Nurses as substitutes for doctors in primary care

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 ( ), 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 foll...

Skill mix change between physicians, nurse practitioners, physician assistants, and nurses in nursing homes: A qualitative study

“…It is expected that NPs and PA substitute for ECPs more than RNs, given their level of education, qualifications, and authorizations (Ackermann & Kemle, ; Aigner, Drew, & Phipps, ). Nevertheless, RNs might sometimes substitute for physicians, as the work of physicians goes beyond reserved procedures; for example, patient assessment (Bedin et al, ; Laurant et al, ).…”

Integration of nurses in general practice: A thematic synthesis of the perspectives of general practitioners, practice nurses and patients living with chronic illness

“…• This paper deepens our understanding of traditional role concepts legal frameworks and reimbursement schemes as limiting barriers to a more integrated interprofessional collaboration which is required by current and future challenges in primary health care workload, decreases healthcare costs, improves satisfaction of both patient and healthcare provider (HCP) and provides equivalent or improved quality of care (Gielen, Dekker, Francke, Mistiaen, & Kroezen, 2014;Laurant et al, 2018;Martínez-González et al, 2014;Martínez-González, Tandjung, Djalali, & Rosemann, 2015;Parker, Maresco-Pennisi, Clifton, Shams, & Young, 2016;Riisgaard, Nexoe, Le, Sondergaard, & Ledderer, 2016;Watts & Lucatorto, 2014).…”

“…Nevertheless, a better understanding of the potential contribution of nurses working in general practice is needed (Ball, Maben, & Griffiths, ). Research has demonstrated that this task shift generates similar or better health outcomes for a broad range of patient conditions, relieves the GP’s workload, decreases healthcare costs, improves satisfaction of both patient and healthcare provider (HCP) and provides equivalent or improved quality of care (Gielen, Dekker, Francke, Mistiaen, & Kroezen, ; Laurant et al, ; Martínez‐González et al, ; Martínez‐González, Tandjung, Djalali, & Rosemann, ; Parker, Maresco‐Pennisi, Clifton, Shams, & Young, ; Riisgaard, Nexoe, Le, Sondergaard, & Ledderer, ; Watts & Lucatorto, ). A recent overview of systematic reviews by Matthys Remmen, & Van Bogaert, () demonstrated that collaboration between physicians and nurses may have a positive impact on a range of patient outcomes and on a variety of pathologies when embedded within integrated interprofessional collaboration care models with adequately educated nurses (Matthys et al, ).…”

Exploring the relationship between nursing identity and advanced nursing practice: An ethnographic study

“…Advanced nursing practice has been found to be safe and effective (Laurant et al, 2018). However, it may lack acceptability and understanding, leading to underutilisation (Andregård & Jangland, 2015).…”