Research progress of “shared nurses” under the family community hospital integrated management mode

Abstract In order to meet the diverse and multilevel health service needs of the people, following the implementation of the “multi-point practice” of registered physicians by the government in 2009, many pilot projects on the legality of “shared nurses” have been carried out, but there are many difficulties in the process. Through reviewing and researching the relevant literature inland and abroad, this study explores the application of family-community-hospital integrated medical and nursing management model in order to provide a reference for the development and management of “shared nurses” in China.


Introduction
With the widespread development of the shared economy model, "shared nurses" gradually enter people's vision because they can optimize the allocation of nursing resources, break down the barriers of the traditional nursing industry, and provide patients with high-quality and convenient medical experience. However, Article 2 of the Regulations on the Management of Nurses' Professional Registration, which was implemented in 2008, stipulates that nurses may only engage in nursing work within the registered place of practice after they have obtained a nurse's practicing certificate. The multi-point practice of nurses in shared nurses is a clear violation of this stipulation. In view of the problems encountered in the development of "shared nurse," the author systematically analyzed and summarized the literature on the nursing management mode of family-community-hospital integrated medical care and the "shared nurse," and so on in order to provide a reference for the development and management of "shared nurses" in our country.

Status quo and challenges of nursing work in China
The so-called "shared nurse" 1 means, with the permission of the policy of "multi-point practice of nurses," the gathering of professional nurses' resources, relying on the "Internet" of big data, cloud computing, and other technologies, through intelligent, scientific means, resources to the grassroots level, to enhance the service capacity and service level of primary-level medical and health institutions, to promote the reasonable flow of excellent nursing personnel, and to achieve a balanced allocation of high-quality medical resources, and to meet the increasing demand for medical services are few objectives of the current reform of the medical system. The emergence of "shared nurse" greatly satisfies the market demand but also accompanied by the emergence of problems.

Development and research status of "shared nurses" in future medical care
In order to support and promote the development of "Internet + medical care," the country is also constantly exploring. From May 2015, Guangdong Provincial Health and Family Planning Commission issued the Key Work Program for Continuous Improvement of Nursing Services in Guangdong Province for the first time to propose and encourage conditional areas in order to explore the multi-point practice of nurses. It continued to explore and reform the registration system of nurses' practice and gradually implemented the registration of nurses' practice in the region. In April 2017, the Beijing Development and Reform Commission, the Beijing Health and Family Planning Commission, and the Beijing Human Resources and Social Security Bureau jointly issued a message to supplement some price adjustments involved in the new policy of medical reform, clarified the cost of nurses' door-to-door service, and included the service cost into the basic medical and industrial injury insurance reimbursement categories. To a certain extent, it shows that the Beijing Municipal Government supports and encourages nurses to engage in multi-point practice in the form of door-to-door service and home care. From October 2018, the Shandong Province Nursing Society would change the registration of nurses practicing place by providing policy support for the development of "shared nurses." At the end of last year, the National Health Commission responded that the experience of "Internet + medical health" should be summed up to guide the standardized development, indicating that the state recognized and supported "shared nurses." 6 Recently, the National Health Committee formally promulgated the notice on the pilot project of "Internet + nursing service" and the pilot scheme so that the "shared nurses" would be officially recognized.
Because the policy of "multi-point practice" for nurses has not been implemented in China, only pilot projects have been carried out in some areas, and there are few and platform-based management, provide home-todoor care services for patients and their families, let them enjoy high-quality, efficient, and accurate care resources, and meet the needs of different groups.
According to statistics, by the end of 2017, the total number of registered nurses in China was more than 3.8 million, accounting for 42.3% of the professional and technical personnel in health care and family planning, occupying an important position in the field of medical and health care. However, with the increasing population of our country, by the end of 2015, the number of nurses per thousand population is only 2.36, which is far lower than the level of European and American countries. According to WHO, Norway has the largest number of nurses per capita in the world, with 17.27 nurses per 1,000 people, while the European Union has a basic standard of more than 8, compared with 9.8 in the United States and 11.49 in Japan. The allocation of nursing human resources is seriously insufficient, and there is still a big gap between supply and demand of nurses. 2 At the same time, at present, the relationship between nurses and patients is tense, the intensity of nursing work is high, nurses are not satisfied with the salary mechanism, resulting in instability of the nursing teams number, 3 and the rising turnover rate year by year, thus forming a vicious circle. It also results in a shortage of nursing human resources. Some scholars tried to solve the problem of nursing manpower shortage resources by setting up part-time nurses' posts, and the effect was remarkable. 4 However, with the development of aging population and the increasing demand for health, this method can only temporarily relieve the pressure of human resources in hospitals and cannot meet the health needs of the masses for a long time. How to improve the income of nurses, improve the enthusiasm of nurses, play a better professional role, improve the sense of professional identity of nurses, and reduce the loss of excellent nursing personnel have become urgent problems to be solved.
The research shows that the high-quality nursing resources in our country are concentrated in public hospitals and tertiary hospitals, and there is a characteristic of the uneven distribution of high-quality nursing resources. 5 With the continuous expansion of nursing staff and the continuous enrichment of nursing professional content, the scope of nursing service gradually extends from hospital to community and family to provide elderly nursing, chronic disease management, rehabilitation nursing, long-term care, hospice care, and other services for the masses in order to meet the people's diverse, multilevel health services needs. How to encourage and attract outstanding nursing personnel to sink, to promote the radiation of high-quality nursing studies based on this. Because "Sharing nurses" and "Internet + nursing services" are new terms, there are only very few results in the literature. But this did not affect the development of "shared nurses." At present, there are more than 10 Internet medical platforms with "shared nurses" as their main functions, such as Gold-medal Nurses, Medical Care in Home, and so on. 7 These platforms mainly provide more than 10 door-to-door nursing services, such as injection, infusion, blood collection, dressing change, catheterization, sputum suction, stoma care, thread removal, atomization therapy, blood sugar measurement, blood pressure, electrocardiogram, and maternal and infant care services, such as fetal-care needle and postpartum care. The service content involves basic nursing, maternal and infant care, specialized nursing, and testing services. Except physical and family services, it can also be provided for pension institutions. The emergence of "shared nurses" reflects the growing demand of human health care.
"Shared nurses" can not only provide convenient and high-quality medical and nursing services for the masses, alleviate the burden of patients with chronic diseases, solve the problem of travel inconvenience for the elderly and young, reduce the pressure of outpatient clinics, and reduce hospital waiting time but also provide a platform for nurses to transform professional skills into economic benefits and increase reasonable income. At the same time, we should give full play to the potential of nurses, rationally allocate high-quality nursing resources, increase the economic income of nurses, and improve their professional well-being. In the domestic literature research, there are many tendencies to summarize and report on "multi-point practice" by comparing "multi-point practice" of nurses with "multipoint practice" of physicians 8-10 or by investigating and analyzing "multi-point practice" hospitals by nurses 11,12 to promote national policy support for "multi-point practice" and accelerate the steady development of "shared nurses." Because the "multi-point practice" policy has not been implemented, there is no research on "shared nurses" intervention.

Advantages of "shared nurses" under the integrated familycommunity-hospital management model
Family-community-hospital integrated management mode 13 refers to the management mode of "guiding in the hospital, continuing in the community and implementing in the family" under the collaborative efforts of hospitals, communities, and families in order to relieve the symptoms of patients, improve the quality of patients' life, and reduce the burden of disease. At present, the phenomenon of high incidence and heavy burden of chronic diseases in China is becoming increasingly prominent. Lily Wang, Director of Chronic Diseases Department of the Disease Prevention and Control Bureau of the State Health and Family Planning Commission, pointed out in the theme report of the First International Forum on the Development of Chinese Medicine Health Services and the Prevention and Control of Chronic Diseases that the burden of chronic diseases in China accounts for 70% of the total burden of diseases, and the number of deaths exceeds 85% of the total deaths of diseases. However, China's integration management mode is still in the initial stage of development and needs coordination from various aspects to jointly establish and improve the information-sharing platform. Shared nurses under the integrated familycommunity-hospital management model can be used as a service form of "continuing care." The management model and service quality of tertiary hospitals can be extended to families and communities to provide basic nursing services for community patients, to meet patients' needs for follow-up care services and the vision of high-quality health guidance, and to provide patients with on-site medical care clothing. While giving the masses more choices of medical services, we should reduce the pressure of tertiary hospitals to seek medical treatment, solve the shortcomings of the limited practice of nurses, and increase the income of nurses' nursing skills.
With the launch of the national long-term care insurance policy pilot and the incorporation of pilot cities, the long-term care insurance policy will be fully liberalized by 2020. 14,15 After the policy has been implemented, the service cost of "shared nurses" will hopefully be included in the long-term care insurance, which will provide strong economic support for the gradual establishment and improvement of the long-term care security system and the development of "shared nurses" in line with China's characteristics.

Problems in the development of "shared nurses"
Everything has two sides. The birth of a new thing will inevitably be accompanied by problems and contradictions. The most important problem to be solved in the development of "shared nurses" lies in the system obstacles. Practicing nurses in the platform of "Shared nurses" belong to "multi-point practice" outside the registered practice place because they accept the platform dispatch form to provide door-to-door service for the public, which violates the provisions of the nurse byelaw. In 2015, Zhao 11 pointed out in the investigation of nurse byelaw that the current nurse byelaw in China have some problems, such as unclear scope of practice and definition of responsibilities of nurses. The management of registered nurses is still a single registration system, and the registration procedures are complicated, which limits the flow of talents to a certain extent. In future, the formulation of a multi-point practice policy will be based on the current laws and regulations of our country and redesign the scope of nurse practice, registration management, and so on. To promote the development of "shared nurses," it is necessary for the government to give the corresponding policy support to the licensed nurses, to ensure the legitimacy of the practice, and to improve the enthusiasm of the participation of the licensed nurses. Second, the heavy workload of nurses is also the main obstacle to the promotion of this method. 11 Some studies have pointed out that 16 the excessive workload of nurses leads to the unbalance between family and work, which is also an important factor that affects the job satisfaction of nurses, and thus causing the instability of the nurses. This also reflects the current situation of the shortage of nursing human resources in China. However, the survey of nurses shows that most nurses hold a positive attitude toward "shared nurses," and the results show that increasing economic income is the main motivation for nurses to participate in "shared nurses." "Shared nurses" can not only increase the reasonable income of nurses but also give full play to the potential of nurses and rationally allocate high-quality nursing resources.
Third, foreign studies have also pointed out that part-time nurses have lower team awareness than their full-time counterparts and prefer to operate independently, mostly lacking career development goals. At the same time, various forms of nurse practice will lead to a sharp increase in the instability of the nurses' team, increasing interpersonal tension, the turnover of nurses, and the turnover rate of nurses in the first practice unit. 17 Therefore, in future, we will determine the stability of the nursing team, the legitimate rights and interests of patients, and the quality of medical care and other issues.
In addition, nurses provide door-to-door services to patients, and the personal safety of both sides cannot be guaranteed. How to strengthen the identity recognition and qualification authentication system in the sharing platform, so as to ensure the personal safety of both sides and avoid the occurrence of potential safety hazards, is also the top priority of the work of "shared nurses." The nursing staff through the sharing platform to distribute bills, in the process of practicing medical risks, accident disputes responsibility definition, and other issues, also urgently need the government to promulgate relevant laws, regulations, and policies to clarify the tripartite responsibility.
Finally, the Internet medical platform with "shared nurses" as its main function has just started, and there are many contents to be optimized. For example, nurses in the platform are mostly part-time, sharing nurses cannot arrive on time due to work or personal reasons, causing trouble to patients; platforms are mostly prepaid, and refund channels are not perfect; platforms charge higher, and all of them are self-paid and are out of touch with the policy of benefiting the people such as medical insurance, and so on. The shared platform system needs to be optimized. In future research, we should refine the service plan and increase all kinds of emergency plans; at the same time, the government should supervise all kinds of platforms in real time to ensure the normal operation of medical order.

Conclusions
Under the huge demand for high-quality nursing services, especially specialist nursing, the platform of "shared nurses" promotes the reform and development of nursing services, innovates medical service mode, and meets the people's experience and needs for highquality medical and health services. At the same time, it increases the enthusiasm of nursing staff and improves the stability of nursing team in line with the future of the country to promote the sinking of high-quality medical and nursing resources and to build a reasonable pattern of medical reform direction. However, the development of "shared nurses" still needs to rely on the guidance documents issued by departments at all levels to promote the reform and development of the nursing service industry. According to the principles of "government-led, multi-input, market operation and industry management," we should innovate the nursing service mode, increase the supply of nursing service, vigorously promote the reform and development of nursing service industry, and strengthen the construction of the working staff; at the same time, we should expand social employment and promote the rapid development of nursing industry.

Ethical approval
Ethical issues are not involved in this article.

Conflicts of interest
All contributing authors declare no conflicts of interest.