Intended for healthcare professionals


Evidence based substitution of doctors by nurses in primary care?

BMJ 2000; 320 doi: (Published 15 April 2000) Cite this as: BMJ 2000;320:1078
  1. Miranda Laurant, researcher (M.Laurant{at},
  2. Michelle Sergison, research associate,
  3. Shirley Halliwell, research technician,
  4. Bonnie Sibbald, professor of health services research
  1. Centre for Quality of Care Research, Universities of Nijmegen and Maastricht, PO Box 9101, 6500 HB Nijmegen, Netherlands
  2. Research and Development Department, Huddersfield NHS Trust, Huddersfield HD3 3EA
  3. National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL

    EDITOR—Pressures to increase the quality and reduce the cost of primary healthcare delivery have led to the redefinition of the roles of health professionals and the creation of new roles such as nurse practitioners, advanced practice nurses, and clinical nurse specialists. Nurses are currently concerned with many aspects of patient care (asthma, diabetes, prevention of cardiovascular diseases), and they perform a wide range of tasks, ranging from health assessment and education to prescribing. This substitution of care is not well founded on research evidence (controlled trials) and seems to be a consequence of the high demands on primary healthcare providers.

    In the early 1970s new nursing roles were seen to be a possible solution to diverse problems in primary health care, including rising demand and costs, a shift from hospital to primary health care, and the changing roles of medical professionals. The nurse's role was redefined and increasingly began to include types of care provision that had been the province of doctors. Nurses also learnt new skills, which enabled them to fill previously unmet health needs. Thus the change in skill mix was characterised by both substitution and diversification of roles. The effects of these changes on patient health, use of health services, and costs are not clear.

    We have started a systematic review of the effects of substituting nurses for doctors in primary care for the Cochrane Effective Practice and Organisation of Care Group.1 We aim to synthesise world research by measuring the outcomes of patient health (morbidity, satisfaction, and quality of life); process of care (patient compliance, adherence to guidelines); use of resources (frequency and length of consultations, prescriptions, test ordering); and economic variables (cost of the intervention, changes in direct and indirect costs of health care). We will group together comparable studies (clinical activity, outcomes, and type of nurse) and perform a qualitative synthesis of the data unless sufficient studies are found to perform a quantitative meta-analysis.

    A better understanding of the effects of substituting nurses for doctors will help policy makers and healthcare professionals in primary health care to improve quality and optimise the (cost) effectiveness of health services in the future.


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