The July/August 2026 edition of Missouri Medicine includes our critique of Cochrane’s misleadingly titled review about nursing care in hospital settings.
When released in February 2026, the article by nurses Michelle Butler and Marcia Kirwan (and other other authors) entitled “Substitution of Nurses for Physicians in the Hospital Setting…” began to immediately spread misinformation about the efficacy of independent nurse-led care in hospitals. This review claimed that there is “little difference” in the outcomes of nurses substituting physicians vs. physician-led care. The conclusion even claimed that nurses substituting physicians may result in better outcomes in some cases.
But what does the research used in this review by Cochrane really tell us? We conducted a detailed structured analysis of the 82 trials included in their review. Only 10 of them evaluated inpatient hospital care – all of which involved stable or selected patients, and all of them in physician-led or supervised settings. Eleven of the studies addressed low-acuity or pre-operative settings. The remaining majority focused on office-based, outpatient, and protocol-driven care for stable conditions, and often with physician oversight. Of the only 10 inpatient studies, four involved skilled nursing facility care where nurses were acting in nurse roles without making medical decisions; three were of nurses acting as residents in a hospital ward where they were closely supervised by physicians, and provide care to only part of the patient hours per week.
In two of the three studies, nurses were only there 33% of the week. Attributing patient outcomes to the nurses when they were supervised and only with the patients one-third of the hours of the week is very misleading.
In one of the studies in particular, Pioro, the nurse practitioners declined to accept patients, and physicians also declined to transfer patients to the NP service. 47% of the patients on the NP service were cared for by the resident physicians.
The fact is that most of the care on the “nurse” service was delivered by physicians – these studies were comparing physicians to physicians and you would expect to find no difference.
Not one study in this Cochrane Review by Butler evaluated independent, nurse-led management of hospitalized patients or intensive care. A more fitting title would be review of nursing protocols with physician oversight, or review of specially trained nurses for low risk procedures in low risk patients.
In addition, Butler inappropriately used meta-analysis methods and pooled studies that were widely disparate in methods, interventions, and the underlying clinical question. The studies used for this review ranged from NICU patients to low-risk breast cancer follow up care.
How can Cochrane say that there’s no difference in hospital care between nurses and physicians?
We call on Cochrane to retract this report and apologize for their flawed and misleading article The Missouri State Medical Association (MSMA) has been on a mission to protect the health of Missourians since 1850. We are grateful to MSMA for publishing our analysis in response and for helping to spread awareness about the erroneous conclusions in Cochrane’s February review.
Learn more on Missouri Medicine, July/August 2026, Page 284 >
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