Nurses can safely deliver many services traditionally performed by doctors, with little to no difference in deaths, safety events, or how patients felt about their health, according to a new Cochrane review. In some cases, nurse-led care even outperformed doctor-led care.
Healthcare services are facing pressure due to an ageing population, complex health needs, long waiting lists, and doctor shortages. Receiving care from nurses, rather than doctors has been proposed as one way to improve access to hospital services for patients who may otherwise face long waits.
A group of researchers from Ireland, United Kingdom, and Australia evaluated nurse-doctor substitution in inpatient units and outpatient clinics, analyzing 82 randomized studies involving over 28,000 patients across 20 countries. Studies included advanced nurse practitioners, clinical nurse specialists and registered nurses substituting for junior or senior doctors across specialties such as cardiology, diabetes, cancer, obstetrics/gynaecology, and rheumatology.
Nurse-led hospital care matches doctor-led care for safety and effectiveness
The review found little to no difference between nurse-led and doctor-led care for critical outcomes, including mortality, quality of life, self-efficacy, and patient safety events. While most clinical outcomes showed no difference between groups, nurses may achieve better outcomes in some areas, including diabetes control, cancer follow-up, and dermatology. Doctor-led care performed slightly better in a small number of sexual health and medical abortion follow-up services.
"Our findings show that nurse-led services provide care that is just as safe and effective as doctor-led services for many patients," said lead author Professor Michelle Butler from Dublin City University. "In some areas, patients actually experienced better outcomes when nurses led their care."
The models of substitution varied widely, with different grades of nurses operating autonomously, under supervision, or following specialized protocols. There were also differences in training, level of responsibility, and mode of substitution, all of which may influence outcomes.
Butler added, "In some cases, patients had earlier, more frequent, or on-demand appointments with nurses, or had an additional educational component to their care, which may have helped to improve their outcomes."
Evidence on direct costs was limited and varied across studies, partly due to differences in reporting methods, currencies and time periods. Seventeen studies reported reduced costs for nurse-led care, while nine suggested higher costs due to longer consultations, referrals, or prescription differences.
Not a one-size-fits-all solution
However, nurse-doctor substitution is not a one-size-fits-all approach. The authors caution that these interventions should always be interpreted within context.
"Nurse substitution isn't simply a one-for-one replacement," said Timothy Schultz, senior author and researcher from Flinders Health and Medical Research Institute. "To work well, these services need the right training, support and models of care, but the evidence shows patients are not disadvantaged and can benefit in meaningful ways."
Expanding nurse-led services may help address doctor shortages, but the authors urge that policymakers should consider the impact of these interventions on the nursing workforce, including training and organization.
While the evidence base was substantial, the authors note important gaps. Most studies were from high-income countries, with the majority (39%) conducted in the United Kingdom. The authors call for more studies across specialties, nurse roles and patient types not yet evaluated, as well as stronger consistency in how outcomes are measured. They also highlight the need for more research in low- and middle-income countries, where nurse-led roles could potentially improve access to care in regions facing doctor shortages.
