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Cited by 614Nursing Roles and PracticesPrimary Care and Health OutcomesNursing education and management

Nurses as substitutes for doctors in primary care

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Laurant, Miranda, van der Biezen, Mieke, Wijers, Nancy, Watananirun, Kanokwaroon, Kontopantelis, Evangelos, van Vught, Anneke JAH·2018·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd001271.pub3PMC PMC6367893
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Abstract

BACKGROUND: Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. OBJECTIVES: Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'. SELECTION CRITERIA: Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. MAIN RESULTS: For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low. AUTHORS' CONCLUSIONS: This review shows that for some ongoing and urgent physical complaints and for chronic conditions

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  • Many studies with strong research designs have shown nursing-intensive primary care models to be safe and effective.

    “Many studies with strong research designs have shown nursing-intensive primary care models to be safe and effective.8,11,18-26”

    From Evaluating the cost of NP-led vs. GP-led primary care in British Columbia (2024) · cites this paper as [11]

    The Abstract (Main results) reports 18 randomised trials and says nurse-led care probably produces similar or better health outcomes than doctor-led care. But the claim’s unqualified statement that these models have been shown to be safe and effective overstates the review: mortality evidence is low certainty, and the Results (Risk of bias in included studies) note methodological shortcomings across the trials. Page numbers are not available in our copy. (LLM, conf=0.84)

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  • Measurable clinical outcomes are systematically found to be equivalent to those produced by medical models, though patient satisfaction tends to be higher for nurse-provided services.

    “Measurable clinical outcomes are systematically found to be equivalent11,18,19,23,27-32 to those produced by medical models, though patient satisfaction tends to be higher for nurse-provided services.11,19,21,26,27,29,30,33,34”

    From Evaluating the cost of NP-led vs. GP-led primary care in British Columbia (2024) · cites this paper as [11]

    In Results > Effects of interventions (page not provided), the review reports similar HbA1c and cholesterol outcomes, but says nurse-led care probably slightly improves systolic and diastolic blood pressure compared with doctor-led care. Thus, describing measurable clinical outcomes as systematically equivalent overstates the findings. The same section reports that patient satisfaction is probably slightly higher with nurse-led care. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Increased involvement of non-physicians such as Registered Nurses and Nurse Practitioners has long been recognized as an effective way to enhance access to primary care services.

    “Increased involvement of non-physicians such as Registered Nurses (RNs) and Nurse Practitioners (NPs) has long been recognized as an effective way to enhance access to primary care services.6-12”

    From Evaluating the cost of NP-led vs. GP-led primary care in British Columbia (2024) · cites this paper as [11]

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Research works printed but not linked: 6

  1. Cochrane Effective Practice, Organisation of Care (EPOC). Suggested risk of bias criteria for EPOC reviews. EPOC Resources for Review Authors 2017. Available at epoc.cochrane.org/epoc‐specific‐resources‐review‐authors.
  2. Kuethe M, Vaessen‐Verberne A, Mulder P, Bindels P, Aalderen W van. Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: randomised controlled trial with two‐year follow‐up. Primary Care Respiratory Journal 2011; 20: 84–91. [DOI: 10.4104/pcrj.2011.00003] PMC6549809 21311842 · DOI
  3. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
  4. World Health Organization. WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting ‐ OPTIMIZEMNH. Geneva: World Health Organization, 2012. 23844452
  5. Winter C. Quality Health Care: Patient Assessment. [Master of Science Thesis]. Long Beach, CA: California State University, 1981.
  6. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews 2005, Issue 2. [DOI: 10.1002/14651858.CD001271.pub2] 15846614 · DOI

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Authors
Laurant, M., van der Biezen, M., Wijers, N., Watananirun, K., Kontopantelis, E., & van Vught, A. J.
Affiliations
  • HAN University of Applied Sciences (NL)
  • Radboud Institute for Health Sciences, IQ healthcare; Radboud University Medical Center; PO Box 9101 Nijmegen Netherlands 6500 HB
  • Zorgbelang Gelderland; Arnhem Netherlands
  • Siriraj Hospital (TH)
  • University of Manchester (GB)
  • HAN University of Applied Sciences; Faculty of Health and Social Studies; Nijmegen Netherlands
Corresponding author
Laurant, Miranda
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2018-07-16
Volume
2019
Issue
2
Pages
CD001271-CD001271
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd001271.pub3
PMC
PMC6367893
OpenAlex
W2884744493
Cited by
614
References
91
Citations by year
2026: 44 · 2025: 76 · 2024: 77 · 2023: 97 · 2022: 89 · 2021: 92 · 2020: 72 · 2019: 49 · 2018: 10 · 2017: 3 · 2012: 1
FWCI
10.15
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • Research Explorer (The University of Manchester) (submittedVersion, other-oa)
  • Radboud Repository (Radboud University) (submittedVersion)
Topics
  • Health Sciences › Health Professions › General Health Professions › Nursing Roles and Practices
  • Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
  • Health Sciences › Nursing › Research and Theory › Nursing education and management
Keywords
nurse-led primary care, primary care providers, nurse-led clinics, patient outcomes, process of care, health care utilization, health care costs, primary care access, chronic disease, multimorbidity, community-based care, quality of care
MeSH terms
Family Practice, Health Services Needs and Demand, Humans, Nurse Practitioners, Nursing Staff, Primary Health Care, Quality of Health Care, Randomized Controlled Trials as Topic, Personnel Delegation, Practice Patterns, Nurses'

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