Nurse practitioners (NPs) and physician assistants (PAs) can autonomously substitute for elderly care physicians (ECPs) in a nursing home setting because of the high level of collaborative care they provide, according to a study published in BMJ Open.

Researchers in the Netherlands selected 7 nursing homes in which NPs (n=3), PAs (n=2), and registered nurses (RNs; n=2) were compared with ECPs (n=15) and medical doctors (n=2). Data collected consisted of observations of the NP/PA/RN and an ECP/MD; interviews with the participants; questionnaires filled out by the NP/PA/RN, ECPs/MDs, and managing directors/managers of the facility; and analysis of internal policy documents.

The clinicians worked in 3 types of units: unit for residents with physical disabilities, dementia special care unit, and geriatric rehabilitation unit. Autonomous substitution for ECPs was present in 4 of the facilities; in 2 cases, the professional was a PA and in 2 cases the professional was an NP. In 3 of the cases, 2 PAs and 1 NP worked on their own unit or units with an ECP in the background as an expert colleague rather than a supervisor; in one case, the NP and the ECP shared responsibility for residents on a unit and worked together closely. Factors that made substitution successful were organizational factors that acknowledge NPs and PAs as independent clinicians, as well as individual factors such as the proactivity of the clinician.

Continue Reading

In facilities 3, 4, and 7, the collaboration between the NP, PA, and ECP was based on trust. The ECP shared responsibilities with the NP or PA, and the clinicians all shared the same views on what constituted good resident care, which was established through the use of ad hoc meetings. In certain cases, however, the ECP did not trust the NP or PA, and responsibilities of care were not equally shared.

Related Articles

In all cases, the professionals performed tasks such as the structural evaluation of restraints, writing care programs, enhancing rehabilitation climate by implementing a breakfast or lunch buffet, educating the care team, and being a member of working groups who discussed specific themes and innovations such as fall prevention.

“Our description of three mechanisms of substitution showed that according to participants, the NPs and PAs are able to deliver similar quality of healthcare as the ECPs, based on the condition that the collaboration between the NP or PAs and the ECP is qualified as successful,” the authors concluded.


Lovink MH, Laurant MG, van Vught AJ, et al. Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: a realist evaluation case study. BMJ Open. 2019;9(5):e028169.