Historical Roots of Hospital Nursing Centrism in China (1835–Present): A Path Dependence Analysis

ABSTRACT

Aim

To trace the historical evolution of hospital nursing centrism in China (1835–present) and examine how institutional path dependence has shaped the subordinate status of nursing within a doctor‐dominated healthcare system.

Background/Introduction

Despite major expansions in nursing education and policy advocacy, China's nursing profession remains structurally marginalized. Understanding the roots of this subordination requires a historical and institutional lens.

Methods

Drawing on path dependence theory, this study analyzes five critical phases in the development of nursing in China from 1835 to the present. A four‐dimensional analytical framework that encompasses professional, organizational, fiscal, and governance institutions was applied to archival records, policy documents, academic studies, and interview data.

Results or Findings

Findings reveal that nursing has been persistently embedded in a “doctor‐led, nurse‐subordinate” governance structure. Although educational and legislative reforms expanded nursing's professional scope, entrenched institutional arrangements across the four dimensions have locked nursing into a structurally dependent position.

Discussion

The historical institutionalization of nursing as an auxiliary role has limited its professional identity, participation in governance, and access to resources. The analysis highlights the limitations of reforms focused solely on education and policy without restructuring governance mechanisms.

Conclusion

The professional development of nursing in China has been constrained by enduring path‐dependent forces. To achieve true professionalization, reforms must address deep‐seated institutional logics.

Implications for Nursing and Nursing Policy

Professional empowerment requires the redesign of nursing roles, decision‐making power, and career pathways within hospital governance. Policy reforms should dismantle hierarchical governance structures and institutionalize nurses’ participation in leadership, ensuring equitable distribution of authority and resources.

1. Introduction

Nursing is a cornerstone of the modern healthcare system; its professionalism, autonomy, and degree of professionalization bear directly on the quality of medical services and improvements in population health (Aiken et al. 2017; Stewart et al. 2025). Yet in China, nursing has persistently lagged behind international peers: nurses remain marginalized within medical hierarchies, their roles lack clarity, and pathways for professional advancement are constrained (Ye et al. 2020; Zhang et al. 2021). These constraints not only impede the effective allocation of nursing human resources but also limit overall system efficiency (Du et al. 2025; Wang et al. 2024).

Existing studies have examined the hospital‐dominant structure of China's healthcare system, noting that resource allocation skewed toward hospitals constrains primary health care (Liu et al. 2019; Zhao et al. 2025a). Yet two fundamental questions remain underexplored: why nursing has remained in a subordinate position and why its path to professionalization has been obstructed. Existing research on medical resource allocation and institutional evolution concentrates largely on macro‐level policy, fiscal mechanisms, and physician–patient relations (Feng et al. 2023; Sun and Luo 2017), while paying scant attention to the interplay between the nursing profession's own developmental trajectory and its institutional environment.

A historical lens is therefore essential. Understanding how nursing became structurally subordinated within the hospital system helps to reveal why incremental policy remedies repeatedly encounter bottlenecks (He et al. 2024; You et al. 2015). In fact, Western hospitals and modern nursing institutions entered China as early as the mid‐nineteenth century (Tsang et al. 2013). This development coincided with the global spread of nursing reforms led by Florence Nightingale in the latter part of the 19th century, which profoundly shaped the trajectory of nursing professionalism in countries such as the United Kingdom, Canada, and Australia. However, China followed a markedly different path. Although missionary hospitals played a key role in transmitting Western medical and nursing models, China's semi‐colonial status and state‐centered development approach created a unique institutional logic. Within this framework, nursing became deeply embedded in physician‐dominated hospital structures and failed to gain professional autonomy. In this light, China's nursing evolution must be understood not only through internal institutional dynamics but also within a broader transnational context that is shaped by colonial encounters, missionary medicine, and globally circulating models of nursing professionalism.

Yet despite early exposure to global nursing reforms, nursing in China, unlike in countries such as the United States, Canada, the United Kingdom, Australia, and New Zealand, has not achieved professional independence across three key dimensions: professional, organizational, and governance. Specifically, professional independence refers to the autonomy of nurses in terms of education, training, clinical practice, and the development of their own knowledge systems, which is distinct from a physician‐dominated framework; organizational independence entails nurses holding clearly defined, independent roles, responsibilities, and promotion pathways within hospital structures; governance independence highlights nurses’ formal representation and active participation in institutional decision‐making processes (Buerhaus et al. 2017; Daly and Jackson 2020; Traynor 2013; Wang and Zhao 2009; Zou et al. 2012).

In contrast, nursing in China has become increasingly entrenched in a service‐oriented and subordinate role within hospital systems (Li et al. 2024c; Zhong et al. 2025). A structural pattern of “doctor‐led, nurse‐subordinate” dynamics has gradually emerged, shaping a hospital governance system in which nurses are systematically marginalized in terms of professional development, resource allocation, and participation in decision‐making. This study defines this phenomenon as hospital nursing centrism, which refers to the institutionalized embedding of the nursing profession into auxiliary and supportive roles that constrain its ability to achieve true professional autonomy. This governance structure did not emerge organically; rather, it is deeply rooted in a specific historical trajectory and institutional logic, thereby warranting in‐depth analysis through the lens of path dependence theory.

Path dependence refers to a historical process in which early institutional choices exert a long‐term influence on subsequent development. Two mechanisms primarily drive it. The first is the self‐reinforcing mechanism, whereby initial institutional arrangements are continuously strengthened through cumulative advantages, leading to increasing structural stability. The second is the reactive sequence mechanism, in which early events trigger a chain of causal processes that progressively constrain future choices, ultimately resulting in a condition known as path lock‐in (Arthur 1989; David 1994; Djelic and Quack 2007; Petermann et al. 2019; Powell 2024). The path dependence theory has been widely applied to explain variation in welfare institutions and healthcare systems (Gorsky 2012; Hacker 1998) and has been used to analyze institutional transformations in health systems in developing countries (Whyle and Olivier 2024) as well as the institutional evolution of Chinese hospitals (Xu et al. 2019). Although path dependence theory emerged within Western liberal–democratic contexts (Arthur 1989), its applicability under China's political system has been amply demonstrated (Chen and Bao 2014; Liu and Yu 2022; Mattlin and Nojonen 2015; Zhang et al. 2025a). Yet in the domain of nursing's professional development, path dependence theory has not been systematically employed.

Against this backdrop, this study applies the path dependence analysis framework to trace the institutional evolution of China's nursing profession from 1835 to the present and to reveal how critical historical junctures progressively locked in nursing's subordinate status. The year 1835 marked both the establishment of the first modern hospital on the Chinese mainland and the starting point for the importation of the modern nursing system (Xu et al. 2019; Zou et al. 2012), whereas 1949, the founding of the People's Republic of China, signaled the onset of the institutionalized phase of the medical system and nursing development (Cooke and Zhan 2013; Garfield 1978). It addresses two core questions: Why has the nursing profession in China long failed to achieve independence? What are the institutional mechanisms by which a hospital‐dominant structure shapes nursing's development? In doing so, the study makes three contributions: empirically, by uncovering the historical roots of nursing's subordination; theoretically, by extending path dependence analysis to the study of professional development in health care; and practically, by highlighting the need for systemic governance reforms, beyond educational expansion and policy declarations, to achieve substantive professional empowerment.

The remainder of this study is organized as follows. Section 2 outlines the theoretical framework and research methodology, including the application of path dependence theory and a four‐dimensional institutional lens. Section 3 traces the historical trajectory of nursing development in China across five key periods (1835–present), emphasizing critical junctures and mechanisms of institutional lock‐in. Section 4 explores the implications of the findings for theoretical discourse, governance reform, and cross‐national comparison, while also acknowledging the study's limitations. Finally, Section 5 concludes by summarizing the main contributions and offering practical recommendations for overcoming path‐dependent constraints.

2. Method

This study draws on the theoretical framework of path dependence developed within historical institutionalism (Kalinowski 2013), with particular attention to the cyclical analytical approach to institutional evolution (Atkinson 2014). Studies on path dependence commonly distinguish between two developmental phases. The first includes both “critical juncture” and “critical node”: the former refers to historical periods that potentially initiate institutional development trajectories, characterized by a high degree of institutional fluidity (David 2007; Pierson 2000); the latter represents periods of concentrated institutional transformation, where the convergence of different institutional forces may trigger a redirection of the established path (Kay 2005; Wilsford 1994). The second developmental phase can be described as “post‐critical node development,” a period marked by increasing institutional stability and policy evolution characterized by gradualism and continuity. During this stage, institutional choices become deeply constrained by existing structures, representing a phase dominated by “systemic logic” (Tuohy 1999). This study also adopts the refined critical juncture analytical approach proposed by Capoccia (2015) and, considering the particularities of the nursing system, constructs an analytical pathway for examining the evolution of the nursing profession.

In terms of institutional content, we adopt the World Health Organization's (WHO) classification of health system building blocks (World Health Organization 2007), supplemented by the healthcare governance framework proposed by Duran et al. (2018). Our analysis focuses on four institutional arrangements most closely associated with the hospital and nursing systems. First, professional institutions refer to policies concerning the allocation of nursing human resources and education and training, which determine the size, competencies, and professional boundaries of the nursing workforce. Second, organizational institutions pertain to the structural division of labor among medical institutions, with a particular focus on the institutional boundaries and degree of service integration between hospitals, nursing education institutions, and nursing service providers. Third, fiscal institutions include funding sources, payment mechanisms, and incentive structures within both the nursing and hospital systems. Fourth, governance institutions address the distribution of responsibilities, authority, and institutionalized relationships among the government, hospital administrators, and nursing personnel. This four‐dimensional framework helps reveal the structural constraints on the professional autonomy of nursing embedded in institutional trajectories.

Regarding data sources, this study utilizes a diverse array of primary and secondary historical materials, systematically organized and interpreted through a combination of historical institutional analysis and textual analysis.

The primary sources fall into four categories: First, original archival materials from modern missionary hospitals and nursing schools were primarily obtained through university library collections and medical history archive databases, such as the Harvard Medical School Digital Collection and the Peking Union Medical College History Museum. These materials include missionary annual reports, nurse training course schedules, early teaching resources, and hospital administrative records (such as Chen 1935; Clark 1994; Ding 1936; Lin 1938; Peking Union Medical College and Hospital 1918, 1942; Wong and Wu 1936). The archival materials included in this study were selected based on the following criteria: (1) direct relevance to nursing policies, institutional structures, or hospital governance; (2) representation of key historical milestones in Chinese nursing development (see Appendix 1 and Figure 1), such as the establishment of the first Western hospital in Guangzhou in 1835, the founding of the Peking Union Medical College School of Nursing in 1920, the integration of nursing into the national health system after the founding of the People's Republic of China (PRC) in 1949, the resumption and expansion of nursing education following the 1978 reform and opening‐up, and the rapid advancement of nursing education after China acceded to the World Trade Organization (WTO) in 2001; and (3) reliability and originality of the archival sources.

FIGURE 1.

Hospital nursing centralism in China: Historical timeline and institutional structure.

Second, policy documents and internal reports issued by various levels of government since the founding of the PRC were collected, mainly via platforms such as the China National Knowledge Infrastructure (CNKI) government document database and the official website of the National Health Commission. These documents include key policy texts from the National Health Commission, the Ministry of Human Resources and Social Security, the State Council, and local health authorities, addressing nursing workforce allocation, professional qualifications, post management, promotion pathways, and health system reform (such as National Health and Family Planning Commission of the PRC 2016; State Council of the PRC 2008).

Third, domestic and international academic literature on nursing education and professional development was reviewed, with a focus on topics such as professionalization, occupational status, and hospital governance. A systematic literature review was conducted using databases including Web of Science, CNKI, and PubMed, along with source‐tracing analysis based on citation networks in key texts (such as Jiang 2017; Li et al. 2024a, 2024b, 2025; Nathan 1981; Rocha 2013; Wang and Zhao 2008, 2009; Wang 1987; Watt 2004; Wong et al. 2012; Yan et al. 2014).

Fourth, interview data and oral recollections from nursing experts, educators, and policymakers were utilized, primarily sourced from existing oral history archives and memoirs, rather than collected through interviews conducted directly by the authors. These include the Peking Union Medical College Hospital Centennial Oral History Project, nursing school documentary collections, and interviews published in professional journals. These firsthand accounts offer valuable insights into nursing development and institutional change, enriching the micro‐level details of macro‐institutional analysis (such as Douglas 1994; Li 2001; Shi 2007; Wang 2022; Zhang 2018). This study systematically analyzed oral accounts from 23 published interviewees, including 9 retired nurses, 7 nursing educators, and 7 hospital administrators or policymakers. Participants were selected based on their representative involvement in institutional reforms, hospital governance, or nursing education during key historical periods.

Using NVivo software, the research team conducted thematic coding of the interview data and cross‐referenced the results with historical policy documents and archival materials to identify areas of convergence and divergence. Most interviews were closely aligned with policy records, particularly in highlighting limited nurse participation in governance and constrained opportunities for career advancement. However, several accounts revealed instances of informal institutional innovation, such as localized management reforms within hospitals. These divergences were interpreted as institutional fissures and were further examined through analysis of policy texts and organizational structures.

This framework, while developed in the Chinese context, is designed to be transferable to other national settings, offering a methodological pathway for examining the institutional evolution of nursing and informing reform strategies.

3. The Evolution of Hospital Nursing Development (1835–Present)

The historical evolution of the nursing profession in China spans nearly 190 years, with its key historical turning points illustrated in Figure 1 and Appendices 1 and 2. Overall, the development of the nursing profession has been closely intertwined with the institutional evolution of the medical system and has further reinforced the structural lock‐in of nursing's subordinate status within that framework. Nevertheless, key historical events have served as critical turning points in the trajectory of nursing's development and transformation (Hall et al. 2024). The founding of the Canton Ophthalmic Hospital in 1835 marked the initial institutional embedding of nursing within the hospital system and established the starting point of a “doctor‐led, nurse‐subordinate” structure. The establishment of Peking Union Medical College Nursing in 1920 marked the formal beginning of nursing education in China. After the founding of the PRC in 1949, the state incorporated nursing into the public health system as a supplementary function, thereby reinforcing its marginal status. Although the reform and opening‐up in 1978 led to the expansion of educational opportunities, the shift toward market‐oriented hospital governance, which emphasizes cost control, further constrained nursing's institutional influence. Following China's accession to the WTO in 2001, nursing education continued to advance, including the expansion of undergraduate programs, the institutionalization of master's degrees in the late 2000s (particularly in 2006), and the establishment of doctoral programs in 2011. However, despite these developments, nursing has not achieved a “vertical breakthrough” in institutional status due to the persistence of historical inertia, resulting in ongoing tension between “professional advancement” and “institutional weakness.” As such, the introduction of nursing services alongside Western hospitals in 1835 set a professional trajectory increasingly characterized by subordination, marginalization, and limited professionalization under the combined influence of institutional, cultural, and governance structures. According to path dependence theory, choices made during the early stages of institutional development can, through self‐reinforcing mechanisms, evolve into institutional inertia. Over time, this process may lead to path lock‐in, thereby imposing structural constraints on future development. Using a five‐stage historical framework, we analyzed how nursing has been institutionally embedded within China's hospital system and why it has persistently failed to achieve institutional autonomy across successive reforms.

3.1. Germination Period of Nursing: Subordination Within Missionary Hospitals (1835–1920)

In 1835, the establishment of the Ophthalmic Hospital in Canton marked the introduction of the modern Western hospital system to China and signaled the beginning of missionary medicine in the country (Grypma 2007). Subsequently, hospitals such as Shanghai Renji Hospital (1844), Tianjin Morrison Hospital (1861), and Qingdao German Red Cross Hospital (1898) were founded, forming the early prototype of a modern hospital network (Cho 2021; Lincoln 1905; Yan 2013).

Nursing services were introduced alongside hospital operations, but initially did not constitute an independent profession. Instead, nursing functioned as auxiliary labor under the direction of physicians. During this period, nursing staff in missionary hospitals were primarily nuns, female church members, or untrained assistants who were responsible for basic patient care and logistical support (Jiang 2017). During this period, nurses were imbued with a professional ethos of humility and submission. They were regarded as “doctor's assistants” and described as the “hand of God,” gently caring for patients at their bedsides and quietly performing nursing duties under the supervision of church‐affiliated physicians (Clark 1994; Ding 1936; Wong and Wu 1936). This characterization reflects the broader colonial‐missionary ideology, in which nurses who were often local women or religious converts were positioned as subordinate caregivers within a framework dominated by Western male medical authority. The hierarchical structure of nursing during this era echoed both religious and imperial power dynamics. From an institutional perspective, nursing was deeply embedded in religious‐charitable organizations. In terms of professional institutions, nursing lacked a formal training system, with roles informally assumed by nuns or laywomen, absent professional standards or systematic instruction (Chen 1996). Organizationally, nursing was entirely subordinate to the missionary hospitals, with no independent departments or hierarchical structures (Grypma 2007). Fiscally, hospitals were funded by churches, and nursing roles functioned largely as auxiliary labor (Li 2016). In terms of governance institutions, doctors held exclusive administrative authority, while nurses lacked autonomy and representation, being excluded from hospital decision‐making structures (Liu 1991). Most critically, the nursing role was institutionally designated as auxiliary to doctors, structurally marginalizing nursing within hospital hierarchies (He et al. 2020). As hospital systems expanded, this institutional configuration was reproduced and amplified, establishing the foundation for nursing's long‐standing weak status in China. This period thus constituted a critical node, which was an early critical juncture, at which the basic structure of a “doctor‐led, nurse‐subordinate” hospital system was established, forming the point of departure for path dependence.

3.2. The Germinal Phase of Nursing's Quasi‐Professionalization: Initial Formation of Nursing Education and Continued Institutional Weakness (1920–1949)

The establishment of the Peking Union Medical College of Nursing in 1920 marked the formal beginning of a structured nursing education system in China (Allison 1993; Grypma 2008). Funded by the China Medical Board, the college was the first to systematically implement a Western‐style nurse training program, introducing standardized curricula, professional norms, and public health principles. This initiative laid the foundation for the professionalization and institutionalization of nursing in China (Allison 1993; Fu et al. 2025). Institutionally, while nursing achieved initial developments in professional institutions through school‐based education, resources remained limited, lacking standardized certification and licensure (Yan et al. 2014). Organizationally, nursing remained embedded within the hospital and medical hierarchy, where authorities resided with doctors and nurses who served mainly as auxiliary labor (Watt 2004). Fiscally, nursing education relied on missionary funding and lacked formalized public financial support (Erickson 2012). From a governance perspective, nurses were excluded from hospital decision‐making, lacking professional organizations and representative institutions (Lu et al. 2018). Although Peking Union Medical College established formal nursing education, early nursing leaders such as Qiaozhi Lin remained constrained by entrenched institutional hierarchies (Jiang 2017; Sun et al. 2001). Nursing was widely perceived as emotional and compliant labor, and this gendered professional stereotype was systematically embedded in the training curricula (Allison 1993).

Despite signs of emerging professional identity, nursing continued to occupy a marginal institutional position. Nurses lacked decision‐making power in hospital governance, and socially, the profession was perceived as female‐oriented service work without professional recognition. Hospitals, as doctor‐centered institutions, systematically reproduced this hierarchical division of labor through patterns of resource allocation, power distribution, and professional representation (Wakefield 2017). This stage reflects the self‐reinforcement mechanism of path dependence: as doctors consolidated authority, nurses faced persistent barriers to upward mobility and professional voice, resulting in institutional inertia.

3.3. Period of Institutionalized Subordination of Nursing: Nursing Integration and Weakening Under the Planned Economy (1949–1978)

Following the founding of the PRC in 1949, the state established a unified health service system. Nurses were integrated into the barefoot doctor system as an auxiliary force, primarily responsible for logistical support and maternal‐child health care, while barefoot doctors, though often less formally trained, held broader authority in community health services (Jewell 1996; Youngsub and Hyoungsup 2018; Zhang 2008) (Note: The barefoot doctor system refers to a healthcare model implemented in China from the mid‐1960s to the early 1980s. It was founded on principles such as “prevention first,” the “integration of traditional Chinese and Western medicine,” and “mass‐run health services.” Under this system, rural collective economic organizations (e.g., production brigades) trained local farmers as primary healthcare workers who combined agricultural and medical responsibilities. These practitioners were tasked with delivering basic medical care, disease prevention, and health education in rural areas. As a core component of China's rural primary healthcare system, the barefoot doctor model played a pivotal role in improving public health in rural communities during the mid‐20th century. Institutionally, several key characteristics emerged. In professional institutions, nursing became part of the state system, but training remained task‐oriented with little emphasis on professional development (Sun 2021). Organizationally, nurses were incorporated into the barefoot doctor system and public health networks, lacking dedicated hospital departments or positions (Rosenthal and Greiner 1982). Fiscally, the state controlled resources centrally, and nursing investment was largely directed at fulfilling public health mandates, with little room for professional growth (Hsiao 1984). In governance institutions, nursing was framed as an executive role, with ambiguous boundaries and minimal autonomy or voice (Chan and Wong 1999; Mathers and Huang 2014). Nurses were incorporated into public service rosters, undertaking immunization, family planning, and basic care tasks, but their professional status remained underappreciated (Gross 2018). Education was dominated by vocational‐level programs, with an emphasis on technical skill acquisition rather than clinical reasoning, leadership, or research capabilities (Chen 1996; Dong and Phillips 2008). Nurses were classified as subordinate technical staff, with career advancement dependent on doctor‐centric hierarchies, preventing the formation of independent career pathways (Jaffe et al. 2022). This stage represented the path lock‐in phase, where nursing remained structurally embedded in a “doctor‐led, nurse‐subordinate” framework. Even when incorporated into the national health system, nursing failed to achieve institutional autonomy, further entrenching path‐dependent constraints.

3.4. Period of Nursing Education Expansion amid Discursive Absence: Growth and Institutional Constraints During the Reform Era (1978–2001)

Following the reform and opening‐up in 1978, China initiated a series of market‐oriented medical reforms, which led to a significant quantitative expansion in nursing education, including vocational, associate, and undergraduate programs (Xu et al. 2020). Various nursing vocational schools and associate degree colleges were established in succession, and undergraduate nursing education was piloted in the early 1990s and gradually expanded. For example, in 1993, the State Education Commission of China approved the establishment of undergraduate nursing programs. As a result, the nursing education and training system was progressively improved (Wong and Zhao 2012). Institutionally, several features characterized this period. At the level of professional institutions, nursing schools at various levels proliferated, and disciplinary systems expanded, but autonomy remained limited, with nursing programs often embedded within medical schools (Xu et al. 2000). Organizationally, hospital‐based nursing service systems began to take shape, yet internal structures remained doctor‐centered, and nursing roles lacked functional completeness (Lu et al. 2008). In fiscal institutions, the decentralization of hospital finances and the drive for profitability led to nursing labor being treated as a cost–control variable, resulting in limited investment (Tian et al. 2011). In governance institutions, hospital management structures remained doctor‐dominated, and nurses continued to lack representation in policy‐making and institutional administration (Gao et al. 2012).

Although the number of nurses increased rapidly and hospitals demonstrated growing demand for nursing labor, and professional thresholds rose (Sun et al. 2001), the institutional empowerment of nursing remained absent. As hospitals acquired fiscal autonomy, the profit motive further reinforced doctor‐centered organizational logics. Doctors were positioned as revenue generators, while nurses were viewed primarily as cost centers (Gao et al. 2012). Despite expansion in education and employment, the governance structure continued to subordinate nursing. Policy inputs into nursing were limited, and nurses remained excluded from institutional management, professional regulation, and clinical decision‐making (Yan et al. 2014). Nursing roles became entrenched within an “operational, compliance‐oriented, and service‐oriented” framework, limiting efforts to construct a professional identity (Mao et al. 2021). This phase thus reflects a lock‐in mechanism in the development of the nursing profession: the entrenched power and resource distribution structures within hospital systems continually reproduce the marginal position of nursing, with educational expansion failing to translate into institutional empowerment.

3.5. Period of Nursing Professionalization Attempts and Institutional Predicaments: Navigating Specialization and Governance Challenges (2001–Present)

The 21st century has seen continuous development in the nursing discipline; particularly following China's accession to the WTO in 2001, a comprehensive higher nursing education system has been gradually established and expanded. Undergraduate programs have been widely implemented; master's education, although initiated in 1999, achieved substantive institutional development in the late 2000s; and doctoral programs were launched in 2011, marking the initial formation of a high‐level nursing talent training system. Meanwhile, national policies have actively promoted the specialization of clinical nursing pathways and reforms to the career advancement system. Regulations such as the 2008 Regulations on Nurses have further advanced the legislative process and standardized governance of the nursing profession (Chang et al. 2023). At the institutional level, professional institutions saw increased educational consolidation, yet the autonomy of nursing education remained constrained (Zou et al. 2012). Organizationally, nursing departments gained visibility within hospitals, but remained bound to doctor‐centered logic, with unclear delineations of responsibilities and management authority (Lu et al. 2008). In fiscal institutions, although policy support increased, salaries and budgets for nursing positions remained uncompetitive, and financial safeguards were insufficient (Hu et al. 2023). From a governance standpoint, while policies emphasized increasing nursing participation, most hospitals failed to establish formal mechanisms for nursing representation in decision‐making structures (Zhang et al. 2021).

Although various policy documents have advocated for “enhancing the status of nurses,” “expanding the functional scope of nursing,” and “building a nurse‐centered care system”, in practice, the institutional position of nursing remains weak (Wong 2010). In most hospitals, nurses are excluded from core decision‐making; nursing departments lack independence in administrative ranking, budget allocation, and promotion mechanisms. Societal stereotypes surrounding the profession have not fundamentally shifted, resulting in persistently low occupational attractiveness and high attrition rates (Tang et al. 2023). This phase is therefore characterized as path dependence continuity: although nursing has achieved horizontal expansion in education and academic development, its institutional status has not experienced a vertical breakthrough due to enduring historical path dependencies, generating a persistent tension between “professionalization efforts” and “institutional weakness.”

Overall, the historical trajectory of China's nursing profession can be divided into five distinct stages (see Figure 1 and Appendices 1 and 2), each demarcated by major institutional shifts and aligned with the logic of path dependence theory core concepts: “critical junctures,” “path lock‐in,” and “institutional persistence.” The establishment of the first Western hospital in Guangzhou in 1835 introduced nursing as an auxiliary service, with the “doctor‐led, nurse‐subordinate” configuration being institutionalized to mark a critical node in the professionalization of nursing. Although Peking Union Medical College and other institutions actively promoted the institutionalization of nursing education as early as 1920, the professional identity of nurses remained weak. A self‐reinforcing mechanism continued to perpetuate the marginalization of the nursing profession. Following the founding of the PRC in 1949, nursing was incorporated into the national health system but was institutionalized as an executive role, further constraining its professional identity. After the reform and opening‐up in 1978, China's nursing pre‐licensure education system underwent significant expansion, yet hospital marketization reinforced doctor‐centered logics, leaving nursing underrepresented in governance and resource distribution. Since China acceded to the WTO in 2001, the professional development of nursing has accelerated significantly. This growth has been accompanied by the gradual enhancement of undergraduate and postgraduate nursing education, as well as the implementation of policies and regulations such as the Regulations on Nurses. However, the governance status and public perception of the nursing profession have not undergone a fundamental transformation, resulting in a persistent contradiction between “professional expansion” and “institutional weakness.” Across nearly two centuries, the institutional development of nursing in China has exhibited four persistent structural constraints, including professional dependency, organizational marginality, fiscal limitation, and governance exclusion. While reforms have improved education levels and disciplinary construction, they have consistently failed to dismantle the deeply embedded institutional logic of doctor‐dominated systems, rendering nursing professionalization subject to enduring historical path dependence.

4. Discussion

This study demonstrates that the evolution of the hospital nursing profession in China, being characterized by “nursing centrism,” follows a distinct path‐dependent trajectory that has consistently revolved around a “doctor‐led, nurse‐subordinate” hospital structure. Since the introduction of Western medicine and hospital institutions in 1835, nursing has been institutionally embedded within a governance system centered on doctors. Subsequent structural transformations, such as the establishment of a unified state system in 1949 and the expansion of professional education after 1978, have failed to alter the subordinate organizational position of nursing. Although professionalization efforts have steadily advanced in policy and education, the nursing profession remains marginalized in terms of governance authority, resource distribution, and occupational recognition due to entrenched institutional inertia. Consequently, reform efforts have yielded success in “horizontal expansion” but encountered persistent obstacles in achieving a “vertical breakthrough.”

Unlike existing literature that largely focuses on macro‐level fiscal arrangements, service delivery models, or public health system reforms (Cai et al. 2025; Li 2025; Liu et al. 2025, 2008; Yip et al. 2012; Meng et al. 2015; Wang et al. 2019; Zhao et al. 2025a), this study adopts a nursing‐centered perspective to systematically analyze how hospital‐dominated structures have reinforced nursing subordination across four dimensions: professional institutions, organizational institutions, fiscal institutions, and governance institutions. This approach enriches the applied dimensions of path dependence theory within healthcare institutional research and fills a theoretical gap in the historical institutional analysis of nursing development.

Compared with studies on the international evolution of nursing systems (Almetari 2024; Bursiek et al. 2025; Choi and Kim 2019; Labrague et al. 2019; Oshodi et al. 2019; Hu et al. 2025; Turner et al. 2007), China's nursing profession remains significantly underdeveloped. Institutional autonomy and professional empowerment have not yielded substantive outcomes. Although policy documents have repeatedly emphasized goals such as “enhancing the status of nurses” and “optimizing career pathways,” nurses remain excluded from decision‐making and resource allocation within hospital governance. Their professional identity continues to be constructed as a subordinate technical role. Moreover, the social perception of nursing as a “feminized occupation” compounds the structural marginalization of the profession, reinforcing what previous scholars describe as a technocratic, rigidly hierarchical medical governance model in China (Chen et al. 2024; Lu et al. 2018; Ren et al. 2024; Wang et al. 2011; Xu 2025; Zhang and Petrini 2008). This contradiction between the appearance of modernization and the structural weakness of nursing has left the profession in a visible yet disempowered position, forming a stable structure of institutionalized low status.

The primary theoretical contribution of this study lies in the systematic application of path dependence theory to the historical development of the nursing profession. It establishes a longitudinal analytical framework spanning from 1835 to the present, across five historical stages, and reveals how initial institutional choices, self‐reinforcing mechanisms, and path lock‐in effects have collectively shaped the evolutionary logic of nursing in China. By incorporating four institutional dimensions (professional, organizational, fiscal, and governance), the study proposes that “nursing professionalization is constrained by an unchanged governance structure.” This offers a structural explanation for the persistence of occupational inequality within China's health system. In contrast to conventional linear analyses in policy or education research, this study highlights the combined effect of institutional inertia and structural exclusion, arguing that educational expansion and legislative advocacy alone are insufficient to overcome the governance‐based path lock‐in affecting the nursing profession.

At the practical level, this study proposes three key recommendations for nursing development. First, policy reforms should move beyond mere educational expansion and rhetorical commitments to focus on restructuring governance mechanisms and institutional authority, thereby granting nurses substantive participation rights and legal status. Second, in hospital management, the entrenched “doctor‐led, nurse‐subordinate” model of resource and power distribution must be dismantled, with attention given to independent design of nursing career systems, promotion pathways, and budgetary authority. Third, nursing education should transition from operational training to the cultivation of governance capacity and professional autonomy, creating a coherent trajectory from academic training to institutional empowerment. In parallel, public image campaigns should challenge gendered and service‐oriented stereotypes of nursing to enhance professional recognition and systemic attractiveness. These recommendations aim to break the structural constraints produced by path dependence and promote a nursing profession that is professionalized, autonomous, and institutionally equal.

This study, however, has certain limitations. First, archival materials related to nursing systems from certain historical periods have been lost, particularly those from the early Republic of China (1912–1927) and the 14‐year War of Resistance Against Japan (1931–1945). As a result, the specific mechanisms underlying the evolution of these systems still require further empirical investigation. Second, this study focuses primarily on the evolution of national‐level institutions and has not fully addressed the heterogeneity of nursing development across regions, urban–rural divides, or local governance systems. Third, while this study acknowledges the limits of education‐centered reforms, it has not fully interrogated the deeper structural reasons why governance reforms have been resisted or failed. Cultural norms that position nursing as a gendered and subordinate occupation, centralized political‐administrative hierarchies that prioritize physician leadership, and hospital governance frameworks that structurally marginalize nurses from decision‐making processes have jointly constrained institutional change. These factors may have systematically weakened the implementation or sustainability of governance innovations intended to empower nursing. Fourth, the analysis of the “counterfactual path” of institutional change remains underdeveloped. For instance, it is worth investigating whether the reform of the nursing education system during the Republic of China period, along with the gradual establishment of nursing governance‐related regulations after 2001, particularly the promulgation of the Regulations on Nurses and the ongoing legislative development of the Nurses Law, constituted a potential “window of opportunity” for the transformation of the nursing system. This question warrants further exploration in future research. Fifth, the study is confined to China and lacks cross‐national comparison, which limits the generalizability of its findings. Lastly, regarding research methodology, this study employs textual analysis and a historical institutionalist framework to analyze multisource documents. However, limitations remain with respect to reproducibility. On the one hand, some materials were obtained from non‐public or unsystematized archives and publications, making external access difficult. On the other hand, a systematic data collection and coding procedure has not yet been established, and transparency in the disclosure of methodological details remains insufficient. These issues limit the extent to which external scholars can assess the rigor and verifiability of the research.

Future research may proceed along six directions: First, researchers should recover fragmented nursing records from 1912–1945 through triangulation with missionary archives, hospital yearbooks, and oral recollections to reconstruct missing institutional mechanisms. Second, comparative case studies across provinces, urban–rural contexts, and hospital types may reveal how regional governance and fiscal differences shape divergent nursing trajectories. Third, future work should interrogate cultural norms, centralized administrative hierarchies, and physician‐dominated hospital structures that resist governance reforms. Mixed methods may reveal how these institutional forces limit nursing autonomy. Fourth, scholars should investigate whether the 1920s education reforms and post‐2001 regulatory efforts (e.g., Regulations on Nurses, draft Nurses Law) constituted missed institutional breakthroughs. Fifth, cross‐national studies could help assess whether China's experience reflects broader patterns or unique constraints in nursing governance. Furthermore, future research should improve transparency and reproducibility through standardized archival protocols, open‐source coding procedures, and methodological disclosure. Moreover, future research should also investigate the role of individual nursing pioneers and their efforts, whether successful or constrained, in reshaping governance dynamics. Understanding how professional agency intersected with institutional barriers can reveal micro‐level pathways for disrupting historical subordination. These directions will enhance scholarly rigor and deepen understanding of institutional asymmetries in global health systems.

5. Conclusion

This study systematically examines the development of China's nursing profession since its inception in 1835, utilizing path dependence theory. It uncovers the underlying logic embedded within a “doctor‐led, nurse‐subordinate” institutional structure. Despite the ongoing expansion of the nursing education system and repeated policy initiatives aimed at enhancing the status of nurses, the long‐term reinforcement of a four‐pronged system consisting of “four institutional dimensions (professional, organizational, fiscal, and governance)” has marginalized the nursing profession within governance frameworks. Consequently, its professionalization process has faced significant institutional constraints.

The theoretical contribution of this study lies in the development of an analytical framework that spans five historical stages and integrates four‐dimensional institutional mechanisms. This study marks the first systematic application of path dependence theory to the analysis of nursing development in China, thereby addressing a gap in historical institutional analysis within this field. Furthermore, it highlights the challenge of overcoming the subordinate status of the nursing profession within the organizational structure through education expansion and legislative measures alone.

On a practical level, this study suggests that future breakthroughs require intentional mechanisms that counteract institutional lock‐in. These may include legally mandated quotas for nurse representation in governance bodies, performance‐based financial incentives tied to nursing leadership outcomes, and institutional redesigns that embed nursing roles within strategic decision‐making. Reforms must focus on governance participation rights, resource control, and professional identity formation. Furthermore, the findings provide useful implications for international nursing reforms, underscoring that meaningful institutional change can only be achieved by addressing deep‐seated structural barriers rather than focusing merely on superficial professional development.

6. Implications for Nursing Practice and Policy

This study underscores the urgent need to dismantle the entrenched “doctor‐led, nurse‐subordinate” structure to achieve genuine professionalization and institutional equality for nurses within China's healthcare system. Nursing practice must move beyond operational roles to gain formal governance participation, while hospitals should establish independent promotion systems and budget authority to enhance professional autonomy. Nursing education needs to shift its focus toward leadership and governance capacity to align with modern healthcare demands. Simultaneously, public discourse and policy must challenge the gendered stereotype of nursing as a subordinate, feminized role to elevate its professional image and attract qualified talent. Reforms must be comprehensive, integrating governance, education, finance, and professional standards, as isolated changes are insufficient to overcome historical path dependencies. Although grounded in the Chinese context, the findings have global relevance for other countries facing similar structural inequalities, offering comparative insights into how institutional design can promote or inhibit nursing empowerment.

Author Contributions

Study design: DW and YL. Data collection: DW. Data analysis: JZL and DW. Manuscript drafting: JZL. Manuscript revision: XL, HD, YL and JZL. Conceptual contributions: YL and JZL.

Conflicts of Interest

The authors have no competing and conflicting interests.

Funding Information

The authors have nothing to report.

Ethics Statement

The data used in this study are secondary data, which are sourced from publicly available and legally authorized databases, with no direct or indirect human involvement. The data collection process adhered to relevant legal regulations to ensure the protection of individual privacy and other legal rights. Therefore, ethical approval from an ethics committee is not required for this study.

APPENDIX 1.

1.1.

Historical trajectory of nursing professional development in China (1835–present).

Period	Critical node / event	Key characteristics	Stage of professional path development
Germination period of nursing (Subordinate stage) (1835–1920)	The establishment of the first Western hospital in Guangzhou in 1835; nursing was introduced alongside.	Nursing roles were subordinated to hospitals and missionaries, lacking autonomy.	Critical node stage in path development.
The germinal phase of nursing's Quasi‐professionalization (Period of weak institutionalization in education) (1920–1978)	In 1920, the Peking Union Medical College School of Nursing was established, marking the formal inception of a structured nursing education system in China.	Vocational education was initiated but remained marginalized, as nursing was regarded as a servile occupation.	Self‐reinforcement stage in the developmental path.
Period of institutionalized subordination of nursing (Planned economy subordination stage) (1949–1978)	The founding of the PRC in 1949; nursing was incorporated into the national health system.	Nursing roles became instrumentalized for public health and political agendas.	Path lock‐in stage.
Period of nursing education expansion amid discursive absence (Reform period) (1978–2001)	Following the reform and opening‐up in 1978, vocational and associate degree nursing education quickly resumed, while undergraduate nursing education was established in 1993 and has since gradually expanded.	Educational expansion occurred, but the doctor‐centered institutional structure remained unchanged.	Lock‐in mechanism stage in the path.
Period of nursing professionalization attempts and institutional predicaments (Modern stage) (2001–present)	Following China's accession to the WTO in 2001, the nursing discipline has undergone rapid development. Undergraduate education has continued to expand, master's programs were initiated in 1999 and have gradually become institutionalized, and doctoral programs were established in 2011.	Professionalization of nursing advanced, but institutional empowerment and discursive authority remained weak.	Path dependence continuity stage.

APPENDIX 2.

2.1.

Comparative table of institutional influences on the development of nursing in China (1835–present).

Period	Professional institutions	Organizational institutions	Fiscal institutions	Governance institutions
Germination period of nursing (Subordinate stage) (1835–1920)	Nursing lacked independent training; roles were undertaken by nuns or lay religious women; professionalization was absent.	Nursing was fully embedded within missionary hospitals, with no independent institutional structure.	Funding relied on church donations; nursing was framed as auxiliary expenditure.	Nursing affairs were dominated by doctors; nurses had no institutional voice.
The germinal phase of nursing's Quasi‐professionalization (Period of weak institutionalization in education) (1920–1978)	Nursing schools emerged, but training remained limited, lacking standardized professional criteria.	Nursing schools were structurally tied to hospitals; governance authority resided with doctors.	Nursing education was funded by missionary organizations, with no fiscal support from the state.	Nursing was incorporated into hospital governance structures but lacked professional autonomy.
Period of institutionalized subordination of nursing (Planned economy subordination stage) (1949–1978)	Nursing was incorporated into the state system; education remained task‐oriented and lacked professional content.	Nursing was integrated into the “barefoot doctor–public health” network, with no institutional space for independence.	State investment was limited; nursing resources were concentrated in public health assignments.	Nursing was subordinated to political objectives; professional autonomy was further diminished.
Period of nursing education expansion amid discursive absence (Reform period) (1978–2001)	Nursing education expanded yet remained primarily affiliated with medical schools; institutional independence was lacking.	Nursing service systems expanded, but hospital structures reinforced doctor‐centered hierarchies.	Under marketization, nursing salaries and status remained lower than those of doctors; incentives were insufficient.	Hospital governance emphasized doctor dominance; nursing lacked representational mechanisms.
Period of nursing professionalization attempts and institutional predicaments (Modern stage) (2001–present)	The nursing education system has undergone continuous improvement, characterized by the expansion of undergraduate programs, the institutionalization of master's education, and the establishment of doctoral programs in 2011. However, its academic and institutional autonomy remains limited.	Within hospital governance, nursing lacked decision‐making power; disciplinary development had not translated into institutional space.	National policy support remained limited; the nursing profession lacked stable fiscal guarantees.	While nursing development was recognized at the policy level, governance structures failed to deliver genuine institutional empowerment.

Data Availability Statement

Data will be made available upon request by contacting the primary corresponding author.