Can Nurses Safely Replace Physicians in Some Roles?

Hospital systems are under severe strain in many countries, including Spain: an aging population, a higher number of patients with multiple health conditions, long waiting lists, and shortages of medical staff. Consequently, ideas are circulating on how to reform the system to improve patient access to hospital services without increasing physicians’ workloads.

One proposal under consideration is shifting part of physicians’ workload to nursing staff. The obvious question is whether that can be done without compromising patient safety or quality of care.

To help answer that question, a team of researchers from Ireland, UK, and Australia conducted a Cochrane review to evaluate the effects of staff substitution in inpatient units and outpatient clinics. They analyzed 82 randomized studies (7-1907 patients per study) that included a total of 28,041 patients across 20 countries. These studies examined advanced practice nurses, clinical nurse specialists, and registered nurses who substituted for physicians in cardiology, diabetes, cancer, obstetrics/gynecology and rheumatology clinics, among others.

Safety and Effectiveness

The review found little difference between care provided by the two professional groups for key outcomes, including mortality, quality of life, self-efficacy, and patient safety events. Although most clinical outcomes did not differ between groups, nursing staff may have achieved better results in some areas, such as diabetes control, cancer follow-up, and dermatology. Physician-provided care performed slightly better in a small number of sexual-health follow-up services and medical abortion care.

However, these results must be interpreted with great caution because the substitution models analyzed in the Cochrane review were highly heterogeneous, making it difficult to draw generalized conclusions: Studies involved nursing staff working at different levels — autonomously, under supervision, or following specialized protocols. There were also differences in training, levels of responsibility, and the way substitution was implemented, all of which can affect key outcomes. “In some cases, with nurse staff, appointments were given earlier, more frequently, and on demand, or included an added educational component to care, which could have helped improve patient outcomes,” Michelle Butler, professor at Dublin City University, Dublin, Ireland, and an author of the Cochrane review, said in a press release.

Regarding the impact on direct costs, a key parameter for assessing the effectiveness of substitution, the evidence was limited and varied across studies, partly due to differences in publication methods, the currencies of the countries where the studies were conducted, and the time periods. Seventeen studies reported a reduction in the costs of care provided by nursing staff, while nine pointed to higher costs due to longer consultations, referrals, or differences in prescribing.

Gaps in the Evidence

The review also highlighted major gaps in the available evidence, the most important being that most studies were carried out in high-income countries, mainly the UK (39%), which may bias the findings. Studies were not evenly distributed across specialties, nursing roles, patient types or outcome measures.

A Universal Solution?

The answer is unequivocal: No. This is something you might already have guessed from the conclusions presented above. Therefore, the authors warn that these interventions must always be interpreted in the context in which they were implemented. “Substituting with nursing staff is not simply replacing people,” said Timothy Schultz, PhD, researcher at the Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia, and coauthor of the review. “To function well, these services need appropriate training, support, and care models.”

Therefore, according to the Cochrane review, expanding services delivered by nursing staff could be a tool to address physician shortages — provided policymakers consider the overall effects of these interventions on nursing staff, including their training and organization, and account for the socioeconomic context where substitution would be implemented.

Luis Miguel Alonso Suárez,  president of the Spanish Association of Nursing and Health, does not share that view. He told Univadis Spain, part of the Medscape Professional Network, that simply proposing this option “is wrong and unfair to both doctors and nurses. Medical and nursing university degrees train each profession for its scope of practice. If there are not enough doctors, we should train or recruit more doctors — that is logical. Moreover, in Spain’s National Health System, current nursing staff are not even sufficient to cover nursing tasks, which means that, if one followed the premise of substituting physicians with nurses, we might also consider substituting nurses with specialist technicians with vocational training rather than a nursing degree.”

New App for Traumatic Brain Injury (TBI) Evaluation
You can access the app here:
https://apps.apple.com/app/id6753718476