'White coat effect' smaller for nurses than doctors

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Mean blood pressure readings lower for nurses compared to those made by doctors at same visit.

'White coat effect' smaller for nurses than doctors
'White coat effect' smaller for nurses than doctors

HealthDay News -- Doctors' readings of blood pressure are often higher than measurements made by nurses at the same visit, according to researchers.

In an analysis of data from 15 studies, nurse-measured BP readings were lower an average of -7.00 mm Hg systolic and -3.8 mm Hg diastolic than doctors' measurements, Christopher E. Clark, PhD, from the University of Exeter in the United Kingdom, and colleagues reported in the British Journal of General Practice.

"This systematic difference has implications for hypertension diagnosis and management," the researchers wrote.

They conducted a systematic literature of 11 studies involving hypertensive populations and four studies involving mixed hypertensive and normotensive populations to identify differences in mean BP measurements by doctors and nurses at the same visit.

Overall, doctors' readings were more frequently used than nurses' readings to diagnose white coat hypertension (relative risk, 1.6; 95% CI=1.2-2.1), the researchers found.

Differences in mean BP readings were seen among patients both with and without hypertension, but the difference was smaller when the researchers accounted for the risk of study bias (systolic −4.6 mm Hg; diastolic −1.7 mm Hg), the researchers found. Measurement disparities appeared to be greater for female than for male study participants.

"Nurses' [BP] readings are better predictors of early target organ damage in hypertension than doctors' readings, but they do not eliminate the white coat effect compared with home or ambulatory readings," the researchers concluded. "Automated office [BP] readings may yield readings lower than those obtained in the presence of health professionals by reducing (but not abolishing) white coat effects."

In an accompanying editorial, Christine A'Court, a clinical researcher and general practitioner (GP), and Richard J. McManus, a primary care professor and GP, both of the Nuffield Department of Primary Care Health Sciences and the University of Oxford in the U.K., said the study findings raise important implications for clinical practice.

"[T]he prudent practitioner would ensure nurse-led blood pressure measurement is recorded," they wrote. However, they noted that GPs who continue to rely on nurse-led BP measurement should recognize that it does not eliminate white coat hypertension.

"Future service design might incorporate fully automated manometers used in patients seated restfully, but alone in a clinic setting," Court and McManus wrote. "The observed difference in systolic blood pressure of 5–13 mmHg between such readings and manual readings, and the apparent proximity of the readings to ‘gold standard' ambulatory readings needs further evaluation, but offers the prospect of an on-site measurement which could be

combined with same-day clinical decision-making."


  1. Clark CE et al. Br J Gen Pract. 2014; doi:10.3399/bjgp14X677851.
  2. A'Court C, McManus RJ. Br J Gen Pract. 2014; doi: 10.3399/bjgp14X677734.

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