Impact of nurse-led interventions with prescriptive authority on blood pressure control in hypertension management: a systematic review and meta-analysis

Abstract

Background

Since the 1960s, advanced practice nurses have gradually emerged worldwide. They are playing an increasingly role in hypertension management, due to their field of expertise at the interface of nursing and medicine. However, there seems to be little evidence to date of their impact on blood pressure control in hypertension management, even though this is a major chronic pathology, with significant cardiovascular morbidity and mortality. Given the lack of trials assessing advanced practice nurse-led interventions in hypertension management, this systematic review and meta-analysis aimed to evaluate the effectiveness of nurse-led interventions with prescriptive authority in improving BP control compared to usual physician-led care.

Method

A systematic review and meta-analysis of randomized controlled trials (RCTs) focused on our topic were conducted. A random-effects model was used to estimate pooled mean differences for BP reduction and odds ratios (OR) for BP control. Sensitivity analyses and publication bias assessments were performed.

Results

A meta-analysis of five RCTs showed a significant reduction in systolic BP (-17.73 mmHg, 95% CI: -29.19 to -6.27, p = 0.0024, I² = 99.1%). After excluding two highly influential studies, the effect remained significant (-16.54 mmHg, 95% CI: -23.26 to -9.83, p < 0.001) with reduced heterogeneity (I² = 78.4%). For diastolic BP, a meta-analysis of four RCTs reported a reduction of -9.96 mmHg (95% CI: -18.56 to -1.36, p = 0.0232, I² = 95.6%), which remained significant after sensitivity analysis (-13.25 mmHg, 95% CI: -21.63 to -4.87, p = 0.0019, I² = 89.4%). No robust conclusion could be drawn for BP control (OR) due to the limited number of studies.

Conclusion

Nurse-led interventions with prescriptive authority significantly reduced blood pressure levels versus usual physician-led care. These findings support the implementation of advanced practice nurses (or similar) in hypertension management, but more research is needed to improve the evidence given the significant lack of data in the literature.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03328-x.

Background

The International Council of Nurses (ICN) defined in 2020 the APN as “a generalist or specialized nurse who has acquired, through additional graduate education (minimum of a master’s degree), the expert knowledge base, complex decision-making skills and clinical competencies for Advanced Nursing Practice, the characteristics of which are shaped by the context in which they are credentialed to practice.” [1]. The two most identified APN roles are clinical nurse specialists (CNS) and nurse practitioners (NP). A CNS is an “APN providing expert clinical advice and care based on established diagnoses in specialized areas of practice, taking a systems approach to practice as a member of the health care team.” A NP is an “APN integrating clinical skills associated with nursing and medicine to assess, diagnose and manage patients in primary care settings and acute care populations, but also providing ongoing care to chronically ill populations.” [1]. The profession first appeared in the United States and has gradually been established in several countries over the years. To date, it is best established in English-speaking countries, but other countries are gradually catching up, with, for example, France who has implemented it since 2018 (second French-speaking country to implement the profession). One of the missions of these professionals is to provide follow-up care for chronic pathologies such as HTN.

Hypertension (HTN) is defined by a high blood pressure (BP) with a systolic BP (SBP) superior or equal to 140 mmHg and/or a diastolic BP (DBP) superior or equal to 90 mmHg [2]. Called the “silent killer” because of its asymptomatic nature, this disease is a major cause of premature deaths worldwide and can lead to a variety of cardiovascular (CV) complications, including stroke, myocardial infarction and renal failure [3]. In 2015, for example, 8.5 million deaths were associated with HTN [4]. In March 2023, the World Health Organization estimated that 1.28 billion adults aged 30–79 years worldwide had HTN, making it the first chronic disease worldwide [5, 6]. Almost half of adults with HTN (46%) were unaware of their condition. Among hypertensive adults, only 42% were diagnosed and treated, and only 21% were controlled. These alarming rates of screening, diagnosis and control could be explained, at least in part, by therapeutic inertia in the diagnosis and titration of treatment. The lack of medical time may represent a considerable obstacle to these elements and to therapeutic education, which is the keystone of the HTN management to ensure good therapeutic adherence in this context of asymptomatic disease [7]. The implementation of multi-disciplinary management could solve few of these barriers as medication adherence or even accessibility of care.

The role of nurses in HTN management has considerably evolved over the last few decades, particularly with the emergence of the APN profession and its wide range of skills. Literature highlighted the evolution of nursing skills over the years with increasing independence in practice [8, 9]. As nurses’ skills evolved through on-the-job training or graduation, their role in HTN evolved to include physical assessment, medication and lifestyle prescribing, and greater independence in practice. It is worth noting that the range of APNs’ skills can vary widely, depending on the country and the diploma.

This systematic review and meta-analysis were conducted as part of a Ph.D. thesis in public health and nursing on the role of APNs in HTN management in France, with a view to conducting a clinical trial to assess the impact of an APN intervention on BP control compared with usual care in HTN management. To date, there are no data on the impact of an APN intervention on BP control in HTN management in France. This may be due to two factors: (a) the recent and difficult establishment of the profession in the country in 2018, and (b) the need to further develop nursing research in the country. In the absence of publications on this topic in France, preliminary research has been carried out internationally and has revealed very limited data about nurse-led intervention in HTN management, particularly when the intervention falls within the scope of skills associated with advanced nursing practice. To illustrate our point, Clarck et al., mentioned, in their systematic review and meta-analysis aimed to examine nurse-led interventions to improve BP control in hypertensive population, the lack of good quality evidence [10]. The authors retained only 33 RCTs with a wide range of heterogeneity in interventions, and only a tiny proportion of these proposed interventions related to APNs’ skills. Similarly, Smigorovsky et al. also highlighted the lack of data, particularly good quality data, in their systematic review and meta-analysis focused on nurse-led interventions in CVD management [11]. In view of this lack of data, especially when focusing on APNs, the heterogeneity of the nurse-led interventions, and the context in which this study was conducted, it seemed appropriate to extend the scope of our research to include interventions carried out by nurses whose area of expertise was as close as possible to that of APNs in France. The main difference that distinguishes APNs in the clinical aspect of their practice in France is their ability to prescribe/renew therapies previously restricted to doctors, in particular antihypertensive drugs for HTN management. The rest of their management involves skills common to the whole nursing profession, as measurement and monitoring of BP, therapeutic education and support in optimizing lifestyle habits. Thus, this systematic review and meta-analysis aimed to evaluate the impact of nurse-led HTN management with prescriptive authority on BP control, using systolic/diastolic BP (SBP/DBP) reduction and the proportion of patients with controlled BP, versus usual physician-led care in hypertension management. When interpreting the results, it should be borne in mind that they will need to be interpreted differently depending on the nursing and/or APN skills specific to each state.

Methods

Data sources

This systematic review and meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to ensure methodological transparency and rigor.

This systematic review and meta-analysis were conducted between March and April 2025.

Six databases were used: Pubmed, CINHAL, Cairn, Embase, Cochrane and Google scholar.

Protocol registration

A protocol was written for this study and registered at PROSPERO against the registration number CRD420251008654.

Eligibility criteria

To enable us to overview the impact of a nurse-led intervention on BP control and to ensure the robustness of our conclusions, only RCTs were selected. As mentioned earlier, the nurse-led intervention had to include a prescribing authority in hypertension management. Therefore, it had to be clearly explained in the presentation of the intervention that the nurse could prescribe or at least renew the antihypertensive drugs independently (following an algorithm/protocol or not) without having to call on a physician systematically. The intervention also had to be compared to physician management or usual care. Similarly, the description of the control group had to clearly state that the management was routine and/or provided by a physician, as these two methods of management are similar in practice. Finally, given the heterogeneity of the populations identified in preliminary search, and regarding to the context in which this study was carried out, it was decided to set up another major inclusion criterion for populations: adults with HTN.

Some exclusion criteria supplemented the inclusion criteria in relation to the intervention to obtain more specific results. A reference was excluded if (a) it was not possible to clearly identify the nurse-led intervention in the context of interventions carried out by a team of healthcare professionals and/or (b) it could not be independently evaluated.

Search strategy

Research was firstly performed to identify the best MeSH terms and keywords to obtain reliable data about our topic. The search terms used included the following MeSH, keywords and Boolean terms: “nurs*” AND “hypertension” OR “high blood pressure”. The keyword “trial*” was added when it was not possible to apply a filter for study type. For example, the research equation used for Pubmed database was (“nurs“[Title]) AND ((“hypertension“[Title]) OR (“blood pressure“[Title])) and the research equation used for Google Scholar database was (nurs* AND (“hypertension” OR “blood pressure”) AND trial).

Filters were used according to databases’ options: MeSH terms/keywords included in title +/- abstract, RCTs, free full text, English and French languages, adults aged 19 or more and limited to the 2000–2025 period. No filter about geographical location was applied for this systematic review and meta-analysis.

Selection process

Data screening and duplicate removal was carried out by one reviewer. Given the rapid lack of relevant references in the databases (based on titles/ abstracts reading) during the preliminary search, it was decided to include a screening stop after 50 consecutive irrelevant references based on reading the title only for database with more than 1000 references only.

Data analysis of the retained references was carried out independently by two reviewers. A time was set aside to discuss each reference: its relevance to the theme of our systematic review and meta-analysis, its methodology and its results. According to these parameters and our eligibility criteria, it was decided to (not) include these references in our systematic review and meta-analysis.

A final review was then carried out one last time with a third, more experienced reviewer. The references selected constituted our final sample.

Statistical analysis

All references were reviewed in detail to decide whether to include them in each meta-analysis model (SBP, DBP, BP control rate).

All meta-analyses were conducted using a random-effects model to account for between-study variability. The Restricted Maximum Likelihood (REML) estimator was chosen over the DerSimonian-Laird (DL) estimator because it provides a more robust estimate of between-study variance, particularly when the number of studies is limited. Heterogeneity was assessed using Cochran’s Q test, which detects significant heterogeneity, the I² statistic, which quantifies the proportion of variability due to true heterogeneity rather than chance, and Tau², which estimates the variance between study effects.

For SBP and DBP, sensitivity analyses were performed to assess the robustness of the results. The Baujat plot was used to identify studies contributing most to heterogeneity, the Leave-One-Out (LOO) analysis examined the impact of each study by recalculating the pooled effect after its exclusion, and the Influence plot highlighted studies with disproportionate influence on the overall estimate. Publication bias was assessed using a Funnel plot, and in case of asymmetry, the Trim-and-Fill method was applied to estimate the potential impact of missing studies. Additionally, a meta-regression was conducted to examine whether follow-up duration influenced the observed effects.

All analyses were performed in R (Version 2024.12.1 + 563) using the meta package.

Results

Study selection

A total of 1155 references were identified by screening the databases by reading the titles. Note that only two databases required the screening to be stopped after 50 consecutive irrelevant references: Cochrane and Google Scholar.

Of the 618 references retained after duplicate exclusion, 595 were excluded on reading the abstract by the first reviewer.

Among the 23 RTCs assessed for eligibility, only 6 RCTs met all our eligibility criteria. These 6 RCTs were reviewed by all reviewers and constituted our final sample.

A PRISMA flow diagram summarizes the systematic study selection process (Fig. 1).

Fig. 1.

PRISMA flow diagram – systematic study selection process

Study characteristics

A total of six RCTs was included in our systematic review, comparing nurse-led HTN management with usual physician-led care (Table 1). The sample sizes ranged from 76 to 1,407 participants for a total of 2,275 participants. Half of RCTs had for population hypertensive adults with diabetes. All interventions involved prescriptive authority. In most studies, nurses were allowed to adjust or titrate treatment, although the context may be slightly different with drug treatment adjustments using pharmacological treatment algorithms in one study (Tobe et al., 2018). It should also be noted that nurses were restricted to renewals in one study (Yip et al., 2018), which contrasts with the other studies. The comparator in all studies was usual physician-led care. The follow-up periods varied across the included studies, ranging from 3 to 12 months: Guerra-Riccio et al. (2004) assessed outcomes at 90 and 180 days, while Denver et al. (2003) followed participants for 16 weeks. New et al. (2003), Rudd et al. (2004), Tobe et al. (2006), and Yip et al. (2018) all conducted follow-ups over a 12-months period. Among the studies reporting BP changes, nurse-led interventions led to significant reductions in SBP, ranging from − 12.6 mmHg (Denver et al., 2003) to -36 mmHg (Guerra-Riccio et al., 2004, at 180 days). Similarly, reductions in DBP ranged from − 6.5 mmHg (Rudd et al., 2004) to -21 mmHg (Guerra-Riccio et al., 2004), with all results being statistically significant (p < 0.05). Three studies reported controlled BP rates. Denver et al. (2003) found that 38% of patients in the nurse-led group achieved SBP < 140 mmHg, compared to 12% in usual care (p = 0.003). New et al. (2003) reported a 37% higher likelihood of BP control in the nurse-led group (OR = 1.37, 95% CI: 1.11–1.69, p = 0.003). Yip et al. (2018) showed no significant difference between nurse-led and physician-led care in a context of non-inferiority RCT.

Table 1.

Characteristics of included studies

Study (Year, Country)	Type of study	Sample size & Inclusion criteria	Intervention components	Control	SBP change (mmHg)	DBP change (mmHg)	BP control rate (Intervention vs. Control)
Guerra-Riccio et al. (2004, Brazil)	RCT	N = 76, hypertensive patients receiving standard physician care	Frequent nurse visits, BP monitoring, treatment adjustments	Usual care	-35 at 90 days, -36 at 180 days (p < 0.05)	-19 at 90 days, -21 at 180 days (p < 0.05)	Not mentioned
Denver et al. (2003, UK)	RCT	N = 150, Type 2 diabetes patients with uncontrolled HTN	Nurse-led hypertension clinic, lifestyle advice, medication adjustments	Usual physician care	-12.6 (p < 0.0001)	Not mentioned	38% in nurse-led group vs. 12% in control group (p = 0.003)
New et al. (2003, UK)	RCT	N = 1,407 Subgroup: n = 1,014 diabetic patients with HTN ≥ 140/80 mmHg included in BP control protocol)	Specialist nurse-led clinic, lifestyle advice, medication titration	Standard care	-1.95 (95% CI: -4.49 to 0.60, p = 0.13)	-0.79 (95% CI: -2.18 to 0.60, p = 0.27)	Subgroup analysis: 26.6% in nurse-led group vs. 24.1% in control group (OR = 1.14, 95% CI: 0.86–1.51, p = 0.37)
Rudd et al. (2004, USA)	RCT	N = 150, hypertensive patients requiring drug therapy	Nurse-managed intervention, BP monitoring, medication titration	Standard care	-14.2 (p = 0.01)	-6.5 (p = 0.05)	Not mentioned
Tobe et al. (2006, Canada)	RCT	N = 99, First Nations people with HTN and diabetes	Home care nurses following a pharmacologic treatment algorithm	Usual care	-24.0 (p < 0.001)	-11.6 (p = 0.05)	Not mentioned
Yip et al. (2018, China)	RCT, Non-inferiority trial	N = 393, Patients with controlled HTN in primary care	Nurse-led repeat prescription program (renewal only)	Standard care	+ 0.53 (mITT, 95% CI: -2.05 to 3.11) / +0.43 (PP, 95% CI: -2.16 to 3.02)	+ 1.23 (mITT, 95% CI: -0.27 to 2.73) / +1.16 (PP, 95% CI: -0.35 to 2.67)	Not mentioned

The study by Yip et al. (2018) was not included in any meta-analysis model to estimate the impact of nurse-led interventions on BP control because it was a non-inferiority RCT in patients who were already well controlled, with no significant reduction in BP. Therefore, its inclusion in the meta-analyses was not relevant to our objective. It should also be noted that the intervention contrasted with the other interventions (renewal only) and was disadvantageous in terms of heterogeneity.

The study by Denver et al. (2003) was excluded from the DBP meta-analysis model because the study did not report the variation in DBP. Similarly, half of the RCTs could not be included in the meta-analysis model for the OR for BP control because of missing data on the rate of controlled BP (Guerra-Riccio et al. (2004), Rudd et al. (2003) and Tobe et al. (2006)).

Systolic blood pressure

A total of five studies was selected for this meta-analysis (Guerra-Riccio (2004), Denver (2003), New (2003, subgroup), Rudd (2004), Tobe (2006)) (Fig. 1, Supplemental file 1). This last showed a mean reduction of -17.73 mmHg (95% CI: -29.19 to -6.27, p = 0.002) under a random-effects model. Heterogeneity was high (I² = 99.1%).

Sensitivity analysis (Baujat plot, Leave-One-Out, Influence plot) identified Guerra-Riccio (2004) and New (2003, subgroup) as highly influential on the overall effect and heterogeneity (Figs. 1, 2 and 3, Supplemental file 2). After excluding these studies, the effect remained significant at -16.54 mmHg (95% CI: -23.26 to -9.83, p < 0.001), with reduced heterogeneity (I² = 78.4%) (Fig. 2).

Fig. 2.

Primary forest plot for SBP

Fig. 3.

Primary forest plot for DBP

Publication bias assessment via the Funnel plot and Trim-and-Fill method (Supplemental file 3) did not indicate major bias (Fig. 1, Supplemental file 3).

Meta-regression based on follow-up duration did not reveal a significant moderating effect (p = 0.63).

Diastolic blood pressure

A total of four studies was selected for this meta-analysis (Guerra-Riccio (2004), New (2003, subgroup), Rudd (2004), Tobe (2006)) (Fig. 2, Supplemental file 1). This last showed a mean reduction of -9.96 mmHg (95% CI: -18.56 to -1.36, p = 0.02) with high heterogeneity (I² = 95.6%) (Fig. 3).

Sensitivity analysis identified New (2003, subgroup) as highly influential (Figs. 4 to 6, Supplemental file 2). After excluding this study, the overall effect remained significant (-13.25 mmHg, 95% CI: -21.63 to -4.86, p = 0.002) with reduced heterogeneity (I² = 89.4%) (Fig. 3).

Fig. 4.

Primary forest plot for OR of BP control

Publication bias assessment (Fig. 2, Supplemental file 3) and meta-regression by follow-up duration (p = 0.59) showed no significant effects.

Odds ratio for blood pressure control

The pooled estimate suggested a positive trend (OR = 2.06, 95% CI [0.63; 6.70]) despite a wide confidence interval reflecting substantial heterogeneity (Fig. 4). Indeed, The Denver (2003) study showed a significant effect (OR = 3.80, 95% CI [2.49; 5.80]), whereas the New (2003) study presented a more modest and non-significant effect (OR = 1.14, 95% CI [0.86; 1.51]). The random-effects model, based on two studies, estimated a log(OR) of 0.7222 (95% CI: [-0.4575; 1.9019]), without reaching statistical significance (z = 1.20, p = 0.23). Total heterogeneity was high, with τ² = 0.6912, indicating substantial variability between studies. The I² index of 95.37% confirmed that nearly all observed variability was due to differences between studies rather than sampling error. Cochran’s Q test (Q = 21.5992, p < 0.0001) further supported this finding by showing significant heterogeneity.

Only a meta-analysis was performed due to the limited number of available studies for the OR for BP control. Sensitivity analyses such as Baujat, LOO, and Influence plots were not feasible, as removing one study would eliminate the meta-analysis itself. The Funnel plot, Egger’s test, and Trim-and-Fill method were also not conducted, as they require a larger number of studies (typically ≥ 10) to be interpretable. Similarly, a meta-regression was not applicable, as a regression model with only two data points is not statistically meaningful.

Discussion

As a reminder, this systematic review and meta-analysis aimed to evaluate the impact of nurse-led hypertension management with prescriptive authority on BP control versus usual physician-led care in hypertension management. This study was deemed necessary because preliminary research revealed a significant lack of data on advanced nursing practice in HTN management and a complete absence of systematic reviews and meta-analyses of the impact of this specific type of intervention on BP control in HTN management.

Our systematic review highlighted the significant lack of data on this topic, as only six RCTs could be selected. In addition, the power of the selected RCTs was limited due to the small sample size and an estimate of the effect on BP limited by short follow-up periods.

Meta-analyses showed a significant decrease of SBP of -16.54 mmHg (95% CI: -23.26 to -9.83, p < 0.001), with a reduced heterogeneity (I² = 78.4%), a significant decrease of DBP of -13.25 mmHg, 95% CI: -21.63 to -4.86, p = 0.0019) with a reduced heterogeneity (I² = 89.4%). Meta-analysis for the OR of BP control did not show a significant effect of the intervention, but the small number of studies analyzed did not allow us to draw any conclusions.

As mentioned above, the heterogeneity of our results can be explained by several parameters such as the study population, the duration of the study, and other aspects of each intervention that could lead to a difference in results between our studies. Regarding the study population, some of the studies focused on uncontrolled patients (Denver et al. (2003), New et al. (2003)) or even patients with severe HTN (Guerra-Riccio et al. (2004), while others had no inclusion criteria regarding BP control. Two studies also focused on diabetic and hypertensive patients (Denver et al. (2003), New et al. (2003), Tobe et al. (2006)), knowing that it can be more difficult to achieve good BP control in these patients. The study duration ranged from 3 to 6 months (Guerra-Riccio et al. (2004), Rudd et al. (2004)) to 12 months in the other RCTs. BP measurement varied with repeated BP measurements in one study (Guerra-Riccio et al. (2004)) and even BP monitoring in another (Rudd et al. (2004)). Finally, although the heterogeneity of the interventions was largely limited using our inclusion criteria, they still showed notable differences, regarding the presence of an algorithm (Tobe et al. 2006) or frequent visits (Guerra-Riccio et al. (2004)).

Comparison with the literature is difficult given the paucity of data on the added value of advanced nursing practice in HTN management, particularly in our particular area of focus. In 2010, Clarck et al. conducted a systematic review and meta-analysis, from which we shared 5 RCTs in our selection, with the aim of examining trials of a nursing intervention in the context of primary care to clarify the evidence base, determine whether prescribing is an important intervention, and identify areas for further study. This systematic review and meta-analysis identified 33 RCTs with a total of 18,481 participants. Although their conclusions corroborate ours with a proven effectiveness of nursing intervention on BP control in HTN management, the effect on the difference in SBP and DBP was significantly smaller [10]. Subgroup analyses were performed for interventions where the nurse had prescriptive authority and showed: a weighted mean difference in SBP of -8.2 mmHg [-11.5; -4.9] for interventions with a treatment algorithm, a mean difference of -8.9 [-12.5; -5.3] mmHg for SBP and − 4.0 [-5.3; -2.7] mmHg for DBP, much smaller differences compared to our results. These differences can be explained, on the one hand, by the high degree of heterogeneity of our results due to the small number of studies included in our systematic review and meta-analysis, and, on the other hand, by the possible presence of confounding factors in the studies selected by Clarck et al., particularly due to certain group interventions where the nurse prescription could not be analyzed in isolation. Indeed, as a reminder, our eligibility criteria allowed a more targeted estimation of the impact of nurse-led interventions with prescriptive authority on BP control by limiting confounding factors, in particular multiprofessional intervention models where the impact of this specific skill could not be isolated.

Strengths and limitations

The main limitation of our study is the small sample size, as only 6 RCTs were included in our systematic review. This can be explained partly by the scarcity of literature, but also by our eligibility criteria. Although this choice allowed us to better evaluate the impact of nurse-led intervention with prescriptive authority on BP control in HTN, it also significantly reduced the size of our sample, the power of our study, and the relevance of our results. Despite these shortcomings, our systematic review and meta-analysis has two major advantages: it has highlighted the significant lack of data, particularly of good quality, on our topic, and it has provided an initial summary of the few RCTs conducted on our specific topic, in the absence of a study such as ours in the literature.

As mentioned above, and despite our strict eligibility criteria, the other main limitation of our study was the heterogeneity of the included studies, particularly in terms of population, intervention protocols, and blood pressure measurement methods, limits the generalizability of the results to the broader hypertensive population. This heterogeneity in the included studies also emerged in the results of the analyses conducted. Nevertheless, our statistical analyses made it possible to limit this phenomenon. The transition to a random effects model allowed us to consider the differences between studies. The exclusion of influential studies (Guerra-Riccio 2004 and New 2003, subgroup) allowed us to obtain more homogeneous results. The sensitivity analyses (Leave-One-Out, Baujat, Influence plot) allowed us to check the robustness of the conclusions. Finally, the meta-regression allowed us to test potential explanatory factors (follow-up, intervention). Our statistical analyses thus reduced the heterogeneity of our results without compromising the significance of the estimated effects. Other statistical approaches to further reduce the heterogeneity of the results were limited by the very small number of studies included in our models. The production of scientific data in years to come and the inclusion of a greater number of studies in future meta-analysis models will undoubtedly make it possible to better estimate the effects of our intervention.

Implications

The lack of data identified in our literature review, with no studies identified for the period from 2006 to 2018, contrasts with the progress made in the nursing profession in recent years. There is a total lack of data on this subject in Europe (except the UK), even though nursing has evolved considerably there in recent years with the gradual implementation of advanced nursing practice, as in France, Germany and Spain, for example. Even in countries where advanced nursing practice has been in place for more than fifty years, such as Canada and the United States, there is again very little data. Canada is, however, an example in terms of the implementation of advanced nursing practice, the involvement of nurses in the management of hypertension and the optimization of hypertension control. Indeed, the country set up the Canadian Hypertension Education Program in 2000 which aimed to involve nurses more with easier access to them; and authorizing (1) screening (2), ambulatory BP measurements (3), therapeutic adjustments using a national protocol for nurse clinicians and finally authorizing (1) diagnosis and (2) initiation of antihypertensive treatments to nurse practitioners [12]. The country has thus seen a remarkable improvement in the rate of knowledge and control of hypertension, rising from 13% to over 80% for the former and from 10 to 70% for the latter between 1990 and 2010 [13, 14]. In view of this progress, it seems a matter for regret that there is not more data on the impact of nursing interventions, particularly those with prescriptive authority, on BP control in hypertension management.

As a reminder, HTN is a major and reversible CV risk factor on the one hand, but also the most common chronic pathology in France and worldwide with consistently poor rates of awareness, treatment and control, particularly in France where no improvement has been observed in its management for some twenty years [15, 16]. Beyond our subject, it also seems essential to conduct research projects to assess the impact of nursing interventions on CV morbidity and mortality in hypertensive patients and the impact of nursing interventions on healthcare costs. These two parameters are major elements in assessing the effectiveness of interventions in care and in supporting public health decisions and policies. In 2024, Guo et al. published the results of their RCT aimed to demonstrate the effectiveness of a multifaceted intensive BP control model on CV morbidity and mortality in hypertensive adults [17]. The total sample included 33,995 participants. The care model included, in particular, the intervention of non-physician healthcare providers with a scope of practice comparable to that of APNs in France and the interventions selected in our study. This RCT provided the first data on the impact of this type of multiprofessional care model and showed a significant benefit in favor of the model tested on CV morbidity and mortality in hypertensive patients. Although the intervention of these healthcare providers cannot be evaluated in isolation and is subject to confounding factors such as stricter blood pressure control with a target of less than 130/80 mmHg, it has demonstrated significant benefits in terms of both BP control and CV morbidity and mortality. Despite the results of this large trial, there is still a need for similar and more targeted RCTs to estimate the impact of nurse-led interventions with prescriptive authority on CV morbidity and mortality, on a larger scale, on health care costs as mentioned above, particularly in Europe.

In light of the above, we support the urgent call to action for nurses to improve HTN control and CV health, particularly by engaging in research, issued by Hannan et al. in 2022 [18]. They challenged nurse researchers to address current challenges in CV health and HTN control, prioritizing research where there is insufficient evidence to guide practice. Our systematic review and meta-analysis highlighted the lack of data on the impact of nursing interventions with prescriptive authority on BP control in HTN management. It is therefore essential that research projects on this topic are carried out in the coming years and extended to include CV morbidity and mortality and healthcare costs to better objectify their impact on the care of hypertensive patients.

Conclusion

This systematic review and meta-analysis provided, for the first time, a synthesis of RCTs assessing the impact of a nurse-led intervention with prescriptive authority on BP control in HTN management. In the absence of major publication bias and after adjustment for confounding factors, this meta-analysis demonstrated the effectiveness of these interventions in reducing SBP and DBP levels and reinforced the idea that the involvement of APNs (or similar) in HTN management improves BP control. However, given the significant lack of data, particularly of good quality and in certain regions such as Europe, these results must be interpreted with caution, and further research is needed to improve the evidence.

Electronic supplementary material

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Abbreviations

APN

Advanced Practice Nurse

CV

Cardiovascular

(S/D)BP

(Systolic/Diastolic) Blood Pressure

HTN

Hypertension

RCT

Randomized Controlled Trial

Author contributions

JV conducted this systematic review and meta-analysis. HL provided a review of references. JB supervised this work and provided a review of references. All authors reviewed the manuscript.

Funding

None.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.