University of Science and Technology of China, Division of Life Sciences and Medicine, Hefei 230027, China
Email: drzhang@ustc.edu.cn

Abstract

A section in the Health News 70th-anniversary special issue titled "Learning from Nurse Liang Jielian in 1954" recounts the history of Liang's creation and promotion of the painless injection method, describing it as "the most heartwarming scene in China's nursing field of that era." This article further contextualizes Liang's work through comparative analysis with seminal international literature on the topic—including Nicoll & Hesby's highly-cited review (130 citations) in Applied Nursing Research (2002)—and contemporary textbooks such as the 9th edition of The Royal Marsden Manual of Clinical Nursing Procedures (Dougherty & Lister, 2015). The results confirm that Liang's innovation predated international counterparts by two decades, and its principal techniques remain applicable today.

Liang Jielian had no formal schooling; her entire professional training consisted of a four-week course with the Chinese Red Cross Ambulance Corps during the Anti-Japanese War. Her innovation was not in an obscure technique, but in a foundational procedure used extensively by thousands of nurses worldwide—further underscoring the inherent innovative capacity of the Chinese people. China's contemporary registered and practical nurses have received excellent education and possess superior innovative talents and wisdom. By building their confidence, they can undoubtedly create more numerous and meaningful advanced concepts and methods, such as novel approaches to better address the needs of an aging society. Consequently, the widely held ideal of a painless and fulfilling life in old age may become attainable.

A new method for painless injection achieves genuine social significance only when translated into widespread, long-term application through learning, promotion, continuing education, and persistence. In these aspects, China has led other nations by at least thirty to forty years. This success is primarily attributed to the firsthand experience and support from leaders at all levels; the organization and mobilization by the Ministry of Health and the Chinese Nursing Association; broad dissemination by media outlets such as Health News and nursing journals; and most critically, the sustained efforts and educational leadership of generations of nursing experts including Mei Zuyi, Yin Lei, Li Xiaohan, and Shang Shaomei, coupled with the active learning and long-term commitment of countless nurses. In short, this case powerfully illustrates our nation's systemic advantage in implementing beneficial initiatives with greater speed and effectiveness.

Keywords: painless injection; Liang Jielian; innovation confidence; painless elderly life

In the early years of the People's Republic, vaccination was a central component of the Patriotic Health Campaign [1-2]. However, injection-induced pain posed a major barrier to widespread vaccination. The Chinese Medical Association's "Epidemic Prevention Knowledge" noted that fear of pain made some people reluctant to receive shots [3], and news reports documented forced vaccinations of those who hid to avoid the pain [4]. International research also shows that pain during vaccination is a common problem that can lead to lifelong vaccine hesitancy or reduced willingness to vaccinate [5]. Solving the problem of painful injections thus became an urgent priority. Nurse Liang Jielian participated in these vaccination campaigns and recognized that only by reducing or eliminating injection pain (hereinafter "painless injection") could public willingness to vaccinate be improved—motivating her to develop the painless injection method [6-8].

The Health News 70th-anniversary special issue's segment "Learning from Nurse Liang Jielian in 1954" and the column "Small Technology Brings Big Change" in Health News's 90th-anniversary series both document the history and significance of this innovation [1, 9]. As one account notes, "Nurses nationwide learning and improving injection methods was the most heartwarming scene in China's nursing field of that era" [1]. Liang's method was "recognized and highly praised by patients" [9] and hailed as an "excellent injection technique" [10].

[FIGURE:1] Left: Liang Jielian as a nurse at the Central No. 2 Hospital (1952) and Xuanwu Hospital (1958). Right: Health News 70th-anniversary special issue, "Learning from Nurse Liang Jielian in 1954."

Given that Liang developed this technique seventy years ago, does it remain applicable today, and what is its international standing? To address these questions, this article compares Chinese and international literature on painless injection techniques and textbooks, yielding encouraging results: China developed the painless injection method in the early 1950s—twenty years ahead of international counterparts—and the technique remains applicable today.

1. R&D Process and Outcomes of the Painless Injection Method

In 1952, while conducting vaccinations, Liang Jielian explored methods to reduce or eliminate injection pain, such as rapid needle insertion, achieving satisfactory results [6]. In 1953, hospital leaders including Jin Maoyue, a renowned physician, provided strong support [8], enabling systematic observation and research that yielded even better outcomes [7].

In January 1954, Health News published an interview titled "Learning Nurse Liang Jielian's Injection Method," which first reported novel techniques including muscle relaxation, rapid insertion, appropriate injection speed, and avoiding post-injection massage [6]. In 1956, Liang more comprehensively introduced the key points of her method in People's Daily, Nursing Journal (now Chinese Journal of Nursing), and Health News [7, 11-12]. She was invited to share her experience in 25 provinces, autonomous regions, and municipalities [1] (Figure 2 [FIGURE:2]). In 1957, People's Medical Publishing House published her book Painless Injection Method [8].

[FIGURE:2] Liang Jielian presenting at a Shanghai nursing conference (right) and with Wu Zheying (first Chinese president of the Chinese Nursing Association, renowned nursing education expert, and "Mother of Nurses") (left). (Photos provided by Liang's family)

2. China's Painless Injection Method: Twenty Years Ahead and Still Applicable

Nicoll and Hesby's 2002 review (cited 130 times) provides a brief history: "Nurse researchers focused attention on IM injections beginning in the 1970s... studies by Lang et al. (1976), Itty et al. (1977), Kruszewski et al. (1979), and Barnhill et al. (1996) examined procedures to minimize pain, an area of continuing interest" [13]. China's research on painless injection was published between 1954-1957—twenty years earlier than international efforts.

Note 1: This review has been cited over 130 times in SCI. The original English text reads: "...Nurse researchers focused attention on IM injections, beginning in the1970s,… (p.151) and procedures to minimize pain (Barnhill …1996; Itty… 1977; Kruszewski…1979; Lang…,1976). This is an area of study that continues to be of interest to nurse researchers. ([13] p.152)." A PDF screenshot of the original is provided in Appendix 1.1, marked in yellow.

Are Liang's methods from seventy years ago still applicable today? Dougherty and Lister's 2015 textbook The Royal Marsden Manual of Clinical Nursing Procedures presents techniques for reducing injection pain and guidelines for intramuscular injection [14]. The Nursing Times website's recommended technique for reducing injection pain is based on this textbook [15]. This article compares Liang's method with the textbook's approach, with results shown in Table 1 [TABLE:1].

Table 1. Comparison of Liang Jielian's Painless Injection Method (1956-1957) with International Textbooks (2015)

Liang Jielian (1956-1957) Dougherty & Lister Textbook (2015, 9th ed.) Select appropriate syringe and needle Correct length and gauge of needle Appropriate site: avoid major nerves/vessels Correct site Proper positioning: muscle relaxation Positioning of patient so that muscles are relaxed Avoid alcohol stimulation: wait until dry Clean the injection site with alcohol and allow to dry Before insertion: displace skin slightly¹; rapid insertion with practice method Z-track; Stretch skin slightly around the injection site; Insert and remove the needle smoothly and quickly Vertical insertion (IM): safe needle-holding method; control depth with extended middle finger Correct angle: 90° (for IM); Hold syringe steady once the needle is in the tissue to prevent tissue damage Determine appropriate injection speed based on medication properties; insert slowly but smoothly Insert medication slowly but smoothly Rapid withdrawal; no post-injection massage Withdraw the needle quickly. Apply gentle pressure to any bleeding point but do not massage the site

Note 2: Liang's method is derived from Painless Injection Method (book, 1957 [8]) and "My Experience with Injections" (Health News, 1956 [11]). International source: Dougherty & Lister textbook (2015 [14]): reducing pain (p.722), IM injection guidelines (pp.741-2), z-track (p.741). Screenshots from the original book (National Library copy) are provided in Appendix 2.

Note 3: Liang's skin displacement technique is essentially the same as the recently recommended Z-track method (Dougherty & Lister, 2015 [14] p.741) in operation and effect—both prevent medication leakage and bleeding after injection. Liang noted that displacing the skin eliminates the need to press the injection site with alcohol-soaked cotton, which could cause pain [7]. The only difference is explanatory: Liang believed the skin displaces more than underlying muscle, creating an essentially angled needle tract, while the international view holds that muscle doesn't displace, so the tract remains vertical in muscle while subcutaneous tissue creates the angled path—hence "Z-track."

The above comparison, along with numerous Chinese nursing textbooks from 1958 to present—such as Mei Zuyi & Zhang Yuehua's General Nursing (1958) [16], Yin Lei's Fundamentals of Nursing (2003) [17], and Li Xiaohan & Shang Shaomei's Basic Nursing (2017) [18]—all of which have introduced these techniques, clearly demonstrates that Liang's seventy-year-old method, covering pre-, intra-, and post-injection phases, remains applicable today [9].

That an ordinary nurse like Liang Jielian could achieve such results stems, in her own words, from "the Party's care and cultivation, and the help of comrades and encouragement from patients" [8]. The establishment of New China and support from leaders at all levels provided favorable working conditions and a research environment. More fundamentally, her patient-centered approach, freedom from traditional constraints, keen observation, and extensive practice enabled her to develop effective methods.

Liang worked as a child laborer and never attended formal school [19]. Her only professional training was a four-week wartime health personnel training course organized by Robert Lim of the Chinese Red Cross Ambulance Corps during the Anti-Japanese War [20]. She began observing and contemplating injection pain during her practice [8]. Her innovation was not in an obscure technique but in a foundational technology used extensively by thousands of nurses worldwide—further highlighting the inherent innovative talent of the Chinese people.

Note 4: Modern readers accustomed to internet literature searches may wonder why Nicoll et al.'s reviews (1995, 2002) did not mention Chinese work. The primary reason is the lack of academic exchange between China and the West before reform and opening. Chinese journals and newspapers introducing Liang's method, including Health News and Nursing Journal, were in Chinese without English titles or abstracts. There were no computers, databases, or internet. CNKI, China's most comprehensive database including journals, newspapers, and books, only launched domestically in 2003 and established eight overseas mirror sites in the US and Germany in 2010. Early papers existed only in print and were added to CNKI much later. Searching CNKI with the traditional Chinese characters "梁潔蓮" yields her 1956 paper, but with a clear note: "Online publication date on CNKI platform: 2006-08-09." CNKI's Health News collection begins in 2000, so the 1954 article introducing Liang's work is not included. Therefore, it was impossible for foreign experts like Nicoll to know about China's 1950s progress before 2010, making their omission of Chinese innovations in their 1995 and 2002 reviews understandable and excusable.

3. Building Confidence, Pursuing Original Innovation, and Realizing Dreams

As described above, in the early years of the PRC, Liang Jielian developed an internationally leading painless injection method to solve vaccination pain. Today, addressing population aging is a major and urgent societal need. China's current doctors, registered nurses, and practical nurses are well-trained with higher innovative potential [21]. By building their confidence [22], they can undoubtedly create more advanced concepts and methods, such as new geriatric care philosophies like "prevention first" and "treating before illness" [23-24], leveraging AI and other advanced technologies to alleviate or eliminate pain and suffering in the elderly. This would significantly improve quality of life and happiness for older adults while reducing burdens on younger family members and society. A painless and joyful old age—a universal ideal and dream, especially among the elderly—could thus become attainable.

4. China's Education and Widespread Application of Painless Injection Leads Internationally by 30-40 Years

A new painless injection method achieves genuine social significance only when translated into widespread, long-term application through learning, promotion, continuing education, and persistence. In these aspects, China leads other nations by at least thirty to forty years.

4.1 Learning, Education, and Promotion in the 1950s

The Health News 70th-anniversary special issue describes the historical promotion: "One day in 1954, after receiving an injection from Liang Jielian at the Central No. 2 Hospital without feeling pain, Liu Shaoqi requested the Ministry of Health promote this patient-friendly method... She was invited to share her experience in 25 provinces (autonomous regions, municipalities). In February 1956, Health News published a series of articles including Liang's 'My Experience with Injections' and an editorial 'Improving Injection Methods.' Nurses nationwide learning to improve injection methods was the most heartwarming scene in China's nursing field of that era" [1]. The editorial stated: "The Chinese Nursing Association and medical prevention departments are responsible for organizing nurses to learn, research further, and improve..." [10]. "Changsha, Lanzhou, Beijing and other branches of the Chinese Nursing Association convened local nurses skilled in injection techniques for exchange forums; Shanghai Municipal Health Bureau instructed its units to systematically learn and implement Liang Jielian's method... The Beijing branch specially invited Liang to present her experience and organized injection technique symposiums..." [25]. In October 1956, Liang attended the First National Conference of Activists in Workers' Science and Technology Popularization, where Chairman Mao and other central leaders received delegates [26, 27].

Note 5: Liu Shaoqi was one of the PRC's top leaders at the time.

Chinese Journal of Nursing published papers discussing painless injection as early as 1955 [25], the earliest internationally. In 1956, People's Daily and Chinese Journal of Nursing published Liang's articles "Injections Can Be Painless" [12] and "How I Studied Injection Methods" [7], with the journal reprinting the Health News editorial. In 1957, People's Medical Publishing House published her book Painless Injection Method [8], which was printed three times totaling 43,600 copies—remarkable when the national nursing workforce was only in the hundreds of thousands.

4.2 Sustained Education and Widespread Application

Long-term, broad application requires sustained education. Textbooks played a crucial role. Health News reported the technique's key points in 1954; Liang's monograph Painless Injection Method was published in 1957; and by 1958, the textbook General Nursing [16] detailed the technique—just four years after initial reporting. Internationally, two decades elapsed between research publication and textbook incorporation. Specifically, China's 1958 textbook General Nursing by Mei Zuyi and Zhang Yuehua (72,000 copies) stated in its preface: "This book... combines China's actual conditions and incorporates new theories and achievements in nursing work, such as painless injection, energy conservation principles, and displacement enemas... The Ministry of Health convened a review symposium to revise the textbook." The book introduced all key principles and operational points of painless injection [16]. Subsequent texts like Rural Doctor's Handbook (1971, 1986, printing in the millions) and PLA Doctor's Handbook (1980) also included the content [31-33]. In the 21st century, China's secondary and tertiary nursing planning textbooks have all included painless injection (e.g., Yin Lei's Fundamentals of Nursing (2003), Li Xiaohan & Shang Shaomei's Basic Nursing (2007, 2017) [17-18]).

In contrast, early 1990s international fundamentals textbooks (Berger & Williams, 1992; Craven & Hennle, 1992; Kozier et al., 1993; Kozier et al., 1991; Smith & Duell, 1992; Taylor et al., 1993) were found by Beyea & Nicoll's 1995 review to present "proper" procedures for intramuscular injection that were "often non-research based and usually contained erroneous and/or out-of-date recommendations" [31]. These errors may have constrained foreign experts from developing and applying advanced painless injection techniques earlier. As described above, China began learning, educating, and widely applying painless injection in the 1950s—at least 30-40 years ahead of other countries.

Note 6: This review has been cited over 60 times in SCI. The original English text reads: "However, after a critical review of nursing fundamentals texts it was found that the 'proper' procedure was often non-research based and usually contained erroneous and/or out-of-date recommendations regarding the technique (Berger & Williams, 1992; Craven & Hennle, 1992; Kozier, Erb, Blais, Johnson, & Temple, 1993; Kozier, Erb, & Olivieri, 1991; Smith & Duell, 1992; Taylor, Lillis, & Lemone, 1993). [31] P.23." A PDF screenshot is provided in Appendix 1.2, marked in yellow.

The textbooks cited in Dougherty & Lister's (2015) manual as the basis for painless injection techniques and guidelines include Downie et al.'s (2003) text [32] as possibly the earliest comprehensive international textbook on correct painless injection methods—more than 20 years after Nicoll & Hesby's (2002) review noted that international research on pain-minimizing injection began in the 1970s [13].

Notably, good methods don't guarantee widespread application. A 2011 article titled "Most Nurses Don't Follow Guidelines on IM Injections" [33] and a 2015 study noting that many pain-reducing vaccination methods are not routinely used [5] demonstrate this challenge. In China, besides the organized learning and promotion by Chinese Nursing Association branches [25], People's Daily, Health News, and Guangming Daily reported on learning and application across hospitals in cities large and small (Shanghai, Lüda, Jiamusi, Liuyang), as well as in military and factory hospitals, including by Bai nurses in border defense regions [34-39]. Recent research continues on painless injection techniques and devices [40]. Notably, the "Lingnan Chen's Acupuncture Method," recognized as national intangible cultural heritage [41], acknowledges inspiration from Liang Jielian's painless injection method for its own painless needle insertion technique [42].

In summary, China's sustained education and widespread application of painless injection is highly advanced, leading other nations by at least 30-40 years. This success is primarily attributed to leaders' firsthand experience, emphasis, and support; the Ministry of Health and Chinese Nursing Association's organization and promotion; media dissemination by Health News, nursing journals, People's Daily, and People's Medical Publishing House; and most critically, the sustained efforts and educational leadership of generations of nursing experts such as Mei Zuyi, Yin Lei, Li Xiaohan, and Shang Shaomei, coupled with the active learning and long-term commitment of countless nurses. This case powerfully illustrates our nation's systemic advantage in implementing beneficial initiatives with greater speed and effectiveness.

References

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Appendix 1.1 Nicoll, Hesby. Intramuscular injection: An integrative research review and guideline for evidence-based practice. Applied Nursing Research, 2002, 15(3):149–162. (130+ citations) PDF screenshot of p.152, marked in yellow.

Appendix 1.2 Beyea SC, Nicoll LH. Administration of Medications via the Intramuscular Route: An Integrative Review of the Literature and Research-Based Protocol for the Procedure. Applied Nursing Research, 1995, 8(1): 23-33. P.23 screenshot, marked in yellow.

Appendix 2. International source: Dougherty & Lister textbook (2015 [14]). Screenshots from the National Library copy: (1) Reducing pain Box 12.16 p.722; (2) Technique z-track p.741; (3) IM injection guidelines Procedure Guideline 12.21 pp.741-742.