Barriers to community healthcare delivery in urban China: a nurse perspective

ABSTRACT

Purpose

There is considerable research on China’s community healthcare, but little examining its delivery from a nurse perspective. This article, set in the context of Shenzhen, elicits community nurses’ views on barriers to healthcare delivery, providing an initial evidence framework to improve community nursing practice at organizational and policy levels.

Methods

We used qualitative methods. Data from semi-structured interviews with 42 community nurses in Shenzhen underwent inductive content analysis. Consolidated criteria for reporting qualitative research were consulted to structure our reporting.

Results

Our analysis suggests four elements discouraging community nurses in care delivery: lack of equipment, stressful work environments, staff incompetence, and patient distrust. Centralized means of procurement, management indifference to nurses’ well-being, unsystematic training and reluctance to enter the community healthcare sector, and public prejudices against nursing contributed to these constraints, preventing community nurses from performing patient-centred care, devoting energy to caring, freeing themselves from heavy workloads, and building trust-based care relationships.

Conclusions

Delivery barriers devalued community health services systematically and undermined nurses’ professional advancement and psychological well-being. Targeted management and policy inputs are necessary to reduce caring barriers and enhance the ability of community nursing to safeguard population health.

1. Introduction

Primary care is fundamental to universal health coverage (Fisher et al., 2022). Community healthcare plays a vital role in pursuing the goal of health for all by providing access to a wide array of needs for primary care (World Health Organization, 2018). The World Health Organization (2018) describes community healthcare as an essential branch of health systems, providing basic health services in small local health facilities at individual, family, and community levels.

The overarching market-oriented reforms, launched in the late 1970s, transformed Chinese society. The most dramatic change—the rapid growth in the urban population due to massive internal migration—is still being accommodated (B. Li & Chen, 2022b). This demographic transformation, combined with the challenges to public health arising from societal ageing, chronic disorders, infectious diseases, and multimorbidity, has led China to rely upon its primary care system to safeguard and promote the health of urban dwellers (Figure 1). Chinese authorities began developing a comprehensive community healthcare system in urban areas in the late 1990s to facilitate healthcare provision and distribute health resources efficiently (Bhattacharyya et al., 2011).

Figure 1.

China’s urban primary care system.

Note: Compiled by authors from the literature (B. Li & Chen, 2022a). China runs a three-tier healthcare system, with hospitals occupying the top tier (i.e., Tier 3).

The landmark health reform of 2009 propelled the growth of China’s urban community healthcare. At the outset of this reform, there were approximately 250,000 practitioners and 130,000 beds in about 27,000 community healthcare organizations; recent counts were 520,000, 230,000, and 35,000, respectively (National Health Commission, 2020). With such substantial growth, community healthcare was expected to make a significant difference. The announcement of the “Healthy China 2030” blueprint and the “Healthy China Action” policy will only increase expectations on community health services. Still, notwithstanding these achievements and prospects, China has not yet established an effective delivery system for community healthcare comparable to its Western counterparts, such as Germany, the United Kingdom, the United States, and the Netherlands (Yao et al., 2020), necessitating further radical reforms.

A sizable body of literature on community healthcare delivery in urban China has identified various factors to account for its limitations (B. Li & Chen, 2022a). For example, the fragmentation of social health insurance schemes decreases the likelihood that people will avail themselves of community healthcare for initial treatment and prevents many urban residents from obtaining equal and timely access to community health service facilities (Chung et al., 2016; H. Li et al., 2019; Zhong et al., 2018). With little awareness about its practice, residents are suspicious of service quality, further reinforcing their avoidance of community healthcare (Du et al., 2015). Relationships between service providers and users are intermittent, compromising the ability of community healthcare organizations to provide continuing care (T. Zhang et al., 2020; Yue et al., 2020). The handling of patient information remains substandard, jeopardizing treatment feedback and follow-up examinations (H. Li et al., 2016; Liu et al., 2021). The lack of competent healthcare practitioners and equipment leads to heavy workloads, discouraging innovative treatments and modern medicine (Xia et al., 2020).

Existing studies provide insights into the delivery of community healthcare in urban China. However, few address the issue from the perspective of community nurses. At the vanguard of caring practice, community nurses are a key segment of the community healthcare workforce, with the potential to make significant contributions to meet the healthcare needs of various population groups (World Health Organization, 2017). By 2020, more than 200,000 nurses worked in community health services in China, representing nearly 40% of the country’s community healthcare practitioners (National Health Commission, 2020). Therefore, their opinions on healthcare delivery are among the most pertinent to canvass.

Analysing community nurses’ perspectives can also reveal structural problems inherent in community nursing practice. As an essential component of community healthcare, community nursing is critical for health promotion and patient outcomes (World Health Organization, 2017). In China, community nursing is a blended practice of primary care and public health. Community nurses play a key role in both serving individual patients and protecting the overall health of residential communities. This dual role places nursing in a significant position in China’s community healthcare system, influencing the effectiveness of community healthcare organizations and potentially shaping the entire community healthcare landscape. As we discuss later, insights from front-line nursing staff not only allowed us to capture delivery issues in community health services but also suggested critical changes to strengthen community nursing, thus adding to our study’s practical contributions.

This article, set in the context of Shenzhen, elicits community nurses’ views on barriers to healthcare delivery. As one of China’s Special Economic Zones, Shenzhen is the forerunner in the country’s rapid economic growth. In 2021, Shenzhen’s GDP surpassed RMB three trillion (about US$ 430 million), making it one of the richest Chinese cities (Upton & Huld, 2022). However, Shenzhen’s economic prosperity is not yet fully reflected in its healthcare system (He, 2014). Therefore, it is safe to argue that, for Shenzhen per se, improving community healthcare will be reliant on additional empirical evidence. Moreover, given the fact that Shenzhen is the hub of China’s primary care and public health experiments and reforms (Wu et al., 2016), our study will provide input for policies that can be applied in other Chinese cities to improve their community nursing and healthcare delivery.

Our analysis was driven by three research questions: (i) what barriers do community nurses often encounter during their work?; (ii) how do these barriers influence community nursing practice?; and (iii) what do community nurses consider to be the factors contributing to these barriers? By examining nurses’ opinions, this article opens up a new perspective for critiquing community healthcare delivery and provides an initial framework of evidence on community nursing in urban China, informing progress in community nursing practice at both organizational and policy levels.

2. Data and methods

2.1. Study design

We used qualitative methods (Green & Thorogood, 2018). Data were collected through in-depth semi-structured interviews with 42 community nurses in Shenzhen. Data coding and category abstractions were achieved using an inductive approach (Elo & Kyngäs, 2008). Consolidated criteria for reporting qualitative research (Tong et al., 2007) were used to direct our reporting (see supplementary material). This study was conducted according to the Declaration of Helsinki (World Medical Association, 2022) and received ethical approval from The Hong Kong Polytechnic University Institutional Review Board.

2.2. Study setting

In its evolution from a fishing village to a metropolis, Shenzhen, situated in south China and adjacent to Hong Kong, has flourished over the last four decades. In 1980, the city had a population of less than 500,000; by 2021, it reached to nearly 18 million (Shenzhen Statistics Bureau, 2022). Shenzhen’s GDP multiplied more than 10,000 times in the same period—from less than RMB 300 million to over RMB three trillion (Shenzhen Statistics Bureau, 2022). Along with its rapid urbanization and booming economy, Shenzhen has established an extensive community health service network: more than 10,000 practitioners work in over 700 community healthcare organizations across the city (Shenzhen Municipal Health Commission, 2021). Therefore, Shenzhen provides an ideal site for researching community healthcare delivery. As discussed previously, our study contributes to community healthcare development in Shenzhen and has implications for other cities wishing to emulate Shenzhen’s practice.

2.3. Sampling and participant recruitment

We used purposive sampling to recruit the study sample. We did not set excessive recruitment criteria, thus allowing for diverse opinions. Community nurses with at least one year of full-time work experience were deemed eligible to participate. Forty-two nurses from 24 community healthcare organizations were recruited in the final sample (Table I). Most participants were female (n = 35), aged between 22 and 30 (n = 32), and held a higher degree (n = 37). Community healthcare organizations where participants worked were distributed over seven administrative divisions of Shenzhen: Luohu, Longgang, Longhua, Futian, Nanshan, Bao’an, and Yantian, covering major metropolitan areas and accommodating nearly 90% of the city’s population (Shenzhen Statistics Bureau, 2022).

Table I.

Research participants.

Code	Age	Gender	Educational level	Code	Age	Gender	Educational level
IW1	29	Female	Bachelor’s degree	IW22	37	Female	SV diploma
IW2	25	Female	PSV diploma	IW23	22	Male	PSV diploma
IW3	34	Female	PSV diploma	IW24	26	Female	PSV diploma
IW4	25	Female	PSV diploma	IW25	22	Female	PSV diploma
IW5	25	Female	PSV diploma	IW26	34	Female	PSV diploma
IW6	23	Female	PSV diploma	IW27	23	Female	PSV diploma
IW7	22	Female	PSV diploma	IW28	23	Male	Bachelor’s degree
IW8	25	Female	Bachelor’s degree	IW29	32	Female	PSV diploma
IW9	24	Female	PSV diploma	IW30	23	Female	PSV diploma
IW10	41	Female	SV diploma	IW31	35	Female	PSV diploma
IW11	27	Female	Bachelor’s degree	IW32	26	Female	Bachelor’s degree
IW12	23	Female	PSV diploma	IW33	28	Female	PSV diploma
IW13	24	Female	Bachelor’s degree	IW34	23	Male	PSV diploma
IW14	29	Male	Bachelor’s degree	IW35	33	Female	PSV diploma
IW15	30	Female	Bachelor’s degree	IW36	29	Female	Bachelor’s degree
IW16	31	Female	SV diploma	IW37	24	Female	PSV diploma
IW17	22	Female	PSV diploma	IW38	23	Female	PSV diploma
IW18	30	Male	SV diploma	IW39	32	Female	PSV diploma
IW19	30	Female	Bachelor’s degree	IW40	28	Female	Master’s degree
IW20	23	Female	PSV diploma	IW41	28	Female	Bachelor’s degree
IW21	36	Male	SV diploma	IW42	26	Male	PSV diploma

Note: PSV—post-secondary vocational; SV—secondary vocational. Work locations, by district: Luohu (IW1-IW11), Longgang (IW12-IW16), Longhua (IW17-IW25), Futian (IW26-IW31), Nanshan (IW32-IW35), Bao’an (IW36-IW39), Yantian (IW40-IW42).

BL developed a rapport with community healthcare practitioners while volunteering to provide COVID-19 vaccinations, which helped reach out to community nurses. Participant recruitment was an iterative process, starting with nurses (IW1-IW11) in Luohu’s community healthcare organizations. We then extended our sample by recruiting new participants from other districts during provisional data analysis. From May to December 2021, BL conducted field trips to community healthcare organizations and obtained WeChat contact information of nurses willing to participate. We sent out 42 interview invitations via WeChat, all of which were accepted. We obtained electronic informed consent via WeChat prior to each interview. All participants remained anonymous throughout the research to ensure confidentiality.

2.4. Data collection and analysis

We conducted semi-structured interviews using WeChat phone calls (n = 29) or face-to-face meetings (n = 13) between June and December 2021. These interviews initially took place in Chinese and were later translated into English for this article. Existing literature on China’s community health services helped us draft interview guides, allowing us to identify critical issues in community healthcare, such as equipment and staffing (B. Li & Chen, 2022a). These guides enabled us to start topic-focused conversations with respondents more easily and ensure that we did not miss common issues along the way. Note that our specific interview questions did not come directly from the literature-based guides but were developed from discussions with participants. Specifically, we maintained high flexibility in open-ended interviews, giving participants free rein to express their views. In return, their ideas helped us formulate and modify questions as the interviews progressed. Discussions were held regularly among research team members to promote reflexivity (Barry et al., 1999).

The time and mode of the interview were chosen by the participant. All face-to-face interviews were conducted on workdays in an otherwise unoccupied observation room in participants’ workplaces to minimize distractions. A modest cash incentive (RMB 100) was offered to each participant to facilitate discussion. Each interview lasted about an hour and was tape-recorded. No repeat interviews were conducted. Essential field notes were taken during interviews.

Audio recordings and field notes were transcribed verbatim. Interview transcripts were then analysed through inductive content analysis (Figure 2), allowing insights to emerge and flow from textual data. This analytical method is particularly useful in cases where no existing studies deal with the phenomenon (Elo & Kyngäs, 2008; Lindgren et al., 2020).

Figure 2.

Inductive content analysis.

Note: Compiled by authors from the literature (Elo & Kyngäs, 2008).

Following the open coding paradigm (Gibbs, 2018), we performed line-by-line coding and created coding sheets to develop categories. Figure 3 illustrates our inductive analysis using “trust” as an example. We then reviewed the coded terms and categories to ensure consistency with the textual data. We conducted member checking (Morse, 2015) with three randomly selected participants (IW3, IW9, and IW31). We provided them with their coding results to assess our interpretation of their statements to ensure the accuracy and trustworthiness of our coding. We determined that data saturation was achieved when further analysis revealed no new thematic categories (Hennink & Kaiser, 2022). ATLAS.ti software was used to facilitate our analysis.

Figure 3.

Analytic flow.

Note: IW15, IW24, IW28, and IW33 contributed to the quotes in Figure 3.

3. Findings

Our inductive content analysis generated four salient barriers to community healthcare delivery: lack of equipment, stressful work environments, staff incompetence, and patient distrust. Their adverse effects on community nursing practice were far-reaching. Perceived factors contributing to the existence of these barriers were also identified. We grouped service-delivery barriers and participants’ perceptions of their respective impacts and contributors into four categories (Figure 4).

Figure 4.

Thematic categorizations of barriers to community healthcare delivery.

3.1. Lack of equipment

Alongside the expansion of community health services, Chinese residents’ demand for primary care has burgeoned and become increasingly diverse, leading to an attendant demand for medical equipment. Some types of equipment, however, remained scarce in community health settings, making it difficult for nurses to meet patients’ specific clinical needs. One participant observed:

Patients’ needs vary widely. For example, more and more patients come to us for rehabilitation due to skin ulcers and inflammatory conditions. Infrared lamps are required for this type of treatment. However, since we do not have such equipment, I cannot treat those patients (IW13).

Another also shared her thoughts on medical equipment, describing how a lack of equipment limited community nurses’ ability to provide patient-centred care:

The municipal health department requires community healthcare organizations to set up some advanced equipment, e.g. computed tomography scanners, to meet the increasingly diverse needs of patients. However, most organizations do not have such equipment. Therefore, we lack the necessary equipment support in serving patients. … Patients with related needs continue to be denied timely and appropriate care (IW8).

The lack of equipment also contributed to nurses’ inability to diagnose. Correct diagnosis is essential as it determines the effectiveness and quality of patient-centred care. Providing effective services for patients in their treatment and follow-ups was difficult without precise diagnostic tools. One nurse noted:

We encounter patients with various diagnostic needs, e.g. allergy tests, helicobacter pylori tests, chest x-rays, and gastroscopies. Sadly, we are unable to provide certain services due to a lack of equipment. We have to refer them to hospitals, which reduces their confidence in our services and impedes treatment continuity (IW5).

Nurses blamed the centralized procurement agency, which capped subsidies to community healthcare organizations, for equipment shortages. A nurse, who had been involved in the procurement process, revealed:

Community healthcare organizations are usually affiliated with hospitals and thus have no right to decide what equipment to buy [hospitals decide at their own discretion]. At the bottom of China’s healthcare system, community healthcare organizations are marginalized in this hospital-led procurement process (IW14).

Disparities in the nature of caring exacerbated the underprivileged position of community healthcare organizations in securing funding to purchase equipment. Specifically, hospital care is more specialized and sophisticated, requiring more funds to purchase advanced medical equipment. In contrast, community healthcare with general practice at its core remains less complex, reinforcing the perception that high-end equipment is superfluous for community health services. As one participant explained:

The distinction between hospital care and community healthcare creates a perception that the latter does not need the support of high-end equipment, leading those in charge of procurement to overlook our growing need [for advanced equipment] (IW36).

3.2. Stressful work environments

A comfortable work environment allows community nurses to devote their attention to patient care, laying a solid foundation for long-term efficient services. However, working conditions in many community healthcare organizations left much to be desired. As a nurse commented:

It [the community healthcare organization where the interviewee worked] is shabby and looks like a small clinic, making us look unprofessional. Even more demoralizing are the mosquito infestations in summer and the leaking roof in heavy rains. Such [poor] working conditions make me uncomfortable and fidgety, distracting me from focusing on caring.

(IW19)

Poor physical working conditions not only made it difficult for nurses to concentrate on caring, but also reduced their satisfaction with the overall work environment. This low satisfaction resulted in high nurse turnover, increasing the difficulty of retaining a high-quality nursing workforce in community health settings. As one noted:

It is hard to say that I am happy with the work environment. I do not think this kind of dissatisfaction is uncommon among colleagues. After all, many have left because of it (IW23).

In addition to poor physical working conditions, relationships among community healthcare practitioners were described as unhealthy and fragile, leading to a disharmonious working atmosphere. As a result, community nurses were very likely to experience increased workplace stress, psychologically impeding care delivery. A nurse explained:

Some colleagues do whatever it takes to benefit their own interests, even at the expense of others’, … meddling and gossip are frequent and intrusive. Clearly, I am not in an organization where I feel supported and healed [sigh]. In such a work environment, it is difficult for me to maintain a high level of productivity (IW27).

Participants noted that their managers paid scant attention to working conditions and employee relations issues. One nurse commented:

Our manager seldom holds a meeting to discuss environmental issues. In our weekly and ad-hoc meetings, he assigns tasks, and we report on ours, with little about the work environment (IW41).

Another made a similar observation:

Not sure if our manager knows that there is a problem with the relationship between colleagues. He looks so busy and rarely shows up at the workplace, so how can he know what the problem is? Since he never brought it up publicly, I, as a subordinate, do not want to be nosy (IW9).

Management indifference to work environments adversely affected nurses’ psychological well-being, making them feel stressed and overwhelmed. Nurses were often frustrated in practice as they failed to receive proper attention and support from superiors. As a result, many chose not to devote their energies to caring but instead viewed their work as a job requiring minimal effort. One participant noted:

Why am I fully committed to caring if the manager does not care about front-line caregivers like me? … What I see is that nurses’ caring enthusiasm remains low (IW20).

3.3. Staff incompetence

Healthcare delivery relies upon community nurses, whose knowledge, skills, and experience are critical to providing effective services throughout the course of care. However, a shortage of competent nursing staff hampered the care provided by community healthcare organizations. One nurse shared a common concern:

The shortage of [qualified] nurses is prominent. Many young nurses have no caring experience. … No new hires of experienced nurses have been made in years (IW22).

The lack of competent nurses led to excessive workloads for existing staff. As the government has delegated more tasks to community health service agencies (Wu et al., 2016), community nurses’ workloads have become even heavier. The COVID-19 pandemic further strained and exhausted community nurses on the front lines of caring practice. As one noted:

The situation has been exacerbated by COVID-19 and subsequent government responses, with nurses working overtime. … In addition to patient care, I also need to conduct nucleic acid testing and vaccinations, sometimes around the clock, making me physically and mentally exhausted (IW31).

Two factors emerged as leading causes of the shortage of competent nursing staff in community health settings. First, improving healthcare practitioners’ abilities is mainly achieved through continuing education. However, participants referred to the piecemeal and substandard nature of on-the-job training, compromising their professional development and acquisition of essential skills. One complained:

Training that helps improve my skills is rare. There are some courses, both online and offline, but most of them have nothing to do with my work. … I rarely have time to attend training on a regular basis because of the workload. Some training is scheduled after work, and I can attend. However, after a tiring day, it is difficult for me to concentrate on studying. … It [training] is unsystematic and inconsistent, with little effect on improving my caring ability (IW40).

Second, community healthcare’s poor reputation discouraged medical students from entering the field. Instead, most preferred to work in hospitals because of better welfare and pay, further contributing to the shortage of competent community nurses, as exemplified by one participant:

Working in a hospital is the top choice for medical students. Most of my classmates chose hospitals after graduation. As we all know, community healthcare organizations provide few career development opportunities, while hospitals provide good career prospects and better salary and welfare packages. These disparities between the two tiers of healthcare organizations appear to be the root cause of the failure to recruit and retain qualified nurses in community health settings (IW28).

Male nurses showed a greater disinclination to work in community healthcare. Apart from welfare differentials, the lack of specialization in community nursing made male nurses see themselves as worthless. They generally agreed that speciality and intensive care in hospitals was more likely to unlock their potential, thereby promoting professional growth and sustainability. This perception led to a shortage of male nurses in community healthcare organizations, forcing female nurses to sometimes—if not often—engage in heavy physical work. A nurse explained:

Hospitals need male nurses because some work can only be done by them. … While community healthcare is less intensive than hospital care, we still have cases requiring male support. Since my organization does not have male nurses, the [heavy physical] work must be done by us. Our workload would definitely be less if we had male colleagues (IW2).

3.4. Patient distrust

Trust is a key element of the relationship between service providers and users in healthcare settings (Calnan & Rowe, 2006). Trust-based care relationships can facilitate continuity of care; the level of trust helps determine service quality and value (Khullar, 2019). We found that patients’ generalized trust in community nurses and their care remained exceedingly low, resulting in superficial rather than caring relationships. A nurse expressed her concerns:

It is not uncommon for patients to be sceptical of the quality of my service. In most cases, I try to explain and give them a better sense of care. However, such effort is sometimes interpreted as making excuses for my “mistakes” and leads to arguments. Low levels of trust and ensuing arguments, in turn, adversely impact building rapport between patients and me (IW15).

Moreover, patient distrust had a detrimental effect on community nurses’ psychological well-being, leading them to question their self-worth and ability to care. One nurse confessed:

I feel disrespected when patients do not follow my care instructions. … The lack of self-worth I feel from the job prompts me to question my abilities and whether I should continue to work as a community nurse. This sense of worthlessness leads to unhappiness and self-doubt and compromises the care I provide (IW26).

Nurses with compromised self-worth tended to display negative attitudes in their interactions with patients. This, in turn, further hindered the development of trust-based care relationships. A nurse commented:

“Patient trust can drive me to be more actively involved in care. Without this [motivation], my passion for caring would dissipate. The lack of patient trust and consequent low enthusiasm for caring can lead to a lack of trust in my interactions with patients (IW15).”

We observed that male nurses were disadvantaged in earning patients’ trust. Most male participants seldom felt “being-relied-upon” while working with patients, as one shared:

“Patients trust female nurses more. They often perceive women as better caregivers. … It is harder for us [male nurses] to gain the trust of patients, … and build a trust-based care relationship, … which is very disappointing (IW34).”

Community nurses believed that patient distrust stemmed from public prejudices against nursing. Specifically, the social stereotypes of valuing doctors over nurses pervade Chinese society (Yang & Hao, 2018), exposing community nurses’ vulnerability in seeking patients’ respect and trust. A nurse noted:

Nursing has always been considered inferior in the medical field. … The public perceives nurses to be less trustworthy than doctors (IW33).

Another explained:

When care goes wrong, patients tend to blame nurses and think we are not following doctors’ instructions. However, this is wrong. We care according to doctors’ judgement and advice. Sadly, this is not a perspective patients take. … The long-held belief that nurses are secondary and nursing is less important leads patients to distrust us (IW11).

4. Discussion

4.1. Key findings

This article examines community healthcare delivery in a Chinese urban context using insights from community nurses. Through inductive content analysis, we identified four barriers to care delivery: lack of equipment, stressful work environments, staff incompetence, and patient distrust. We also shed new light on how these barriers impaired community nursing practice by soliciting nurses’ views. Nurses’ perceptions of the contributors to these barriers reflected structural issues embedded within the community healthcare system, suggesting a need for change at organizational and policy levels.

Lack of equipment. Consistent with the literature (McCollum et al., 2014; Pan et al., 2006), our study showed that equipment shortages significantly undermined the delivery of patient-centred care. With the promotion of the “gatekeeper” policy in China, community healthcare organizations serving as designated gatekeepers encounter an increasing number of patients who need both initial treatment and follow-up services. As their purview increases, community nurses deal with a wider variety of patient concerns extending beyond primary care. Despite referrals, many patients still struggle to reach hospital in a timely manner (Sun et al., 2019). At the same time, community healthcare organizations fail to provide certain services due to a lack of medical equipment. This appears to present a dilemma for patients, who feel deprived of both timely access to hospital care (S. Hu et al., 2008; Tang et al., 2013) and effective care in community health settings. Existing studies have identified insufficient funding as the main reason for the lack of equipment (Wang et al., 2013). We furthered this understanding by arguing that the centralized means of procurement is the principal cause of underfunding and consequent equipment shortages in community health settings. Specifically, the hospital-led administrative regime gives hospital sectors an advantage in terms of equipment setting, which ineluctably made community healthcare organizations underprivileged in the equipment procurement and renewal process. The social stereotypes that sophisticated equipment is reserved exclusively for hospital care further prevented community healthcare organizations from upgrading equipment, imposing technological obstacles to enhancing patient-centred care within community nursing.

Stressful work environments. The study findings indicate that the work environment faced by community nurses leaves much to be desired, reflected in both poor physical surroundings and stressful work relationships. Unfavourable working conditions distracted nurses from caregiving, potentially promoting the turnover of community nursing professionals (Cao et al., 2016) and leading to a brain drain of nurses from community health settings. In addition, antagonisms among healthcare practitioners engendered a negative working atmosphere, further compromising caring quality and performance by adding stress to nurses’ day-to-day work. The efficiency of clinical service delivery is hardly improved when nurses’ psychological well-being is poorly served (Abdullah et al., 2021). Our study enriches the literature on work circumstances community nurses face in urban China (Guo et al., 2019; H. X. Hu et al., 2015) by identifying management indifference to the importance of work environments. Without proper attention and care from managers, community nurses were more prone to psychological impotence (e.g., low self-worth), which could hamper their commitment to caring. When nurses’ enthusiasm for care diminishes, how can nursing practice be improved?

Staff incompetence. As the literature shows (Yuan et al., 2012), our study suggests that the absence of qualified nurses was another structural element paralysing the delivery of community health services. Community nurses found it difficult to escape the workload because they lacked essential support of peer nurses with proven skills and extensive caring experience. When nurses cannot be relieved from heavy workloads, the quality and effectiveness of care deteriorate (Kirby & Hurst, 2014). We identified two factors inhibiting the appearance of adequately competent nurses in the community health context. First, cosmetic and unsystematic on-the-job training (Wong et al., 2017) impeded the development of community nurses’ caring expertise. Second, normative differences in job welfare between hospitals and community healthcare organizations disadvantaged the latter in attracting and retaining high-quality nursing staff. Moreover, the reluctance of fresh graduates to enter the field perpetuates a vacuum of community nursing talent.

Patient distrust. Our study revealed that patients’ trust in community nurses and their services remained low, and the care relationship was superficial. This low level of trust adversely affected community nurses’ psychological well-being, making them prone to questioning their ability to care, thereby undermining their confidence in nursing expertise. Community nurses often lacked a sense of self-worth when serving patients and thus would not devote their energies to caring. This, in turn, fuelled patients’ distrust of community nurses and their care, generating a vicious circle of distrust within community healthcare. Trust is essential to care relationships, and a trust-based care relationship helps improve the effectiveness of community health services (T. Zhang et al., 2020; Yue et al., 2020). A lack of trust-based care relationships created a bottleneck in community health services delivery. Our study suggests that patients’ distrust arose from public prejudices against nursing in Chinese society: doctors are the centrepiece of healthcare, while nurses are secondary and their care dismissed (Yang & Hao, 2018).

4.2. Gender-based reflections

Our analysis revealed two striking differences in the perceptions of male and female nurses, covering new grounds for future research attempting to explore gender-related issues in community nursing.

First, male nurses were generally less willing to engage in community nursing practice than female nurses, who comprise most of the nursing workforce. As explained previously, the underlying reason for this low willingness is the difference in caring nature between hospital and community healthcare settings. Male nurses see hospitals offering speciality, intensive, and emergency nursing activities (Phillips & Norman, 2020) as the “land of dreams” that enables them to pursue career success. In contrast, community nursing remains superficial and less advanced as it focuses on general practice and primary care (Yue et al., 2020), making male nurses feel that their uniquely masculine power and abilities are “wasted”.

Second, it was more arduous for male nurses to win patients’ trust as the public perceived them as “uncaring”, an aspect of the gendered nature of the nursing profession. As Evans (2004) argued, the history of nursing is an exclusive history of women’s accomplishments in which male nurses are often seen as anomalies. Male nurses are extremely marginalized and discriminated against in nursing practice, extending to social stereotypes that men should be barred from nursing work (Sasa, 2019). Compared with developed countries, men are far more under-represented in the nursing profession in China and often endure work-related difficulties (H. Zhang & Tu, 2020). Our study showed that higher patient distrust was one such difficulty male community nurses encountered, adversely affecting their ability to provide good patient care.

4.3. Implications for community nursing development

As mentioned previously, our study has practical implications for the development of community nursing in urban China. We discuss these implications from an organizational and policy perspective. First, there is a need to galvanize organizational managers to ensure they pay adequate attention to the work environment faced by community nurses, including physical working conditions and interpersonal relationships. In light of their authority and legitimacy, organizational managers are best placed to improve work environments (James & Bennett, 2022), thus motivating community nurses to devote their energies to caring. Second, radical policy reform is needed. New policy inputs will guide the restructuring of the equipment procurement system and bring about purchasing decentralization, thereby improving the status of community healthcare organizations in equipment acquisition. Policy reforms can also help address the shortage of skilled nurses in community health settings through innovative training practices. Moreover, targeted policy interventions will help overcome public prejudices against nursing by elevating the role of nurses in safeguarding population health. The existing family doctor system would be the cornerstone in this regard, subject to increased concrete policy inputs.

4.4. Limitations

To the best of our knowledge, this is the first qualitative study to examine the delivery of community healthcare in urban China from a nurse perspective. The method of inductive content analysis, while less controlled, allowed us to organize, interpret, and understand verbal material thoroughly. Following the consolidated criteria for reporting qualitative research and member-checking strategies, we ensured the credibility of our findings. By analysing nurses’ perspectives, our study provides an initial framework of evidence for improving community nursing at both organizational and policy levels. However, three caveats should be noted. First, most of our sample was female and young, which could generate a bias. Second, given the diversity of Chinese cities, our findings, based upon a single research site, may not be fully representative. Third, although our qualitative analysis illuminated participants’ experiences in greater depth, it may suffer from the non-generalizability of the findings. Future studies should draw on diverse samples, extended cases, and alternative methods to address these concerns.

5. Conclusions

Since 2009, community healthcare has been championed by the Chinese government as a high priority to promote and safeguard the health of urban dwellers. Considerable resources have been devoted to developing community healthcare, and commendable progress has ensued (B. Li & Chen, 2022a). Nevertheless, a highly functioning delivery system for community health services in urban China has yet to be established, compromising the quality and value of community healthcare and preventing timely access to basic health services.

Taking Shenzhen as a representative city, we canvassed the opinions of nurses on barriers to community healthcare delivery in urban China. Our inductive content analysis identified four significant barriers: lack of equipment, stressful work environments, staff incompetence, and public distrust, jeopardizing community nursing practice. Our study also revealed a host of perceived factors contributing to the caring barriers. Given the complicated and far-reaching nature of these barriers, piecemeal reforms are no longer adequate. We argue that targeted management and policy inputs are necessary to build a competent delivery system and realize the potential of community nurses in advancing public health.

Biographies

Bo Li is a PhD student in the Department of Applied Social Sciences at The Hong Kong Polytechnic University. His research centres around medical sociology, nursing management, and health systems and policy.

Juan Chen is a professor in the Department of Applied Social Sciences at The Hong Kong Polytechnic University. Her research focuses on migration and urbanisation, health and mental health, help-seeking and service use, social policy, and social service systems.

Funding Statement

This work was supported by The Hong Kong Polytechnic University Mental Health Research Centre (Project ID: P0040455) and Department of Applied Social Sciences (funding for research students).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics

The research reported was ethically approved, on 21 April 2021, by The Hong Kong Polytechnic University Institutional Review Board (reference HSEARS20210417003).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/17482631.2023.2220524.