High cost of trained nurses makes hospitals turn to nonprofessionals, Peng Yining reports from Beijing and Chongqing.

Taking care of hospital patients doesn't appear to present much of a challenge to Dai Chang, a 50-year-old father of two and former farmer. For the most part, his work - giving sponge baths, reminding patients to take their medicine and informing the nurses when an intravenous drip needs replacing - doesn't require any professional skills.

However, most observers would be surprised, or even appalled, to see Dai spit on a handkerchief before using it to wipe leftover food from the chest of a patient who had just undergone a coronary bypass and needed to be protected from infection.

Dai has never spent time at nursing school, neither has he undergone any medical training, and he holds no qualifications, but he has taken care of more than 100 patients in his three years as a nursing assistant at a public hospital in the southwestern municipality of Chongqing.

Unqualified, unlicensed nursing assistants, or hugong, "patient care workers" in Chinese, work in most major hospitals in China as a result of a scarcity of nursing resources. Most are migrant workers with no medical background. As such, they cost little to employ and for those people without the time and/or money to take care of sick family members, hiring a hugong is their best option.

Lang Xuelin, 41, makes 100 yuan ($16) a day looking after patients 24/7 at another hospital in Chongqing, although 15 yuan of that sum is paid as commission to the agency that introduced him to the hospital and his employers. Once he's paid for his food and cigarettes, Lang's profit is more than 70 yuan a day, or 2,000 yuan a month. That's far higher than the income he earned as a rice farmer in a village 180 km from the municipality, but about equal to his salary at a factory in Guangdong province several years ago.

"But Guangdong is too far away," he said. "I prefer to work closer to my home and stay with my family. I am getting old. Working in a factory or on construction sites would be difficult for me," he said. "Nursing doesn't require any skills. I just watch the nurses and other workers and learn. It's easy money if you don't have a problem washing urine bowls and changing sheets stained with faeces."

Lang's wife, also a patient care worker at the same hospital, takes care of an 89-year-old patient with Alzheimer's disease.

Personal hygiene

Lang occasionally goes home to plough his rice field - the rice he plants now provides food for the family - and sometimes returns to the sick room with dirty finger nails and mud on his pants, his muddy shoes leaving brown footprints on the hospital's white floor.

At night, he curls up on a small couch or nods off on a wooden chair near the sickbed, in case the patient needs him. Sometimes, he squats in the stairwell and smokes, despite a building-wide ban on smoking.

"He doesn't care about his personal hygiene at all. Sometimes we have to remind him to wash his hands after using the bathroom and before he touches the patient," said Zhang Jingkang, Lang's employer. "But we need him to take care of my sick brother while we are at work."

Nurses are too busy to take care of every patient, said Shi Hongyan, a healthcare expert at the Chinese Association for Life Care. She said in most hospitals each nurse is usually responsible for at least 15 patients. "When the nurse serves meals, the food is often stone cold when it reaches the last patient," she said.

According to Shi, China's hospitals used to hire professionally trained nursing assistants, but that ended during a round of budget cuts in the 1990s when market forces were first introduced and cash-starved hospitals tried to make ends meet.

That resulted in patients having to find healthcare workers through agencies. Either that, or they can employ an unqualified freelance patient care worker from the streets; these people can often be seen wandering around outside hospitals holding boards reading "hugong" and detailing the salary they expect.

Shi said the lack of medical training can cause serious problems and even endanger patients' lives.

"One worker mistook beriberi medicine for eye drops and burned a patient's cornea. Another used boiling water for an enema," she said. "In order to make more money, they sometimes take care of a large number of patients simultaneously, which can result in cross-infection."

Since 2007, the government has been promoting a qualification certificate for nursing assistants. It includes one month of medical training, an examination and clinical practice. The course costs around 1,800 yuan, but the certificate is not obligatory. According to a report by the Chinese Association for Life Care, which is in charge of the training scheme, more than 300 people have earned the certificate so far.

"The number is far too small, compared with the hundreds of thousands of unlicensed nursing assistants," said Luo Jilan, the director of the association.

In 2007, the association wanted to recruit 3,000 trainees, but not a single person showed up to register. "The workers don't want to pay for the training because they can make money without the certificate. And the agencies and hospitals don't want to pay either, because the certificate is not mandatory," said Luo.

Tough work

For patients, high-quality nursing care is an alternative option, but the price has risen in line with improved standards. The United Family Healthcare in Beijing provides home healthcare for chronically ill patients and the elderly from qualified doctors and nurses. An initial assessment and six visits a year costs 10,888 yuan, but five home visits a week costs 178,888 yuan per annum.

For those unable to afford the cost, hugong are the only choice, according to Luo.

"Taking care of patients is tough work and sometimes a dirty job," said Luo, referring to cleaning patient waste and the dangers of becoming infected. "Most hugong are from the countryside and lack proper education and skills."

She also said few hugong have personal insurance or receive any welfare, such as insurance or holiday pay. Their working day may be as long as 24 hours, but the wages remain low. Unless they are fired for a misdemeanor, once they are employed, the hugong don't stop working until the patients are discharged from the hospital.

In fact, hugong are often regarded as de facto servants and so their social status is low. Lang told of how a patient poked him with a stick every night to wake him when his urine bag needed changing.

Now, however, Peking Union Medical College Hospital, one of Beijing's biggest hospitals, is trying to restore the role of qualified nursing assistants. Six work in the hospital's intensive care unit, including Cheng Jianhua, 43, from Sichuan province who has been working in the ICU for more than a year.

She was originally a freelance hugong, but now she's a fulltime hospital employee, which provides her with medical training and welfare. "I make 2,100 yuan a month, about the same salary I got before," she said. "But it's more stable and I only work eight hours a day. Before, I often stayed up all night taking care of the patient, and the next day I still needed to do all the work by myself."

Huang Xiaobin, 52, is in charge of training nursing assistants at the hospital. She admitted that even though the hospital provides welfare, few people are willing to take the job. "Some people quit after a few days, saying there's too much work and that it's too intense or too dirty, or the wages are too low," she said. "We are trying to teach them to become qualified healthcare workers, but we also need to keep them."

Given China's aging population, the demand for nursing assistants is growing in many regions across the country, according to Huang Renjian, director of the Chinese Nurse Association.

Having helped write a textbook for nursing assistants, Huang is adamant that more people should take the course and gain the certificate. To facilitate that, she urged the government to subsidize training and wages to increase income and prestige.

"As their skills improve and their income grows, the stereotype of the nursing assistant will change and reflect what it once was; a stable, professional and decent job," she said.

Contact the writer at pengyining@chinadaily.com.cn

(China Daily 04/09/2013 page6)