Featured Review: Barriers and facilitators to the implementation of doctor‐nurse substitution strategies in primary care

What factors influence implementation of doctor-nurse substitution strategies in primary care?

  • Nurses as substitutes for doctors in primary care: evidence from 66 qualitative studies
  • Patients may accept the use of nurses to deliver services that are usually delivered by doctor
  • Implementation prompts have been developed to help programme managers who are considering implementing task-shifting strategies

 Many people do not get the healthcare they need because of a lack of healthcare workers where they live. Governments across the world are trying different solutions to address this problem. One possible solution is to move tasks from more-specialised to less-specialised health workers, for instance, moving certain tasks from doctors to nurses.

In this Cochrane Review of qualitative studies, the review authors working with the Cochrane EPOC (Effective Practice and Organisation of Care) Group explored peoples' views and experiences of moving tasks from doctors to nurses in primary healthcare, it includes 66 studies (69 papers).

This qualitative evidence synthesis links to another Cochrane Review published in 2018 that assesses the effectiveness of moving tasks from doctors to nurses in primary care. Doctor-nurse substitution is a complex intervention. The Cochrane intervention review on doctor-nurse substitution concluded that the effectiveness of doctor-nurse substitution initiatives was promising. However, the level of organisation and support used in these trials may have been higher than in real-life settings. When implementing complex interventions, we need to consider the contextual factors of each setting. This includes a proper understanding of the factors that might influence the intervention’s implementation, success and sustainability. These factors could include the values and preferences of stakeholders and the feasibility and applicability of the intervention for particular settings and health care systems. Our synthesis of qualitative evidence helped to identify factors influencing the success of substitution interventions, including the attitudes and experience of the health workers themselves and also those of other stakeholders.

Lead author of this Cochrane review Elham Shakibazadeh concluded, “Many people do not get the healthcare they need because of a lack of healthcare workers where they live. Governments across the world are trying different solutions to address this problem. One possible solution is to move tasks from more-specialised to less-specialised health workers, for instance, moving certain tasks from doctors to nurses.”

“Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.”