The socioeconomic value of nursing and midwifery : a rapid systematic review of reviews. Interim policy briefing

This report presents the updated findings of a rapid systematic review of reviews which provide evidence of the benefits and costs of nursing and midwifery, both within the healthcare system and wider society. It includes research which evaluates role substitution options, where nurses or midwives take on responsibilities currently undertaken by other health professionals (and vice versa). Division of labour in the health professions is constantly shifting in all directions and it should be noted that role substitution is not simply a phenomenon whereby nurses substitute for doctors. The review also includes research evidence useful to the development of cost-benefit and cost-effectiveness analyses. Given the large volume of research on nursing and midwifery, the scope of the review was targeted to three areas: mental health nursing, long-term conditions and role substitution. The review has benefited from advice on its scope from Commissioners, expert advisers to the Commission, the Commission Support Office, and Department of Health policy advisors. The findings are drawn from 32 systematic reviews conducted in OECD countries, 17 of which were undertaken in the UK. Most relate to care provided by nurses, with only two reviews looking solely at the role of midwives. This imbalance reflects the difficulty of determining the contribution of midwives working in multidisciplinary teams. Indeed it was sometimes difficult to identify nurses’ contributions which were often concealed within multi-professional health care teams. Research evidence was included only where we could ascertain what was done and by whom, and to what other types of care it was compared. Particular types of nursing, e.g. paediatric nursing, or school nursing were unlikely to overlap with our three topic areas, and are therefore absent or under-represented. The included reviews rarely provided cost or cost-effectiveness data. Whilst their authors had often intended to include such analyses, they were frequently limited in this endeavour due to a lack of data in a useable format in the primary studies they contain. Despite these methodological barriers, this review found examples of the benefits of nursing and midwifery in primary care through home visiting interventions, specialist nursing and general practice based nursing including prevention and treatment. Hospital at home and in-patient care were also addressed in the included studies. There was evidence of the benefits of nursing and midwifery for a range of outcomes. This was accompanied by no evidence of difference* in impact between nurses and other providers across other outcomes. An important finding of this review was that nursing and midwifery care when compared with other types of care was not shown to produce adverse outcomes. * The statement “no evidence of difference” does not indicate an absence of evidence nor does it indicate equivalence between comparison groups. Rather it indicates that statistical tests failed to demonstrate a significant difference between nurse/midwife-delivered interventions and those provided by others. Most studies attempt to demonstrate a difference between groups. Demonstrating equivalence, or no difference, is more difficult and relatively rare as this requires a much larger study. Key findings Long term conditions Interventions provided by specialist nurses or led by nurses were shown to have a beneficial impact on a range of outcomes for long term conditions when compared with usual care. Whilst there was little evidence of a difference in clinical benefit of such interventions, there was persuasive evidence that specialised cancer nursing produced benefits in terms of patients’ ability to cope with their condition. Enhanced nursing care for respiratory conditions may result in fewer visits to accident and emergency departments, though there was little evidence of benefit for other outcomes. There may be costs savings associated with nurse-led hospital at home care. General practice nurses may have some benefit in reducing some of the risk factors for heart disease when compared with usual or no care. Whilst cost estimates were provided, overall cost-effectiveness was unclear. Mental health Targeted home visiting by nurses and midwives appears to have a beneficial effect on postnatal depression when compared with routine care. No evidence of a difference in effect was found between home visiting and no home visiting for the amelioration of drug and alcohol abuse in new and pregnant mothers. Mental health nurse-led care compared with usual care does not appear to make a difference in overall readmission rates and psychological symptoms in patients without psychosis. Role comparison Midwife-led care for low-risk women compared to doctor-led care appears to improve a range of maternal outcomes, to reduce the number of procedures in labour, and increase satisfaction with care. There was no evidence of a differential effect for many maternal, foetal or neonatal outcomes, nor was there evidence of any additional adverse outcomes associated with midwife-led care. There is no clear evidence of a differential effect on any outcomes between nurses as first contact and providers of ongoing primary care, and doctors, though patient satisfaction may be higher with nurse-led care. There is no clear evidence of a differential effect on health status, patient satisfaction, quality of care, or resource use between nurses as first contact and providers of emergency care, and doctors, though nurses appear to spend more time with patients. There is some evidence of benefit for nurse-led inpatient units compared with doctor-led units across some outcomes (functional status, psychological well-being, death or discharge to institutional care, re-admission rates). Nurse-led cancer care when compared with doctor-led care appears to be beneficial for physical, satisfaction, and organisational outcomes in some types of cancer. No evidence of a difference between providers was found in terms of survival, psychosocial or resource use related outcomes. Nurse-led care for bronchiectasis patients compared to doctor-led care: there was no evidence of a difference in outcomes (lung function, exercise capacity, infective exacerbations or health-related quality of life). There is some evidence to suggest that hospital admissions are higher in nurse-led care. Specialist diabetes nurse care compared with doctor-delivered care: there was no evidence of a difference in terms of overall glycaemic control though it may be beneficial for patients with poor diabetes control. Evidence about resource use and costs was unclear. Specialist epilepsy nursing care compared with doctor-led care: there was no evidence of a difference in terms of physical or psychosocial outcomes. Secondary prevention care for heart disease provided by specialist cardiac nurses and general practice nurses compared with general practitioners was found to improve mortality rates, general health, diet and levels of exercise and angina symptoms. Other comparative benefits include increased patient follow-up rates and reduced hospital admissions. Cost Effectiveness Very little cost-effectiveness data was available for incorporation into this review. This was due to a) the relatively small numbers of studies addressing costs or cost-effectiveness, and b) limitations in reporting which prevent the use of such data in meta-analyses.