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

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.