Exploring the experiences of unaccompanied care services in China from the perspective of multiple stakeholders: a qualitative study

In hospitals around the world, a quiet shift is taking place in how patients receive their daily care. For generations, the unspoken rule was that when a person fell ill and was admitted to a hospital, their family would stay by their side to feed them, help them to the bathroom, and keep them company. This tradition is deeply rooted in many cultures, where caring for a sick relative is seen as a fundamental duty of love. However, as families become smaller and work demands grow, many people find themselves unable to provide this constant bedside presence. In response, many countries have developed a system where trained helpers, known as healthcare assistants, step in to perform these essential daily tasks. These workers allow professional nurses to focus on complex medical treatments while ensuring the patient's basic needs are met. Yet, introducing a stranger into the intimate space of a sick person's recovery is not simple. It requires a delicate balance of trust, skill, and cultural understanding. In China, where rapid changes in family structure and an aging population are reshaping society, this transition is happening quickly, but it is not without friction.

A team of researchers in Xi'an decided to look closely at this transition, not just from the point of view of the hospital or the workers, but from the eyes of everyone involved. They spoke with patients who were receiving this care, the family members who had hired it, the nurses who supervised the work, and the managers who ran the agencies providing the staff. They wanted to understand what it actually felt like to rely on a stranger for daily care, and whether the system was working as intended. The researchers conducted in-depth conversations with twenty-five people in a large hospital, asking them about their hopes, their frustrations, and their daily experiences. What they found was a story of a service that is desperately needed but still struggling to find its footing.

The study revealed that for many families, this new model of care is a lifeline. Patients and their relatives described how the service solved a practical crisis. Many patients were elderly, and their children were busy with their own jobs and families, or lived far away. Without these professional helpers, these patients would have had no one to bring them water, help them walk, or take them to medical tests. The helpers provided a sense of security, especially during the night when the hospital nurses were busy with other duties. One patient noted that having someone available to push a wheelchair for a scan or carry them to a bathroom made a difficult time much more manageable. For the families, it meant they could go to work or care for other children without the crushing guilt of abandoning a sick parent. The service was clearly filling a gap that traditional family care could no longer fill.

However, the path to accepting this help was not smooth. The researchers found that deep-seated cultural beliefs acted as a significant barrier. In Chinese culture, the idea of filial piety is powerful; it is often seen as a child's duty to personally care for their aging parents. Many patients felt uncomfortable accepting help from a stranger, viewing it as a sign that their family had given up on them. This feeling was often compounded by the cost. Unlike medical treatments that are covered by insurance, the fee for these daily care helpers must be paid entirely out of pocket. For many families, especially those with lower incomes, this extra expense was a heavy burden, leading some to refuse the service even when they needed it. The researchers observed that while younger patients or those who had used such services before were more open to the idea, older adults from rural backgrounds often resisted, preferring to wait for family members even when it was impractical.

Beyond the cultural and financial hurdles, the study uncovered a more troubling issue regarding the quality of the care itself. There was a wide gap between what everyone expected from a healthcare assistant and what was actually happening. Patients, families, and hospital managers all agreed on what a good helper should be like. They wanted someone who was kind, patient, and attentive, someone who could not only perform tasks but also offer a listening ear and a comforting word. They imagined a worker who would notice if a patient seemed in pain or if their condition was changing. But in reality, the researchers heard a different story. The nurses and managers described the helpers as often working mechanically, simply completing a checklist of tasks without much initiative. They reported that the helpers often lacked the communication skills to connect with patients and did not have the training to spot early signs of medical trouble. This created a sense of distance; patients felt lonely and awkward, waiting for help rather than enjoying a supportive relationship.

This disconnect between expectation and reality had a direct impact on trust. The study showed that trust was not given immediately; it had to be earned slowly over time. A family member might start out feeling only half-convinced, but after seeing a helper act with kindness and responsibility for a few days, their confidence would grow. However, because the helpers often lacked the necessary skills and emotional engagement, this process was slow and fragile. When a helper acted only as a task-completer rather than a caring companion, the patient felt isolated. The researchers noted that this lack of emotional connection was a major limitation of the current system. The helpers were there to do a job, but the patients needed a human connection, and the current workforce was not equipped to provide both.

The structure of the system itself also contributed to these problems. The hospitals did not employ the helpers directly; instead, they were hired by outside agencies. This created a confusing situation where the hospital was responsible for the quality of care but had no real power to hire, fire, or discipline the workers. The agencies controlled the staff but had little incentive to ensure high quality because they were not directly responsible for patient outcomes. This separation led to high turnover rates, with helpers leaving their jobs frequently. Because the staff changed so often, it was impossible for them to learn the specific needs of a hospital department or to build lasting relationships with the patients. The researchers found that the constant churn of staff prevented the development of a stable, skilled team.

Despite these challenges, the people involved in the study had a clear vision of how things could improve. They imagined a system where helpers were assigned to specific hospital departments for the long term, allowing them to become familiar with the environment and the patients. They wanted clear rules about who was responsible for what, so that nurses and helpers could work together smoothly. They also suggested that the number of helpers assigned to each patient should depend on how sick the patient was, ensuring that those with the most needs received the most attention. The consensus was that for this service to truly succeed, the helpers needed better training, not just in physical tasks but in communication and observation. They needed to be seen as professional members of the healthcare team, with a clear career path and fair pay, rather than as temporary workers.

The study concluded that while the unaccompanied care model is a necessary response to modern family life, it is currently held back by cultural resistance, financial barriers, and a workforce that is not yet fully ready for the role. The researchers emphasized that the gap between the ideal helper and the real helper is the most critical issue to address. Until the helpers are trained to be both skilled and compassionate, and until the system supports them with stable jobs and clear responsibilities, the full potential of this care model will remain out of reach. The findings suggest that simply hiring more people is not enough; the focus must shift to building a workforce that can truly bridge the gap between medical necessity and human connection.