Advanced nurse practitioners, clinical nurse specialists, and registered nurses are able to provide many services traditionally performed by physicians with comparable outcomes regarding treatment, efficacy, and patient perceptions of health status.

That’s the takeaway from a recent review published in the Cochrane Database of Systematic Reviews that assessed nurse vs doctor substitution within inpatient units and outpatient clinics, drawing upon 82 randomized studies that encompassed more than 28,000 patients across 20 countries.

The roles undertaken by these nursing professionals were examined as they executed tasks traditionally performed by junior or senior doctors across various specialties, including cardiology, diabetes, oncology, obstetrics and gynecology, and rheumatology.

In certain instances, the research indicated that nurse-led care demonstrated superior outcomes than doctor-led care.

The healthcare industry, both nationally and internationally, is experiencing increased demands due to an aging population, more complex health requirements, extended waiting periods, and shortages of medical professionals. The proposal to have patients receive care from nurses instead of doctors has been suggested as a strategy to enhance access to hospital services for patients who might otherwise experience long wait times to see a medical provider.

“We wanted to know if nurse-physician substitution is as safe and effective as usual care,” said Michelle Butler, professor of Nursing and Health Services Research at Dublin City University, Dublin, Ireland, who co-wrote the original review protocol. Butler’s team identified four types of nurse-physician substitution: nurse-led inpatient care, nurse-led clinics, nurse-physician role substitution, and nurse-physician task substitution.

Data was analyzed for three critical outcomes: death rates (mortality); rates of complications, errors, and adverse events (patient safety events); and clinical outcomes.

“From our analysis we found there is probably little to no difference, meaning nurse-physician substitution is probably as safe and effective,” continued Butler. “We also found that there may be improvements in a small number of clinical outcomes.”

Additionally, researchers examined two other important patient outcomes: patient self-rated quality of life and self-efficacy, a patient’s feeling of their ability to achieve goals.

“We found there is probably little to no difference between care provided by a nurse or a doctor,” noted Butler.

With respect to hospital medicine and the dynamics of this study, nurse-led care continues to demonstrate effectiveness and significance and is becoming increasingly essential within the US healthcare system.

“While the title (of the study) is certainly gripping, the information isn’t new,” said Russell W. Ledford, MD, director, Section of Hospital Medicine, associate professor of clinical medicine, Vanderbilt University Hospital in Nashville, Tennessee. “Hospitals have increasingly moved to care models that compartmentalize tasks related to specific, low acuity conditions that are designed to be led by advanced practice providers or specially trained nurses. This has been necessary in the setting of increasing costs, physician shortages, and increased specialization, among other constraints.”

Perceptions Among Medical Specialties

Tim Schultz, PhD, senior research fellow at the College of Medicine and Public Health, Flinders University, Adelaide, South Australia, who also co-wrote the original review protocol, clarified that the review isn’t suggesting that nurses replace doctors but, he said, that where they take on care traditionally provided by doctors, the outcomes are similar.

“Our findings show that for the outcomes selected, nurse-led care may be as good as traditional doctor-led care, but our review also highlights the range of arrangements to be considered when implementing nurse-physician substitution initiatives,” Schultz said. “The development of new models of care should be based on multidisciplinary — including medical, nursing, and allied health — insights and patient input.”

One scenario could be waiting times for medical care.

“For example, nurses may take on care for patients in the emergency department with minor injuries, inpatient care for medical patients whose condition has stabilized, or follow-up care for patients in nurse-led clinics, freeing up doctors to provide care for patients who are sicker or have additional needs,” cited Schultz.

Delving deeper into the research, some specialties were represented better in initiatives — rheumatology, cancer, diabetes, and respiratory disease — the data suggested.

Interestingly, physician-led care outpaced nursing care in specific specialties.

“We found two studies where outcomes were better where doctors provided care,” reported Vera McCarthy, PhD, a senior lecturer in the School of Nursing and Midwifery at University College Cork, Cork, Ireland, who was also affiliated with the review.

One study of sexual health screening of asymptomatic patients attending a sexual health study in the UK found data recording was more complete when performed by doctors. Another study of medical abortion in Ethiopia found the time to fetal expulsion was longer when performed by nurses and midwives, she said.

Impact of Clinical Training on Nursing Care and Outcomes

Across studies, nurses were from a range of nursing grades including registered nurses, nurse specialists, and nurse practitioner/advanced nurse practitioners, said Marcia Kirwan, associate professor at Dublin City University, in the School of Nursing, Psychotherapy and Community Health, Dublin, Ireland, who was also among the review’s research team.

“Not all nurses were provided with training and there was no clear relationship between whether training was provided and the grade of nurse,” said Kirwan.

Researched analyzed the impact of nursing grades and additional training on outcomes. They found that there may be fewer patient safety events and a slight improvement in relative performance of practitioners where care is provided by nurse specialists but otherwise did not identify a difference in outcomes between grades of nurses, she said.

“We did not identify any difference in outcomes related to whether additional training was provided or not.”

No reported disclosures.