In the near future, maybe as soon as September, elderly people in Germany will be treated by the first batch of foreign nurses sent from China, greeting them in German with a Chinese accent.

German labor authorities and the Chinese Ministry of Commerce signed an agreement at the end of last year to send about 150 Chinese nurses to work in German care homes, aiming to help plug a shortfall of medical personnel in the country.

"It is an exception to our usual recruitment as our partner in such a specific field this time, China, is not a European country," said Beate Raabe, press officer of the Federal Employment Agency, the largest service provider in the German labor market.

No nurses on call

A shortage of nurses is a global problem. Countries like the US, Britain and Austria have been recruiting nurses from lower middle-income countries like Vietnam and the Philippines for years to try and plug the gap.

Now they are turning to populous China to try and solve the problem. Su Juan, 28, is one of the 25 nurses currently learning German language and culture at the Shandong International Nurse Training Center.

"Unlike working conditions at home, I believe the experience of working abroad will really broaden my views and expand my knowledge," Su told the Global Times.

The problem is, China itself is lacking millions of nurses to take care of its own growing elderly population. Similar programs seeking to send Chinese nurses abroad have sparked concerns about how to relieve China's nurse shortage.

"I am not that worried," Wang Zhuwen, director of operations at the training center, told the Global Times. "80 percent of nurses sent abroad choose to come back to China eventually, and when they do, they have more opportunities."

Su is no stranger to working abroad. Back in 2008, two years after graduation from Shanxi Medical University, she signed up to be a nurse in Saudi Arabia.

"It wasn't easy for a fresh graduate to find a job. Even if you are lucky enough to get one, the work is very stressful, so why not go abroad?" she asked.

After a few months of language training, Su and some 12 other Chinese nurses were sent to work in Almana General Hospital. The nurses soon began noticing the differences.

"Those who had only ever worked in Chinese hospitals said it was like heaven to them," Su said. "The work was comparatively relaxing and it was more interesting to work with people from around the world."

China's doctor-to-nurse ratio was at 1 to 1.16 in 2010, below the World Bank's proposed standard of above 1 to 2 on average, according to Guo Yanhong, vice director of the ministry's medical administration division.

Poor conditions

Low pay is another reason forcing qualified nurses to leave China. In Saudi Arabia, Su earned about 4,500 yuan ($722) a month, far higher than her classmates who made a starting salary of about 2,000 yuan at home.

Now her next destination is Germany. After eight months of studying the language and culture, she will be working in a less stressful environment while earning 2,400 euros ($3,171) a month.

"We often hear stories about those who work abroad being able to feed their whole family at home," a former nurse at Beijing Hospital, surnamed Wang, told the Global Times. "More importantly, nurses get more respect in foreign countries than in China."

"Usually you need some connections to work in a good hospital," she said. "Why else would nurses from all over the country all be fighting for it?"

Germany reportedly will need 220,000 nurses in the next decade, especially medical personnel specializing in geriatric care, as this is an unpopular specialization among nursing staff. In recent years, the country has turned toward other European countries for help. Now it looks to China.

"China is home to many young people who want to seek their fortune abroad and are willing to invest a lot of time and effort," Monika Varnhagen, the head of the Germany Labor  Office's international placement agency, told Der Spiegel magazine.

It is estimated that about 60,000 trained nurses are not working in their chosen field in Shandong Province alone. Although the pilot project is limited to only 150 nurses for the moment, Wang Zhuwen said its future depends on results and the center might expand its cooperation programs in the future.

"Despite the nursing crisis, some hospitals are reluctant to hire new people. They think it is doctors bring in profit, not the nurses," Wang Zhuwen explained as some doctors charge patients for unnecessary treatments and drugs.

Like Su, many medical school graduates have a huge interest in working abroad. Those who stay and struggle at home often change their profession or drop down to work as pharmacists or even masseurs.

Global outreach

Since 2005, the Shandong agency has sent about 1,000 Chinese nurses to fill the rising number of hospital vacancies in Singapore, Japan, Saudi Arabia, Canada and Austria.

The most popular destination is the US. To help more Chinese nurses go global, the Commission on Graduates of Foreign Nursing Schools opened its first exam center in Beijing to take the registered nurse license exam in 2003.

China had around 2 million registered nurses in 2010, up 52 percent from 2005, according to the Ministry of Health. However, the situation remains worrying. Zhong Nanshan, a renowned Chinese respiratory disease expert, warned that China is suffering a medical brain drain.

But the agency sees it in a positive way. "It might have a negative influence on the industry in the short term, but in the long term it will bring the whole profession to a higher level," Wang Zhuwen said.

The biggest difficulty to working abroad is likely to be the language barriers. Like other foreign nurses, Su said she had language and communication problem when she first arrived in Saudi Arabia. She also learned new concepts, such as emotional support for patients that were hard to express in Chinese.

"Unlike in China, nurses are required to provide emotional support to the patient. That was a totally new thing to me," she said.

40-year-old Li Miaozhen, a Chinese nurse who worked in a hospital in Los Angeles, told the Global Times that nurses in the United States are like diplomats.

"We were like diplomats in the hospital as patients might file complaints against you if you communicated with them poorly," Li said.  

Cultural differences

However, many foreign nurses are not accustomed to the amount of independent judgment and time spent documenting medical care required by the American system, according to the studies of Professor Yu (Philip) Xu of University of Nevada, Las Vegas (UNLV), one of only a few researchers in the nation who study how this population adjusts as part of the American workforce.

Xu, a foreign-trained nurse himself, found out that language and communication barriers are to blame for many medical errors. According to his study, an estimated 100,000 people die every year as the result of medical errors in the US and it is impossible to determine how much internationally trained nurses contribute to these medical errors, the Las Vegas Sun reported.

Indeed, many Chinese nurses assigned to a foreign country are new graduates with little actual work experience even though specialized training is provided on arrival.

"If you make a mistake in China, they put all the blame on you; but in the foreign countries, they first go to your supervisor and ask if you are overloaded with work or if you have any family problems," Wang Lin said.

It was also reported that foreign nurses experience alienation, racism and oppression. Xu's research found that Chinese nurses in the US often found themselves "socially isolated and paralyzed by their communication inadequacies."

No panacea

Realizing that an increasing number of foreign nurses might not be able to solve the nursing shortage alone, the United States is spending millions of dollars to promote nursing education and capacity building.

Nor do foreign nurses seem to be welcomed by nursing labor unions. Importing foreign nurses is seen as posing a threat to the job security of hundreds of thousands of American trained nurses not currently working in their field.

"If unemployment is spiking, why do we need to bring in nurses from another country?" Ann Converso, president of United American Nurses, was quoted as saying by Business Week.

China is also working on a solution. The Ministry of Civil Affairs has reportedly allocated 30 million yuan to train more caregivers to take care of the country's aging population last year. It aims to train 6 million caregivers by the end of 2020.

Recruitment requirements have also been relaxed to attract more nursing. In Wang's hospital, restrictions involving hukou, China's household registration system, has been lifted to attract talents from outside Beijing.