 2010). As the data analysis
progressed, the category "entering the ideal workplace" indicated that the
Grade three hospitals were initially regarded by participants as the ideal
workplace, where the most well educated and best qualified nurses were
recruited (Zhu 2012). A decision was made to narrow down and focus on the
former nurses from Grade three hospitals only in order to address the reality
fully and effectively (Zhu 2012).
Data Analysis
The process of theoretical sampling and the constant comparative analysis
was followed as outlined by Glaser and Strauss (1967). We were concerned
that the accuracy of the study should be achieved by basing it on culture
sensitivity. Therefore, all interviews were recoded and transcribed verbatim
and kept as the most original data for the researchers to check the accuracy of
interpretation and translation during different stages of analysis and
presentation by constantly comparing one piece of data with another, back and
forward between two languages. Glaser and Strauss (1967) emphasise that a
comprehensive literature review should be avoided by following a grounded
approach before the data analysis. Therefore we only start to integrate literature
review into analysis as second data when the core categories emerged clearly
from primary in-depth interview data, which avoids contaminating participants'
accounts due to the preconceptions from reading the literature.
Findings
The core category "Mismatched Expectations: Individual vs.
Organization" emerged from the following five conceptualized subcategories
(Table 4). These conceptualized categories articulated how the nursing
education and employment policy impacts on Chinese nurses' career decision
making.

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September 2015
181
Table 4. Summary of the Conceptualized Categories
Core category
Subcategories
Properties
Mismatched
Expectations:
Individual Vs.
Organizational
Entering nursing with
collective expectations
 Influence of parents.
 Concern for health care for
family.
 Pursuing social mobility by
working in the city.
 Looking for a springboard.
 Advising the potential nursing
students.
Restricting realistic
expectations of nursing
in education
 Creating unrealistic expectations
from enrolment.
 Effects in nursing education.
 Clinical supervisors effects in
work placement.
Choosing the ideal
workplace
 Getting priority to choose ideal
workplace.
 Selecting by the hospitals.
Commitment to the
organization
 Accessing health care for
family.
 Gaining a stable job as woman.
 Attaching to the hospital within
dingbian.
 Expecting doing a good job.
Struggling with a
professional identity
 Gaps between theory and
practice.
 Lack of clear role boundaries
and skill-mix team work.
 Intensifying individual nurses'
workload.
 Working stress and the
wellbeing of nurses.
 Losing confidence in the safety
and quality of health care.
Entering Nursing with Collective Expectations
The participants entered different levels of nursing studies under a variety
of tuition fee arrangements. It was surprising that nearly all of the participants
mentioned that they did not have a clear idea of nursing before they entered
nursing school. The predominant reasons for choosing nursing were influenced
by the views of parents, the social desire to work in the city, the concerns to
provide health care for their families, and the certificates of higher education
for a decent job.
Before the one-child generation, the best and most precious opportunities
for higher education were usually reserved for boys particularly amongst

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poorer families in rural areas. The participants who entered free nursing
education aged 16 to 17 were mainly from families with more than one child
with better school performance than their peers. This age group of nurses
constitute the main nursing workforce in China (Table 2).
With dramatic demographic changes due to the one-child policy and an
unbalanced economic development between the rural and urban area in China,
nursing has been regarded as a job for people who are from rural areas or low
social class.
It is true that very few city residents would send their children to
nursing school; however, in the rural areas, the students…and their
parents… their biggest dream is to work in the cities. … So don't
worry. There are still so many people available. (Ling)
Ling's view echoes the popular view hold in Chinese society. Yan was the
only participant who said she chose nursing by herself although she has
sufficient financial support without having to worry about health care with the
urban residential status.
My dad is a doctor. He wants me to learn medicine. My mum wanted
me to study in my hometown. …I considered that nursing would be
relatively easier than medicine. I also had a desire to go abroad.
(…) Many people said that there was a shortage of nurses in other
countries, so it would be easy to work abroad as a nurse. (…) My
dad was against my decision for nursing studies. He said: "What
good is it to be a nurse? Nurses are shouted at by doctors the whole
day." So it was my own idea to choose nursing. (Yan)
As the only child in their family, Yan regarded choosing nursing as a
chance to be free from her parents' control by working abroad.
The participants mentioned that they were frequently consulted by their
friends, relatives and neighbours for their views on choosing nursing. The
majority of respondents commented that young people should be fully
informed about the nature of the hard work of nursing and make a free decision
based on their personal choice.
Restricting Realistic Expectations of Nursing in Education
In recent years, Chinese higher educational institutions were encouraged
by the government to receive tuition fees from the students instead of offering
free education. There are five classes of nursing enrolment according to the
national entry examination results. First, 2nd and 3rd class students enter
bachelors' degree education, with 3rd class students paying extra tuition fees.
Fourth and 5th class students enter associate degree education. Nursing diploma
education is still provided for students aged 16 to 17, who are less
academically qualified or their family cannot financially support them for their
higher education. While the education market became fiercely competitive for

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183
their institutional survival, several strategies were adopted to attract more
students into different levels of nursing studies.
Firstly, the reality of being a nurse in clinical care was deliberately blurred
in the nursing recruitment process, especially for nursing at 1st and 2nd class
bachelor's degree programme.
The benefits written in the recruitment document were pretty good. It
talks about nursing research, nursing education, and nursing
management, but it didn't say that you would work as a clinical
nurse. (Rao)
It seems that the different images of nursing, which were created in the
enrolment phase, were not subsequently clarified during their theoretical
nursing education. Yuan described how her classmates' attitudes to nursing
changed during their pre-registration nursing studies in the medical
universities.
In the first two years, nursing students and medical students took the
same courses and examinations together. Our classmates studied
hard and we had a very good academic atmosphere. Our average
examination results were much higher than those of medical
students. (…) Then we were separated in the clinical learning stage.
For each disease, usually the doctors gave the lectures first and then
the head nurses introduced the nursing strategies of the diseases at
the end. I found that nursing was not difficult and we could learn by
ourselves. (…) At that time the senior students came back from their
work placement and we realized that we still would become clinical
nurses under the orders of doctors. One of the senior students went
for a Master's degree in medicine, which gave us hope of leaving
nursing, so the majority of our classmates began to prepare for the
medical postgraduate entrance examinations. (…) There were 30
classmates in my class, only 5 to 6 of them are still working as
nurses, 10 of them 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)
The 1st class nursing students were regarded as the best qualified nursing
graduates in China. Nevertheless, it seems that nursing education following the
medical science orientation and led nursing students to undervalue nursing.
Their sound medical foundation seemed to increase the possibility that they
went on to postgraduate study in medicine, work abroad or other careers
outside of nursing.
Secondly, while recruitment to nursing education programmes in top
universities currently faces great challenges, involuntarily transferring students
into nursing studies from other subjects has been another means to increase

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numbers. However, a lack of proper support for students who involuntarily
entered nursing has a negative impact on students' learning.
Meanwhile, the ideal of working abroad as a nurse was encouraged in
Chinese nursing education. This global market strategy has resulted in the
educational institutions increasing their investment to focus on increasing
Chinese nurses' English capability for nursing emigration.
By encouraging the possibility of working abroad, many students
were attracted into nursing studies by the schools. Learning English
became the important task during nursing studies, although it is not
enough for graduates to be qualified for working abroad. However,
the cost of training for working abroad is too expensive for Chinese
nurses, since most of them are from relatively poor families. (Rao)
However, in contrast to the difficulties top universities having to face
during the recruitment of nursing student, a low employment rate in the nursing
diploma education and nursing associate degrees was presented as a challenge
to their educational institutions.
Now the school claims that they will take employment as the priority
orientation. Teachers are very worried about it since the rate of
employment needs to be met. Some students were arranged to sign
fake contracts with some company in the labour market. I would say
what a waste! (Xia)
It is difficult for these diploma level educated nurses to find a permanent
job in the city as they expected. Xia confirmed that fake contracts have been
collaboratively arranged by some educational institutions with intermediary
labour companies to reduce the rate of unemployment of nursing graduates.
Meanwhile, as a way of seeking work opportunities in the city, re-entering
nursing colleges for a higher nursing degree became an attractive choice for
some students with a nursing diploma. Thus the actual employment of nurses
might be overestimated by official statistics provided by the educational
institution and government.
Choosing the Ideal Workplace
Participants regarded the Grade three hospitals as the ideal workplace.
I looked for the big hospitals. The biggest hospitals are the Grade
three hospitals…. Working in the Grade three hospitals means that,
the income, working environment and different aspects of
development would be better. (Ming)
The opportunity to work in the Grade three hospitals for new graduates
means a stable job with a decent income, combined with better opportunities
for personal and career development. Grade three hospitals take a large

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185
recruitment pool for granted and set up stringent recruitment criteria. Chinese
nursing students will often send many applications to different Grade three
hospitals in order to increase the chance of working in their ideal workplace.
As a male nurse, Ming commented on the job interview that selection was
subject to appearance and gender discrimination.
It is a shame to say, but it is true that your height and appearance
are very important…. You know, we just stand and nobody asks you
to sit down. We were chosen by them without respect… such kind of
feeling is bad. The president of the hospital refused to employ any
male nurse in the end. (Ming)
Li also expressed her frustration when she and six new colleagues were
regarded as a good image for the hospital for their appearance and allocated at
the out-patient department in their first year practice. Appearance
discrimination not only undervalues new nurses' enthusiasm for nursing but
also undermined their professional value and identity.
Moreover, the hospital did not provide equal work conditions for all
recruits.
In the year we graduated, the hospital employed about 100 new
nurses. Only a few nurses employed with dingbian; most of us did
not… About 20 were permanent contracted nurses whose treatment
was almost the same as our temporary contracted nurses, but they
have health care insurance although it is lower than those within
dingbian. (…) I did not have the insurance for health care, pension
and seasonal bonus like the permanent staff. I feel that is really
unfair. You know I did the entire job the same as the others. At that
time my salary was only half salary and one third of the monthly
bonus of the new nurses within dingbian. (Li)
Some nurses did not have equal pay and benefits for doing the same job as
the permanent staff within dingbian and subsequently did not feel a sense of
belonging. The high rate of leaving among nurses on temporary contracts has
been widely reported in Chinese nursing literature (Shang et al. 2014).
Committing to the Organization
All participants appreciate the chance of working in the Grade three
hospitals and try to do a good job at the beginning of their career.
When I started to work in the hospital, I never thought that I would
leave the hospital. As it was not easy to get the job in the hospital
(…) I was determined to do the job well with all my heart until
retirement. (Xue)

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The majority of participants were bright students, they were highly
motivated to study and very soon became the key staff or team leaders in their
hospitals. It seems that many participants had a sense of strong organizational
commitment although they still lack nursing commitment.
Most participants said that the benefits of working in the hospital limited
their intention of leaving nursing. When the participants encounter difficulties,
they believed they could pass the difficulties through their efforts, which
helped them to be tolerant and manage to stay in nursing. After leaving
nursing, Ming actively kept certain privileges of working in the hospital by
establishing social connections with his previous colleagues.
The hospital is a huge organization with 1200 staff. Although I left
the hospital, I still have regularly contacted many friends in the
hospital. We have very close relationship and play together. I ask for
help and support whenever I have any personal or work problems
and I also help them when necessary. (Ming)
Nurses who are working in the Grade three hospitals became "precious
resources" for their family, relatives and friends, since nurses can help them to
get safer, easier, cheaper and more effective health care services or even take
advantage of the health insurance, which the public might not be aware of or
understand.
Struggling with a Professional Identity
As Chinese hospitals strictly limited the number of nursing staff, nurses
often had to work beyond their hours. The well-educated and qualified nurses
in the Grade three hospitals struggled with their professional identity since they
could not achieve their individual expectations of nursing without an effective
skill-mix and team work although they had the knowledge and skills to do so.
This often led to fatigue and work stress and less time for personal and family
life. Work related stress was mentioned by participants in relation to suicide,
depression, fatigue, sleep disorder, nervousness, anxieties and sadness.
…Staying in such a condition for a long time is not healthy. You
have no other choice but to quit. (Yang)
It was not surprising that the evidence shows that losing confidence in the
safety and quality of health care within grade three hospital work environment
has pushed nurses into leaving nursing practice, which has been reported by us
elsewhere (Zhu et al. 2014).
Discussion
The evidence indicates that although nursing is not a popular career choice
in Chinese society, it appears that universities currently have no problem in

Athens Journal of Health
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187
attracting students by adopting different strategies. However, the retrospective
experiences of the participants illustrate that the mismatched individual and
organizational expectations of nursing has created, while the educational
institutions mainly emphasis on attracting more students for their institutional
survive, and the hospital organizations emphasis on controlling nursing staffing
for saving budge under a market orientation. These mismatched expectations
has become a barrier for keeping a sustainable nursing workforce in a long
term.
The findings in our study suggested that the interpretation of the current
increasing statistical number should be viewed with caution, because not only
did some nursing students with a higher level of education simply leave clinical
care for other careers, some students with a lower level of education also
delayed joining the real nursing workforce.
The study supports the argument that the reasons why nurses entered
nursing should be considered in association with the reasons why they leave
nursing (Duffield et al. 2004). It should be noted that there is a lack of career
education for the students before they enter the higher education in China, and
many students were reallocated to nursing from other subjects by universities
within Chinese current education system. Therefore it was not surprising that
nearly all leavers said that they did not have a clear idea of nursing before they
entered nursing. The main reason that participants chose nursing was to meet
collective expectations, which were influenced by the views of parents and
relatives, the concerns of the health care for their family, for a decent job via
the higher education, and for social mobility by working in the city. Due to the
inequality of economic, educational and health care provision between the
urban and rural areas in China, nursing mainly attracts young women from
relatively poor rural backgrounds.
Chinese nurses rarely talked about their initial choice of nursing as the
desire to "care for" or "help" others, which has been widely regarded as the
accepted attitude to nursing in nursing literature (Brodie et al. 2004, Mills and
Blaesing 2000). Many western nursing students enter nursing education for
reasons related to personal interest or because of a caring intuition (Brodie et
al. 2004, Mackay and Elliott 2002). The evidence suggests that the current
demographic, financial, and social changes predict a declining eligible number
of nursing applications in China given the one-child generation who were born
after 1978 now becoming the core of the Chinese workforce (Greenhalgh
2008).
The high rate of nursing students' attrition in Western countries has caused
great educational and financial resources wastage (Brewer and Kovner 2001).
Many researchers focus on nursing wastage from the perspective of nursing
educators, and the unexpected high academic requirement was identified as the
main reason for nursing students' attrition (Brodie et al. 2004, Kotecha 2002,
Lavoie-Tremblay et al. 2008, Pellico et al. 2009, Rodgers et al. 2013).
Therefore, these studies are mainly concerned with avoiding students leaving
their pre-registration education by providing support in the educational
settings. However, in our study the majority of leavers were the brightest

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students who worked in their ideal workplaces. It might be too easy to blame
nurses for their educational preparation without an understanding of the
political climate value of nursing within the organizational expectations. In
fact, compared with a relatively high rate of nursing students’ attrition in most
developed countries (Duffield and O'Brien-Pallas 2002), Chinese nursing
students rarely give up their studies because of academic demands in the
current education system and the highly competitive employment market.
Duffield et al. (2004) studied inactive nurses in Australia, and reported that
nurses who were well qualified and skilled were capable of making the
transition to a range of other careers when they decided to leave nursing.
Chinese leavers' seem to have similar experiences. While it may be possible to
attract more students into nursing to ensure the survival of the educational
intuitions, it would inevitably increase students' unrealistic expectations of
nursing when nurses were inspired to choose nursing as a stepping stone for
other careers rather than actively staying in a nursing career.
The highly competitive selectivity in the ideal workplace implicitly forces
the well-educated nurses to accept organizational identity rather than
professional identity. However organizational commitment was not always
associated with a high level of satisfaction, which concurs with previous
literature (Lu et al. 2007, Wagner 2007). Nearly all participants confirmed that
understaffing and a high workload forced nurses to do extra work hours and
sacrifice their off duty time without extra reward. Nurses concentrated on
getting the work done by following organizational rules and procedures,
resulting in well-educated nurses struggling with their professional identity as
part of mismatched expectations of nursing between the individuals and the
hospitals.
Without an effective employment policy to support team work, role
insufficiency and role ambiguity occur since nurses expected to care for
patients with a humanistic orientation, but are instead required to focus on
tasks, which has a negative impact on the morale of the nursing workforce. The
majority of participants expressed an unresolved dilemma when they could not
meet the expectations of both hospital and patients as a clinical nurse.
Conclusions
By examining the leavers' educational and employment experiences, the
present study shows that the current Chinese nursing educational strategies
have not helped nursing students to establish realistic expectations of nursing.
When the individual and organizational expectations of nursing are highly
mismatched, there may be a risk that highly educated nurses simply leave
nursing practice. The education providers and hospital managers need to
consider how to cooperate and reduce the mismatched expectations of nursing
between individuals and organizations by employing mix-skilled teams to
achieve a cost efficient as well as effective health care, which will improve a
safer environment thus avoiding a more serious risk of nursing shortages.

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189
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