Growth and challenges of China's nursing workforce from 1998 to 2018: A retrospective data analysis

Nurses play a vitally important role in promoting equitable and essential care. China undertook bold reforms in its education and healthcare systems since 1990s. The effect of these reforms on the nursing workforce has not been assessed systematically.This study aims to assess the changing trends and the underlying challenges of the nursing workforce in Mainland China in the period of 1998-2018.Retrospective data analysis.Data were acquired from the National Health Statistics Yearbook from 1999 to 2019. Descriptive statistics were used to analyze the nature of the nursing workforce in terms of quantity, quality, and structure. Non-parametric tests were used to compare doctors and nurses in terms of number and work experiences. Global Moran's I index and hotspot analysis were applied to compare the equity in distribution of nurses at national and provincial levels.From 1998 to 2018, the number of nurses increased from 1.22 to 4.10 million with an average rate of increase of 6.3% per annum. The ratio of doctors to nurses changed from 1: 0.61 to 1: 1.14, reaching 1: 1 in 2013. The main educational level of registered nurses elevated to associated degree (48.9%), and nurses with advanced titles increased at the most rapid rate. In 2018, 60.3% of nurses were younger than 35 years old. The Global Moran's I index ranged from 0.211 to 0.198 (Z > 1.96, P < 0.05). Hotspot analysis showed the distribution of nurses was unequally concentrated in the northern region and with the highest distribution in Beijing.Great improvement on the scale and the quality of nursing workforce over the past 20 years has been witnessed in China. However, the shortage of nurses, outflow of younger nurses and the imbalance distribution of nursing workforce among the country are emerging challenges. Plans should not be ignored on continuously cultivating more qualified nurses, retaining younger nurses, attracting nurses to work in rural areas and the northeast region. Tweetable abstract: The number of nurses in Mainland China increased greatly in the period of 1998-2018, with its improvement in quality, structure, and distribution. However, the shortage of nurses, nurse outflow and the imbalance in the distribution are underlying risks that influence nurse development.