What are the effects of hospital care delivered by a nurse instead of a doctor on patient, process of care, and economic outcomes?

Key messages

• There may be little to no difference between care delivered by a nurse and care delivered by a doctor.

• Although the evidence is uncertain, in a small number of cases, clinical outcomes (physical and psychological function, diabetes, and eczema management) and relative performance of practitioner (patient assessment/accuracy of assessment, following practice recommendations, medication management, identifying polyps, and length of time to begin a procedure) may be improved.

• Future studies using random methods of assigning people to treatment groups are needed in low- and middle-income countries.

What do we mean by care delivered by a nurse instead of a doctor?

Care delivered by a nurse instead of a doctor refers to when task(s) or role(s) normally carried out by a doctor are performed by a nurse. These could include, but are not limited to, taking the patient's history and carrying out a physical examination, ordering tests, prescribing medication, and providing patient education. The nurse is responsible for giving the same care to the patient. Nurses may take on these roles independently of the doctor or carry them out under the doctor’s supervision.

There is significant pressure on healthcare services due to ageing populations, chronic diseases, high workloads, expensive treatments, and doctor shortages. To deliver high-quality care, some countries are substituting doctors with nurses who are appropriately trained, thereby allowing improved access to care while controlling the costs of care delivery.

What did we want to find out?

We wanted to find out if:

• care delivered by a nurse differed from care delivered by a doctor on patient, process of care, and economic outcomes in the hospital setting;

• outcomes from care delivered by a nurse in place of a doctor differed by: healthcare setting, patient type, patient disease, intervention type, nurse grade, additional training provided, level of responsibility of the nurse, and method of substitution.

What did we do?

We searched for studies that compared care delivered by a nurse instead of a doctor in hospital settings. We included studies that examined patient outcomes (death, patient safety events, clinical outcomes, quality of life, and self-efficacy), process of care outcomes (relative performance of practitioner), and economic outcomes (direct costs).

What did we find?

We included 82 studies that were conducted worldwide, the majority of which were conducted in the UK (32 studies). The studies included a total of 28,041 participants, ranging in size from 7 to 1907 participants. Most studies lasted for 12 months, with two studies lasting up to five years. Several studies ended in the patient’s discharge or post-procedure.

Main results

• We found that substituting nurses for doctors probably results in little to no difference in death; may result in little to no difference in patient safety events; and may result in a slight improvement in some clinical outcomes (physical and psychological function, diabetes, and eczema management). Substituting nurses for doctors probably results in little to no difference in quality of life and self-efficacy, and may result in a slight improvement in some relative performance of practitioner measures (patient assessment/accuracy of assessment, following practice recommendations, medication management, identifying polyps, and length of time to begin a procedure). It is unclear if substituting nurses for doctors has an effect on direct costs.

• In some cases, quality of life may be better when nurses substitute for doctors in low- and middle-income countries, but relative performance of practitioner may be better in high-income countries.

• When considering differences according to disease type, we found there may be some improvements in relative performance of practitioner for patients with cardiovascular disease attending nurse-led clinics.

• When considering different types of nurse-doctor substitution, we found that clinical outcomes may be better when care is delivered by a nurse rather than a doctor in nurse-led clinics and inpatient care. No difference was found for death, patient safety events, quality of life, or self-efficacy. It is unclear if there are any differences in relative performance of practitioner.

• When considering nurse grade, we found there were fewer patient safety events when care was provided by specialist nurses. There was no difference between the grades of nurses in death, clinical outcomes, quality of life, and self-efficacy.

• Fewer trials provided extra training for specialist or advanced nurse practitioners than for registered nurses. No differences were found when we considered additional training and level of responsibility for any of our outcomes.

• Regarding mode of substitution, the results showed better relative performance of practitioner for standard and enhanced care when nurses substituted for doctors.

What are the limitations of the evidence?

We have only moderate to little confidence in the evidence due to differences in the participants, interventions, and measurement of outcomes. Additionally, only a small number of studies were based in low- and middle-income countries.

How up-to-date is this evidence?

The evidence is current to 25 June 2024.