Hierarchical differentiation and design gaps in China's Internet Plus Nursing Services Policies: a PMC index analysis.

Introduction: As population aging accelerates and digital health technologies continue to expand, integrating internet-based nursing services into long-term care systems has become an important policy priority. However, existing studies have paid limited attention to how policy themes, instrument configurations, and design consistency interact across governance levels in this field. To address this gap, this study develops a three-dimensional analytical framework encompassing policy themes, policy instruments, and design consistency to examine the structural characteristics and design quality of China's "Internet Plus Nursing Services" policies. Methods: From a multi-level governance perspective, this study analyzed 123 national and local policy documents on "Internet Plus Nursing Services" issued in China between 2018 and 2025. A three-dimensional analytical framework integrating keyword co-occurrence analysis, Rothwell and Zegveld's policy instrument framework, and the Policy Modeling Consistency (PMC) index model was applied to examine thematic structures, policy tool configurations, and design quality. Results: National and local policies showed clear hierarchical differentiation in thematic focus, instrument configuration, and design consistency. National policies were more strongly oriented toward regulatory coordination and system governance, whereas local policies placed greater emphasis on service implementation and community-based delivery. Although environment-oriented instruments remained dominant at both levels, structural imbalances persisted, particularly in the alignment between regulatory requirements and incentive arrangements and between supply-side capacity building and demand-side activation. PMC analysis further indicated stronger overall design consistency at the national level than at the local level (7.98 vs. 7.31). Across both levels, policy coverage and evaluation mechanisms remained the weakest dimensions, with local policies showing particularly limited performance in policy coverage (X3 = 0.27), suggesting persistent gaps in service scope, feedback, and adaptive adjustment. Conclusions: Although "Internet Plus Nursing Services" policies have achieved substantial institutional expansion, important gaps remain in internal coordination and design balance. Future policy development should place greater emphasis on aligning regulation with incentives, improving coordination between supply-side capacity building and demand-side activation, and strengthening policy coverage, evaluation, and feedback mechanisms, especially at the local level. These findings suggest that the quality of digital nursing governance depends not only on policy expansion, but also on the structural coherence of policy arrangements across governance levels. The three-dimensional analytical framework developed in this study provides a replicable approach for assessing digital nursing governance and may offer useful insights for other countries advancing digital transformation in long-term care systems.