Substitution of nurses for physicians in the hospital setting for patient, process of care, and economic outcomes.

This is a Cochrane systematic review and meta-analysis evaluating substitution of nurses for physicians in hospital inpatient units and outpatient clinics.

Scope and methods

• Included studies and participants: 82 randomized studies (80 parallel-group, 2 crossover) with 28,041 participants across multiple specialties (including cancer, cardiology, dermatology, endocrinology, gastroenterology, general medicine, neonatology, neurology, obstetrics/gynaecology, ophthalmology, rheumatology, respiratory).
• Settings: Mainly high-income countries; 39% of studies were from the UK.
• Interventions: Specialist nurses, advanced nurse practitioners, and registered nurses substituting for junior and senior doctors, practising autonomously or under supervision, sometimes protocol-driven.
• Outcomes: Mortality, patient safety events, clinical outcomes, quality of life, self-efficacy, practitioner performance, and direct costs.
• Risk of bias and certainty: Risk of bias assessed with RoB 2; about one-third low risk, nearly half with some concerns. Certainty of evidence graded with GRADE.

Key findings

• Mortality: Probably little to no difference between nurse-led and physician-led care (moderate-certainty).
• Patient safety events: May be little to no difference (low-certainty).
• Quality of life: Probably little to no difference (moderate-certainty).
• Self-efficacy: Probably little to no difference (moderate-certainty).
• Clinical outcomes: For most measures, little to no difference; a minority of outcomes may improve with nurse substitution, but evidence is uncertain.
• Practitioner performance: Mixed—some outcomes favor nurses, some favor physicians, many show no difference.
• Direct costs: Low-certainty evidence; narrative synthesis showed costs were lower in 17 studies and higher in 9 (often due to longer consultations, referrals, and prescribing patterns).

Overall conclusion

Substituting nurses for physicians in hospital-based care generally yields similar outcomes to physician-led care for mortality, safety, patient-reported outcomes, and most clinical measures. There may be context-specific advantages or disadvantages, but these are uncertain. Any strategy to use nurse-physician substitution to address physician shortages must also account for implications for the nursing workforce.