Efficacy, Effectiveness, and Efficiency of Nurse‐Led Interventions: Insights From a Critical Systematic Review

ABSTRACT

Healthcare systems worldwide face mounting pressure to deliver high‐quality care while enhancing efficiency and sustainability. Nurse‐led interventions have emerged as promising strategies to optimize care delivery, particularly within value‐based health systems. However, a comprehensive understanding of their clinical impact and economic value remains limited. This systematic review conducted following PRISMA guidelines, searched nine international databases to identify and synthesize formally evaluated nurse‐led interventions, programs, and strategies. Twenty‐eight studies were included, encompassing diverse care settings and patient populations. Most studies reported improvements in clinical outcomes, including reduced hospital readmissions, enhanced quality of life, and improved chronic disease management. Several interventions analyzed effectiveness, particularly those involving advanced nursing roles such as nurse practitioners and case managers. Findings suggest that clinical effectiveness does not necessarily translate into increased professional authority: nurse‐led interventions consistently generate value across patient, organizational, and systemic dimensions, yet nursing leadership remains structurally subordinate within healthcare governance. A systematic agenda for rigorous economic evaluation embedded in nursing research programs is urgently needed, alongside structural reforms that redistribute authority—not merely develop competencies—within healthcare organizations.

1. Introduction

The role of nursing has evolved substantially over recent decades, with nurses increasingly assuming advanced clinical, educational, and managerial responsibilities. Health system reforms and global policy frameworks have progressively supported this expansion, recognizing nurses as key agents for driving quality improvement, innovation, and sustainability in healthcare delivery (Brown 2019; Aspinall et al. 2021; Parsons and Cornett 2011; Figueroa et al. 2019). At the international level, the WHO Global Strategic Directions for Nursing and Midwifery (WHO 2024) explicitly promotes the development of leadership competencies and the advancement of nurses into governance and management positions—not only to strengthen health system performance but also to reduce persistent gender disparities and hierarchical models in healthcare leadership. Similar efforts can be observed in Spain, where initiatives such as the forthcoming Centro de Liderazgo Enfermero, to be launched in 2025 by the Consejo General de Enfermería, highlight the urgent need for stronger nursing involvement in strategic decision‐making and health policy (Romero 2025).

This broadened scope and responsibility within nursing have not been matched by a corresponding increase in organizational authority or influence over strategic decision‐making. Although there is evidence of clinical effectiveness, nursing leadership continues to be primarily limited to operational and coordination roles rather than engaging in strategic governance. According to Abbott's (1988) theory of professional jurisdiction, nursing occupies a “residual” professional space—focused on interpersonal, educational, and coordinating tasks traditionally delegated by medicine—without challenging medicine's primary claims over diagnosis, treatment protocols, and organizational control. This paradox—where clinical success exists without accompanying structural authority—raises important questions about the political and economic dynamics of healthcare work and the enduring gendered hierarchies that define professional boundaries. The ongoing marginalization of nursing from executive decision‐making, despite nurses managing complex clinical programs, suggests that barriers to nursing leadership are not mainly technical (such as lack of evidence or training) but are structural—rooted in professional dominance and gendered organizational cultures (Patrick and Laschinger 2006; Martini et al. 2025). Beyond holding formal leadership titles, nursing leadership increasingly involves influencing clinical practice, shaping care delivery, and promoting professional autonomy across all levels of organizations (Horning and Taylor‐Pearson 2024; Junttila et al. 2023; Porter‐O'Grady et al. 2025). Nursing leadership roles extend from direct patient care to senior executive positions, including chief nursing officers and hospital CEOs (Downey et al. 2011; Lúanaigh and Hughes 2016; Flaubert et al. 2021; Englebright Perlin 2018).

This expansion has materialized in the growing number of nurse‐led interventions, which translate professional competencies into improvements in patient outcomes, care processes, and organizational performance. Evidence demonstrates that nurse‐led programs can enhance quality of life, reduce adverse events, hospital readmissions, and length of stay, and promote interprofessional collaboration and job satisfaction (Grinberg and Sela 2022; Pursio et al. 2023; Specchia et al. 2021; Mamdouh Elkholy et al. 2020; McSherry et al. 2012). However, much less is known about their economic impact and overall efficiency of the interventions within health systems.

In an era of increasing financial pressure, demonstrating clinical efficacy and effectiveness alone is no longer sufficient. Healthcare systems are shifting toward value‐based care models, which emphasize efficient use of resources to achieve optimal patient outcomes (Fernández‐Salido et al. 2024). Evaluating the efficiency and cost‐effectiveness of nurse‐led models has become essential to validate their contribution to the sustainability of health system performance. Although emerging evidence suggests that these models can deliver high‐value care and generate cost savings, their systematic evaluation remains limited by structural barriers—including insufficient training in health economics, weak institutional support for nursing research, unclear role definitions, and lack of engagement in strategic and budgetary decision‐making (Clarke et al. 2021; Alexander et al. 2022; Elsheikh et al. 2023). Limited financial literacy within the profession continues to restrict nurses' capacity to influence resource allocation (Bayram et al. 2022).

The requirement that nursing continuously demonstrate its economic value through cost‐effectiveness analyses (CEAs) reveals an asymmetry of epistemic burden rarely imposed on medical specialties, whose authority is presumed rather than proven (Reverby 1987). While financial literacy and economic evaluation capacity remain tactically necessary for nursing leaders to navigate organizational decision‐making, the framing of evaluation gaps as primarily capacity deficits obscures deeper questions: why must nursing justify contributions in economic terms legible to managerial frameworks while medicine retains authority to define value on clinical grounds? As Folbre (2006) argues, conventional economic frameworks systematically render invisible the forms of work—emotional labor, coordination, health education, and relational continuity—at which nursing excels, valuing instead the technical interventions and productivity metrics privileged within medicalized and managerial paradigms.

Bridging this evidence gap is essential not merely to validate nursing's contributions within existing frameworks but to interrogate the structural conditions that constrain nursing's authority despite demonstrated effectiveness. Current evidence on efficiency of nurse‐led interventions remains fragmented—a fragmentation that may reflect not inadequate research capacity but nursing's contested professional status within healthcare hierarchies (Freidson 1970).

The present systematic review aims to identify and map effective and efficacy interventions, programs, and strategies led by nurses across healthcare settings, with particular focus on whether their efficiencies have been formally evaluated through economic assessments. Beyond cataloguing evidence of clinical and economic impact, this review critically examines how “nursing leadership” is conceptualized, operationalized, and evaluated—interrogating the structural conditions that enable or constrain genuine nursing authority within healthcare organizations. By synthesizing existing evidence through theoretical frameworks of professional jurisdiction, organizational governance, and the political economy of care work, the review seeks not merely to establish nursing's value within existing paradigms but to illuminate the contested terrain where nursing's professional claims encounter medical dominance and managerial control.

2. Theoretical Framework

This review employs a critical interpretive approach rather than a solely evaluative one. While it synthesizes evidence concerning the efficacy, effectiveness, and efficiency of nurse‐led interventions, it also aims to examine the structural conditions that define, enact, and assess nursing leadership within healthcare organizations. Four complementary theoretical frameworks inform the analysis of the findings.

• 1.Abbott's theory of professional jurisdiction (1988) offers a framework for understanding how nursing leadership is situated within broader professional divisions of labor and how authority over clinical, managerial, and strategic domains is allocated.
• 2.Freidson's concept of subordinate professionalism (1970) aids in interpreting tensions between operational autonomy and limited structural authority, especially in contexts where nurses are responsible for implementing organizational initiatives but do not control them.
• 3.Foucauldian ideas of governmentality and disciplinary power (Foucault 1991) provide a perspective through which leadership development programs, succession planning, and financial literacy initiatives can be viewed not only as tools for empowerment but also as technologies that shape professional identities and align nursing practices with organizational goals.
• 4.Drawing on Folbre's political economy of care (2006), the review investigates how dominant economic models may undervalue relational, educational, and coordinative aspects of nursing work, thereby affecting which contributions are recognized in economic evaluations.

Collectively, these perspectives facilitate a critical analysis of nurse‐led interventions that goes beyond clinical and economic outcomes to explore issues of authority, governance, professional jurisdiction, and the valuation of care work.

3. Methods

A systematic literature review was conducted including all types of studies evaluating clinically and efficiently nurse‐led interventions, following the PRISMA 2020 statement according to EQUATOR guidelines.

3.1. Search Methods

A comprehensive search was performed in nine electronic databases: PubMed, Web of Science, Scopus, CINAHL, Center for Reviews and Dissemination (including DARE and NHS EED), HTA Database, RedETSA – BRISA, ECONLIT, and Cochrane Library. Grey literature search in Google Scholar and citation tracking was also performed. The search strategy included terms related to nursing leadership positions (e.g., “nurse manager”; “head nurse”) roles and interventions (e.g., “nursing decision‐making”; “nursing influence”), and health and efficiency outcomes (e.g., “resource management”; “patient ouctomes”; and “cost”). Search terms such as “nurse manager,” “nurse intervention,” and “efficiency” were adapted to each database's specific requirements using appropriate truncation and connected with Boolean operators (the complete search strategy is provided in Supporting Information S1: Supplemental Information 1). Searches were conducted from January 2025 to April 2025.

3.2. Inclusion and Exclusion Criteria

All articles were included regardless of publication date or language, provided they evaluated governmental, managerial, or clinical interventions designed or led by nurses, regardless of role—from Chief Nurse Officers to frontline clinical nurses. Studies included governance interventions, management and resource interventions, and nurse‐led interventions with or without CEAs. Literature reviews, including systematic reviews and meta‐analyses, were excluded from the review results but consulted for theoretical framework development and discussion.

3.3. Study Screening and Data Abstraction

Two reviewers conducted study screening in two stages. The lead author (A.F.J.) selected studies based on title and abstract to assess potential eligibility, with initial screening reviewed by the second author (M.T.‐B.). Full‐text reviews were performed for studies meeting inclusion criteria or when eligibility could not be determined from title or abstract alone. For duplicate publications, only one version was included. Artificial intelligence tools assisted with translation when needed, though no included papers presented comprehension barriers.

All studies meeting inclusion criteria underwent data extraction conducted independently by two authors using a predesigned database to systematically gather identification details, sample characteristics, methodological aspects, leadership features, intervention specifics, cost data, evaluation metrics, key findings, and conclusions. It is relevant to specify that the interventions were classified based on a brief description, the sociodemographic characteristics of the leaders, the nursing leadership and managerial roles developed in the intervention, and the interpretation of these roles by the authors.

To facilitate synthesis and presentation of findings, outcomes reported across included studies were organized into three interdependent levels—patient outcomes, professional outcomes, and organizational outcomes—consistent with contemporary frameworks of value‐based healthcare that conceptualize health outcomes as multi‐level phenomena spanning clinical, functional, and systemic dimensions (Fernández‐Salido et al. 2024; WHO 2024). This framework allows for a structured appraisal of the impact of nurse‐led interventions across clinical, workforce, and institutional dimensions.

3.4. Quality Appraisal

Two authors assessed risk of bias for each included study, with disagreements resolved through discussion until consensus was reached. Study quality was rated using the Joanna Briggs Institute (JBI) tools for both economic evaluation studies and nurse‐led interventions evaluated without cost analysis. The JBI tool questions were answered as “yes” (criterion met, 1 point), “no” or “unclear” (criterion unmet, 0 points), or “not applicable,” with readjusted global scores and thresholds established (1–3 = high risk of bias, 4–6 = moderate risk of bias, and 7–10 = low risk of bias) (Barker et al. 2023; Stone et al. 2024).

All economic evaluation studies underwent additional quality assessment using the Quality of Health Economic Studies (QHES) grading system as a double‐check. The QHES instrument evaluates cost‐minimization, cost‐effectiveness, and cost‐utility analyses, with a perfect quality score of 100. Quality scores were calculated by summing points for questions answered “yes,” allowing stratification of studies by quality level (Ofman et al. 2003). Four quality categories (QC1–QC4) were defined based on obtained scores, with higher categories indicating higher methodological quality (Chiou et al. 2003; Perea‐Bello et al. 2024).

Quality assessment scores were incorporated into the data extraction table. No studies were excluded based on risk of bias or low‐quality scores.

4. Results

A total of 8021 titles were identified through the initial database search. After removing duplicates, 5114 were screened based on titles and abstracts. Fifty‐seven studies were selected for full‐text review, of which 27 met all inclusion criteria. One additional cost‐effectiveness study was identified through citation tracking, but no other records were identified via other methods such as websites or organizations, resulting in the 28 included studies (See PRISMA Diagram in Supporting Information S2: Supplemental Information 2).

4.1. Risk of Bias Assessment

Among the 28 studies, 11 reported cost‐related data and 2 additional studies mentioned intervention costs without any formal analysis. Of the 11, only two constituted complete economic evaluations using cost‐utility analyses with incremental cost‐effectiveness ratios (ICERs). Five studies conducted partial economic evaluations—two cost–benefit analyses (CBAs) and three CEAs without QALY measurement or ICER. The remaining four studies conducted cost comparison analyses without standardized outcome metrics.

QHES quality assessment revealed heterogeneous methodological quality across these studies. Three studies scored 76 or above (QC4), five scored between 51 and 75 (QC3), two fell within the QC2 range (26–50), and one was categorized as QC1 (0–25). Both complete economic evaluations achieved QC4 scores. Among the partial evaluations, scores varied considerably—from QC1 to QC4—reflecting the heterogeneity within this category in terms of methodological rigor. These results aligned with JBI scores and related risk of bias thresholds, with all studies exceeding the high risk of bias threshold except one.

Most studies (60.71%) focused on evaluating effectiveness of nurse‐led interventions primarily in terms of health outcomes and quality of life. All scores exceeded the high risk of bias threshold except one study. All studies reported their aims measurably, and conclusions were justified and related to study results. The complete scores and graphs representation are available in Supporting Information S1: Supplemental Information 1.

As previously noted, to evaluate the quality of the interventions, a systematic categorization of the interventions and roles was established to assess the leadership role of nursing in the implementation process and the development of the study, given that the study design was not typically characterized by nursing. Moreover, outcomes evaluated in each of the interventions are presented too in order to define the most prevalent items analyzed (see the Detailed Classification of Included Interventions in Supporting Information S3: Supplemental Information 3).

4.2. Characteristics of Included Studies

Publications (n = 28) were conducted in nine countries: United States (n = 13), United Kingdom (n = 4), China (n = 3), Canada (n = 2), Australia (n = 2), Spain (n = 1), Israel (n = 1), Germany (n = 1), and Pakistan (n = 1). Research was developed mostly in hospital clinics, including emergency departments (64.29%; n = 18), being clinical interventions the most predominant and showing nursing leadership in developing new clinical or management roles leading patient care, coordinating interdisciplinary teams, and managing resources. The most common health problems were cardiovascular diseases with interventions related to educational and follow‐up programs promoting patients' self‐management. About population age range, only a 7.14% (n = 2) of the studies were implemented in pediatrics. The 32.14% (n = 9) of the interventions applied to population over 60 years old, and the 28.58% (n = 8) did not report age data of the sample.

Clinical interventions were most predominant, showing nursing leadership in developing new clinical or management roles leading patient care, coordinating interdisciplinary teams, and managing resources. Educational or preventive programs emphasized patient empowerment as the main leadership trait. Management interventions situated nursing leadership in developing new care programs, staff management, and new roles.

None of the papers reported full demographic data on leaders who designed or implemented interventions. Only one paper described that 92% of team leaders had a mean age of 44 years, were female, and American white (Markkanen et al. 2024). Most studies (43%, n = 12) were designed by non‐clinical researchers, with only 25% (n = 7) designed by nursing teams. The remainder were designed by multidisciplinary teams (n = 2) or executive boards (n = 7), where Medical Directors typically held dominant decision‐making authority despite nursing representation. Of the 11 interventions designed by nursing or interdisciplinary teams, most (n = 9) focused on clinical effectiveness or efficacy, while only two addressed economic outcomes.

All interventions were implemented by nurses, with 64.29% implemented by registered nurses or clinical specialists, while only eight interventions were delivered by nurses in managerial roles. In two cases, human resources or other healthcare professionals participated under nursing supervision. Nurses thus consistently occupied the implementation role regardless of who designed or governed the intervention (see Table 1). Only Liu et al. (2009) explicitly examined structural authority, finding that just 19% of nurse executives in service‐line organizations reported having nursing line authority over staffing and budgets, compared to 100% in traditional discipline‐based structures. Succession planning programs (Phillips et al. 2018; Morris et al. 2020; Brunero et al. 2009) did not assess whether promoted nurses gained substantive authority over budgets, policies, or organizational priorities. No studies explicitly evaluated whether nurse‐led governance altered organizational priorities, resource allocation processes, or decision‐making structures.

Table 1.

Design and implementation of the intervention.

Leadership characteristics	Number of studies n (%)
Designers	28 (100)
Nursing units	7 (25)
Interdisciplinary teams	2 (7.14)
Executive board	7 (25)
Others (university researchers, associations, or others)	12 (42.86)
Implementation role	28 (100)
Clinical nurse	13 (46.43)
Advanced nurse practitioner/specialist nurse	5 (17.86)
Nurse managers or nurse executives	8 (28.57)
Others (in collaboration with nurses)	2 (7.14)
Intervention type	28 (100)
Clinical	13 (46)
Prevention and education	8 (29)
Management	7 (25)
Duration of the intervention	28 (100)
< 6 months	1 (3.57)
6 to < 12 months	7 (25)
12 to < 18 months	8 (28.57)
18–24 months	4 (14.29)
> 24 months	3 (10.71)
nd	5 (17.86)
Time horizon of the study	28 (100)
12 months	4 (14.29)
24 months	1 (3.57)
60 months	1 (3.57)
72 months	1 (3.57)
nd	21 (75)
Use of technology	28 (100)
Telemonitoring	2 (7.14)
Telehealth	2 (7.14)
IT systems (scheduling, protocols)	3 (10.71)
Ultrasound‐guided procedures	1 (3.57)
No technology use or not specified	20 (71.43)
Intervention setting	28 (100)
Hospitalization	18 (64.29)
Outpatient visits	2 (7.14)
Primary care	5 (17.86)
Home care	3 (10.71)
Health problems	21 (75)
Cardiovascular disease	7 (25)
Diabetis	2 (7.14)
Wounds	1 (3.57)
Tabaquism	2 (7.14)
Surgery	2 (7.14)
Sleep	1 (3.57)
Others or unspecified	6 (21.43)

Nurse‐led interventions produced health‐relevant outcomes that extend beyond the individual patient, encompassing the professional workforce and the broader organizational context in which care is delivered (Figure 1). Several outcome domains—including length of stay, readmission rates, and patient complications—emerge at the intersection of patient and organizational levels, reflecting their dual relevance as indicators of care quality and system efficiency alike. However, no health benefits were identified for the nursing workforce. This integrative pattern reveals that the value generated by nurse‐led interventions is not reducible to any single level of analysis but rather manifests as a system of reinforcing effects across clinical, workforce, and institutional dimensions.

Figure 1.

Three interdependent level outcomes of the nurse‐led interventions.

4.3. Patient Outcomes: Quality of Care Received

A total of 60.71% studies reported patient‐related outcomes. Most were clinical interventions (41.18%) or educational and prevention programs (41.18%), while three management‐focused interventions (17.64%) additionally described patient outcomes.

The most frequent benefits reported were shorter hospital stays, lower readmission and emergency visit rates, and fewer complications (Barth 2001; R. Harris et al. 2005; Zhang et al. 2018; Huang et al. 2022; Madrigal et al. 2023). Other studies highlighted faster wound healing (C. Harris and Shannon 2008), improved psychological well‐being (Zhang et al. 2018), sleep quality (Reynolds et al. 2020), nutritional status, and patient independence (R. Harris et al. 2005). Supporting Information S4: Supplemental Information 4 offers extra information for Patient Benefits.

Nurse‐led educational programs demonstrated positive effects on cardiovascular disease management and quality of life, both as secondary prevention after discharge and as primary prevention in at‐risk patients (Barth 2001; Hebert et al. 2008; Carrington and Stewart 2015; Seidl et al. 2015). Smoking cessation interventions achieved increased abstinence rates, with number of nursing visits being a key determinant (Ali et al. 2023; Martínez et al. 2023), as were greater odds of completing vaccination in nurse‐led campaigns (Nyamathi et al. 2009). However, a medication education program (Nurit et al. 2009) showed limited effectiveness, largely due to nurses' high workload and cultural factors reinforcing physicians as medication reference professionals.

Management‐focused studies also reported patient‐level improvements, such as enhanced rehabilitation through reductions in postoperative pain, malnutrition, deep vein thrombosis, and hospitalization time (R. Harris et al. 2005; Odom et al. 2024). Strengthening nurses' professional identity was associated with improved care quality and fewer medication errors (Xiaoyan et al. 2023).

4.4. Professional Outcomes: Workforce Well‐Being

The 21% of the studies included reported outcomes related to healthcare professionals, mainly within the nursing workforce. Most interventions were management‐focused, except two clinical protocols allowing nurses greater autonomy in patient care (Perrin et al. 2017; Artinian et al. 2007). In both cases, nurses expressed high satisfaction and supported protocol implementation, perceiving benefits in patient satisfaction and reduced follow‐up times. Physicians also endorsed protocols, though their involvement in design may have influenced this agreement.

Professional satisfaction improved in interventions standardizing evaluation criteria, enhancing communication and accuracy in patient assessment (Huang et al. 2022). A multidisciplinary surgical procedure led by nurses promoted nursing professional identity, collaboration, autonomy, and recognition of clinical expertise (Xiaoyan et al. 2023). Management‐level interventions such as open‐shift models and succession planning further reinforced workforce satisfaction and retention (Valentine et al. 2008; Brunero et al. 2009). The open‐shift model achieved measurable organizational improvements, reducing vacancy rates from 6.6% to 4.9% and decreasing turnover from 14.2% to 10.9%, representing a 30% overall reduction (Valentine et al. 2008).

4.5. Organizational Outcomes: What the Economic Evidence Reveals—and Conceals

Most interventions included in this review reported organizational‐level outcomes. This section presents the organizational findings from studies that conducted formal economic evaluations, organized according to their methodological rigor: complete economic evaluations with ICERs (4.5.1), partial economic evaluations including cost–benefit and CEAs without QALY measurement (4.5.2), and cost comparison analyses (4.5.3).

Prior to discussing results by category, it is important to highlight several methodological limitations common to all economic evaluations. Most studies employed short time horizons, with 81.81% using periods of 1 year or less; only two studies extended beyond 1 year (R. Harris et al. 2005; Gosselin et al. 2017). Such short durations tend to underestimate the long‐term benefits by accounting only for implementation costs and neglecting delayed advantages arising from chronic disease management, complication prevention, and ongoing behavioral changes. The economic perspectives adopted were also limited: 64% of studies focused solely on healthcare providers' viewpoints, considering only direct healthcare costs, while none included comprehensive indirect costs such as productivity losses for patients and families or caregiver burden. Decision‐analytic modeling was utilized in just one study (C. Harris and Shannon 2008), and sensitivity analyses were performed in only 45.45% of the evaluations (Stewart 2002; R. Harris et al. 2005; Hebert et al. 2008; Seidl et al. 2015; Liu et al. 2009). Additionally, no studies applied discount rates despite several having follow‐up periods extending over multiple years. These methodological limitations are summarized in the synthesis of the studies provided in Supporting Information S4: Supplemental Information 4, along with cost evaluation.

4.5.1. Complete Economic Evaluations: Cost‐Utility Analyses With ICER

Only two studies (18.18%) conducted full cost‐utility analyses with ICERs and QALY measurement, representing the gold standard for economic evaluation in health.

Hebert et al. (2008) evaluated a 12‐month telephone‐based nurse‐led heart failure management program and found it cost‐effective at $47,510–$50,969 per QALY gained—well below the commonly accepted willingness‐to‐pay threshold of $50,000–$100,000 per QALY. The intervention cost approximately $2177 per patient but was largely offset by reduced hospitalization costs of $2378 per patient; nonetheless, increased outpatient and home care expenses prevented immediate net cost savings within the observation period. Sensitivity analyses employing bootstrap resampling and alternative utility measures (Health Utilities Index Mark 3 vs. EuroQol‐5D) confirmed the robustness of these results, with ICERs varying modestly between $47,510 and $50,969 per QALY.

Conversely, Seidl et al. (2015) could not confirm cost‐effectiveness of post‐myocardial infarction nurse‐based case management within 1 year, as both costs (a reduction of €17.61) and QALYs (a decrease of 0.0163) were slightly lower in the intervention group. The resulting ICER of €1080 per QALY indicates cost savings associated with QALY losses, placing the intervention in an uncertain economic zone. Sensitivity analyses utilizing alternative quality‐of‐life measures (visual analogue scale‐adjusted life years) showed the intervention to be dominant—costing less and producing higher effects—highlighting how outcome measurement choices critically influence conclusions about cost‐effectiveness. The authors acknowledged that 10 participants in the intervention group died before receiving any nursing contact, which may have biased results, leading to the conclusion that cost‐effectiveness could not be definitively established within the 1‐year follow‐up.

Together, these two studies are the only ones in this review capable of informing evidence‐based resource allocation decisions comparable to other health interventions. Their contrasting results—one firmly cost‐effective, the other methodologically inconclusive—underscore the sensitivity of economic conclusions to follow‐up duration and outcome measurement instruments.

4.5.2. Partial Economic Evaluations: Cost–Benefit and Cost‐Effectiveness Analyses

Five studies conducted partial economic evaluations—two CBAs and three CEAs without QALY measurement—providing useful economic signals but falling short of the methodological standard required for comparative resource allocation decisions.

Among CBAs, Crow et al. (2006) evaluated a nurse case management program for high‐risk low‐income diabetic patients and reported a benefit–cost ratio of 2.9:1, with net annual benefits of $149,544 against program costs of $79,250, alongside reductions in clinical visits (51%), laboratory tests (67%), emergency department visits (24%), and hospitalization days (50%) over an 8‐month period. Phillips et al. (2018) assessed a nurse manager succession planning program and reported a BCR of 2.5:1, with annual savings of $87,000 driven by a reduction in nurse manager turnover from 20% to 16% against total program costs of $69,832 over 24 months. Both studies demonstrate positive financial returns, but the absence of QALY data precludes comparison with other health interventions.

Among CEAs, Barth (2001) evaluated a 6‐week nurse‐managed post‐discharge program for congestive heart failure patients. The program reduced hospital readmissions and improved quality of life, but no overall cost savings were observed within the short follow‐up; the control group generated approximately $60 in unexpected costs per patient. Although a cost‐per‐readmission‐avoided metric was calculated, the 6‐week horizon and absence of QALY data limit the conclusions that can be drawn. Stewart (2002) estimated net annual national benefits of £20 million from a specialist heart failure nurse service in the United Kingdom, with scenario analysis indicating that a conservative 30% reduction in readmissions would generate savings exceeding implementation costs by £126 per patient. R. Harris et al. (2005) evaluated a nursing‐led inpatient unit for intermediate care and reported a cost per Barthel Index point improvement of £1044, with lower daily costs than acute wards (£111–117 vs. £124–131); however, overall costs were higher due to a longer length of stay, and without QALY data, definitive conclusions about cost‐effectiveness could not be drawn.

Collectively, these five studies provide partial evidence of economic value across diverse clinical and management contexts, but their methodological scope—whether by limiting to benefit–cost ratios or by measuring effectiveness without standardized health outcomes—prevents robust conclusions about efficiency.

4.5.3. Cost Analyses: Cost Comparison Studies

Four studies reported economic data exclusively through cost comparison approaches, without effectiveness measurement or formal incremental analysis.

C. Harris and Shannon (2008) documented that enterostomal therapy nurses in wound care achieved savings of $5927 per wound when more than 50% of visits were conducted by specialists, alongside nearly halving mean healing times (86 vs. 165 days). This study is distinctive for employing decision‐analytic modeling—the only instance in this review—lending greater robustness to its estimates. Liu et al. (2009) provided the only evidence examining how organizational structure influences costs, finding that nurse executives with direct staffing authority achieved significantly lower nursing costs per admission ($9001 vs. $9496; coefficient −0.0937, p = 0.047), confirmed across multiple sensitivity specifications. Gosselin et al. (2017) documented a progressive cost reduction in a nurse‐led ultrasound‐guided peripheral venous access program, from $430.56 per catheter in Year 1 to $125.06 in Year 6—a trajectory only observable thanks to the study's 72‐month horizon. Odom et al. (2024) reported annual savings of $178,669 from a nurse‐driven centralized spinal orthoses program, alongside reductions in patient length of stay and faster mobilization.

While these studies provide useful cost benchmarks, the absence of standardized outcome measures and comparative effectiveness data limits their capacity to inform resource allocation decisions.

4.5.4. Evaluation of Non‐Economic Studies

Approximately 29% of studies reported outcomes related to organizational efficiency—such as resource utilization, operational metrics, and costs—but did not include formal economic evaluations. Process improvements led by nurse managers enhanced both patient safety and resource efficiency. For example, introducing roles like Senior Nurse or Modern Matron resulted in a 45.3% reduction in medication errors, decreasing from 278 to 126 errors over 6 months. These roles also contributed to a decline in hospital‐acquired infections, although no formal economic analysis was conducted to quantify these benefits (Dealey et al. 2007). Additionally, a nursing intervention utilizing the Pediatric Early Warning Score (PEWS) successfully lowered hospital stay costs and reduced nursing time, assessment durations, and unplanned transfers to intensive care (Huang et al. 2022).

Nurse‐managed protocols further improved efficiency; for instance, implementing a protocol to cease telemetry monitoring decreased monitoring hours from an average of 107–74 hours per patient (p < 0.01) (Perrin et al. 2017), with similar positive outcomes reported by Artinian et al. (2007). The implementation of nurse‐led Enhanced Recovery After Surgery (ERAS) programs—characterized by multidisciplinary teamwork—resulted in reductions in pain, malnutrition, deep vein thrombosis, and hospital length of stay, while also fostering nurses' professional identity and satisfaction with medical collaboration (Xiaoyan et al. 2023).

Efforts to develop the nursing workforce and establish leadership succession plans also yielded organizational benefits. For example, an Australian teaching hospital successfully filled 31 nursing leadership positions primarily through internal promotions (Brunero et al. 2009). Morris et al. (2020) reported that a nurse leadership succession plan enrolled 18 candidates—exceeding the initial target of 15—but did not evaluate its economic impact. A nurse‐led safety coaching program in home care engaged 63% of clients and facilitated safety improvements; nurse managers estimated that approximately 75% of clients receiving follow‐up would sustain safety practices, potentially reducing injuries and hospital admissions. However, the cost savings associated with these initiatives were not quantified (Markkanen et al. 2024).

Overall, these studies suggest that nurse‐led organizational interventions can lead to measurable operational improvements, such as reduced resource use, improved patient safety, streamlined workflows, and workforce development, which are likely to result in cost savings. Nevertheless, the lack of formal economic evaluations remains a significant gap, limiting the ability to measure return on investment, compare the cost‐effectiveness of different interventions, or inform resource allocation decisions based on evidence.

5. Discussion

5.1. Reinterpreting Nursing Leadership Beyond Managerial Functions

This systematic review reveals a fundamental paradox at the heart of contemporary nursing leadership discourse: while empirical evidence demonstrates that nurse‐led interventions might improve clinical quality, workforce sustainability, and organizational efficiency, the conceptualization of nursing leadership itself remains theoretically underdeveloped, definitionally ambiguous, and politically contested (Ferreira et al. 2022; Abd‐El Aliem and Abou Hashish 2021). Nurses represent the largest professional group within the healthcare sector, yet research on nursing leadership and its impact on organizational governance remains disproportionately limited compared to medical or executive leadership scholarship (Heinen et al. 2019; Gottlieb et al. 2012; Wong et al. 2013). Although leadership has been increasingly recognized as a determinant of quality and organizational performance, its roles and expressions within nursing are insufficiently explored and often conflated with managerial functions (Dall'Agnol et al. 2013; Cengiz et al. 2021).

The 28 included studies predominantly frame nursing leadership as a technical solution to healthcare delivery problems—reducing readmissions, optimizing costs, retaining staff—without interrogating the structural conditions that constrain nursing's professional authority or examining how leadership roles may reproduce, rather than challenge, existing hierarchies within healthcare organizations. The reviewed studies frequently overlapped leadership attributes—such as professional influence, empowerment, and innovation—with managerial functions such as planning, supervision, and coordination. This conflation between leadership and management led to the exclusion of several nurse‐led interventions during screening that demonstrated administrative involvement but lacked transformative influence or autonomy—key features distinguishing leadership from management.

This definitional ambiguity reflects deeper epistemological and political tensions surrounding nursing's professional status. Terms such as “nurse‐led,” “nurse‐managed,” and “nurse‐driven” were used interchangeably without clear operational definitions, signaling contested terrain where nursing's jurisdictional claims remain actively disputed. Some studies defined nurse leadership as complete clinical autonomy with independent admission and discharge authority (R. Harris et al. 2005), while others described nurses functioning within physician‐supervised models with limited decision‐making scope (Nurit et al. 2009; Huang et al. 2022).

Following Abbott's (1988) theory of professional jurisdiction, the predominant pattern of nursing activities—patient education, care coordination, follow‐up monitoring—represents nursing occupying residual professional territory: interpersonal and educative work that medicine has delegated as insufficiently prestigious. While these activities demonstrably improve outcomes and reduce costs, they do not challenge medicine's core jurisdictional claims over diagnosis, treatment, and organizational authority. Nursing leadership, as operationalized in most studies, functions within rather than transforms existing professional hierarchies (Aspinall et al. 2023).

The design‐implementation gap exemplifies this subordination: 43% of studies were designed by non‐clinical researchers and 25% by executive boards, while only 25% were designed by nursing teams—yet all interventions were implemented by nurses. This positions nurses as implementers of others' strategic priorities rather than autonomous decision‐makers. Even nursing‐designed interventions focused predominantly on clinical effectiveness (9 of 11) rather than economic evaluation (2 of 11), suggesting either that nursing prioritizes care quality or—more critically—that nurses have constrained access to resources and platforms necessary to conduct economic evaluation and influence budget decisions (Kelly et al. 2023).

Furthermore, the tension between managerial efficiency and care‐centered values remains implicit but underexplored across the included studies. Economic evaluations prioritize cost reduction, length of stay, and productivity metrics (Valentine et al. 2008; Odom et al. 2024; Huang et al. 2022), often neglecting dimensions central to nursing professionalism such as relational continuity, dignity in care, and patient empowerment. No studies explicitly investigate whether nurse‐led governance shifts organizational priorities from throughput efficiency toward care quality, nor whether nursing leadership challenges or reinforces prevailing managerial frameworks.

By framing nursing contributions as management (technical, operational) rather than leadership (visionary, strategic), healthcare organizations extract nursing expertise while maintaining existing power structures. This reflects Freidson's (1970) “subordinate professionalism”: nurses exercise autonomy in executing delegated tasks but lack authority to reshape organizational priorities or resource allocation. These studies should be reinterpreted not merely as evidence that nursing leadership is effective but as documentation of nursing's ambiguous organizational position: clinically competent yet structurally subordinate, operationally vital yet strategically marginalized.

5.2. Clinical Impact Without Structural Authority

The 28 included studies demonstrate that nurse‐led interventions consistently could improve key quality indicators—hospital readmissions (Barth 2001; Stewart 2002; Zhang et al. 2018), length of stay (R. Harris et al. 2005; Odom et al. 2024), quality‐adjusted life years (Hebert et al. 2008; Seidl et al. 2015), and quality‐of‐life measures (Barth 2001; Carrington and Stewart 2015). However, these improvements occurred predominantly through educational and care coordination activities—patient medication education (Nurit et al. 2009), case management (Crow et al. 2006; Hebert et al. 2008), transitional care (Zhang et al. 2018; Madrigal et al. 2023), and self‐management support (Carrington and Stewart 2015; Ali et al. 2023)—rather than through strategic decision‐making authority or resource control.

Consistent with the jurisdictional dynamics outlined above, most improvements emerged from educational, coordinative, and follow‐up activities rather than from areas involving direct organizational authority. These findings reinforce the design–implementation gap described above: nurses generated clinical value primarily through care delivery and coordination activities, while authority over governance, resource allocation, and organizational priorities remained largely external to nursing (Kuethe et al. 2013; Wong et al. 2013; Azzellino et al. 2025).

The short‐term follow‐up periods characterizing 82% of studies (≤ 12 months) may reflect not merely methodological convenience but structural realities: nurse‐led programs frequently operate as time‐limited “projects” rather than permanent organizational structures, suggesting provisional rather than institutionalized authority. When Hebert et al. (2008) noted that patients' health deteriorated after nurses ceased engagement at 12 months, this reveals the precarity of nursing's organizational position—clinical effectiveness depends on continued nursing involvement, yet organizational commitment to sustaining these roles remains contingent. The absence of long‐term evaluations may indicate that many nurse‐led initiatives do not persist beyond implementation periods, consistent with Davies' (1995) observation that nursing innovations are frequently “piloted” rather than permanently funded, maintaining organizational flexibility to withdraw support without challenging established hierarchies. In contemporary audit cultures (Shore and Wright 2015), interventions must demonstrate rapid returns to secure continued funding, creating structural disincentives for investments with delayed benefits. This temporal mismatch systematically disadvantages nursing interventions targeting upstream determinants requiring extended periods to yield outcomes.

5.3. Leadership Development as Governmentality

Several studies examined the impact of nursing leadership structures on professional well‐being and workforce sustainability, revealing significant improvements in nurse satisfaction, retention, and organizational stability. Studies focused on succession planning (Phillips et al. 2018; Morris et al. 2020; Brunero et al. 2009), the Modern Matron role (Dealey et al. 2007), and innovative staffing models (Valentine et al. 2008) consistently demonstrated that investments in nursing leadership development yield measurable returns in workforce metrics.

These findings are typically interpreted as evidence of nursing empowerment through leadership development. However, applying Foucauldian concepts of governmentality and disciplinary power (Foucault 1991), we can alternatively read these interventions as mechanisms through which nurses internalize organizational objectives, transforming potential resistance into self‐regulation. Succession planning programs that cultivate leadership pipelines (Brunero et al. 2009; Morris et al. 2020) simultaneously develop nursing capacity and ensure continuity of institutional norms—nurses are prepared to assume managerial roles within governance structures that remain fundamentally unchanged.

This ambiguity becomes evident when examining what succession planning programs measure as success. Phillips et al. (2018) reduction in nurse manager turnover from 20% to 16% is framed as positive, yet the baseline 20% turnover itself signals organizational dysfunction. Rather than addressing structural conditions generating this turnover, succession planning prepares nurses to assume roles that others have abandoned as untenable. When nurses voluntarily seek these roles—having internalized that assuming managerial positions represents “career advancement”—they participate in what Foucault termed “technologies of the self”: practices through which individuals govern themselves according to organizational norms without experiencing this governance as imposed.

The competencies cultivated through leadership development programs reveal this disciplinary function. Succession planning emphasizes financial management, strategic planning aligned with organizational priorities, and performance evaluation—competencies that enable nurses to operate more effectively within existing hierarchies but not to fundamentally challenge resource allocation, staffing models, or professional subordination. The financial literacy imperative exemplifies this dynamic: nurses seeking leadership positions must demonstrate competency in Return of Investment (ROI) calculations, budget variance analysis, and cost–benefit ratios—translating nursing contributions into metrics legible within dominant managerial frameworks (Ismail et al. 2025; Lunden et al. 2017; Martini et al. 2025). This requirement operates unidirectionally: nurses must learn to “speak the language” of finance and management to participate in decision‐making on clinical aspects and care ethics, while financial and medical leaders need not develop fluency in clinical reasoning or nursing epistemologies.

Liu et al. (2009) demonstrated that nurse executives with direct line authority over staffing achieved significantly lower costs per admission (coefficient = −0.0937, p = 0.047), suggesting that financial competency combined with structural authority produces tangible efficiency gains. However, clinical expertise and relational competencies become insufficient for leadership unless accompanied by economic fluency. The development of financial literacy is thus simultaneously tactically necessary (nurses cannot influence resource allocation without it) and strategically problematic (it reinforces that managerial/economic logics supersede care‐based logics in organizational hierarchies).

The workforce benefits documented—improved satisfaction (Dealey et al. 2007), enhanced professional identity (Xiaoyan et al. 2023), and reduced turnover (Phillips et al. 2018; Valentine et al. 2008)—are genuine and valuable. The critical question is not whether these benefits exist but what structural changes they enable or foreclose. Leadership development is consistently evaluated through individual outcomes (career advancement, competency acquisition, and job satisfaction) and organizational outcomes (turnover reduction, cost savings), but never through measures of collective professional power, authority redistribution, or transformation of governance structures.

Financial and managerial literacy should be considered a core competency for nursing leaders, enabling them to articulate the economic value of nursing‐led programs and influence organizational decision‐making. However, this tactical necessity must be accompanied by critical awareness that financial competency development, succession planning, and leadership training can simultaneously empower nurses to navigate current systems and discipline them to reproduce those systems. Without explicit attention to this distinction, leadership development risks functioning as a sophisticated mechanism of governmentality—producing nurses who voluntarily optimize themselves according to organizational objectives while the fundamental conditions of nursing's professional subordination remain undisturbed.

5.4. The Political Economy of Evidence: What Cost‐Effectiveness Conceals

The economic evidence base for nurse‐led interventions is characterized by a fundamental methodological gap. Only two studies conducted complete economic evaluations meeting gold‐standard criteria — Hebert et al. (2008), which found nurse‐led heart failure management cost‐effective at $47,510–$50,969 per QALY, and Seidl et al. (2015), which could not confirm cost‐effectiveness within a 1‐year horizon. The remaining nine studies with cost data provide useful economic signals but are insufficient to draw robust conclusions about efficiency or to inform comparative resource allocation decisions. This pattern reflects the near‐absence of a systematic culture of economic evaluation within nurse‐led research: cost reporting remains opportunistic and methodologically heterogeneous, rarely designed from the outset to answer whether an intervention represents value for money. The persistent requirement that nursing justify its contributions economically, combined with structural constraints on conducting rigorous evaluation, reflects what Reverby (1987) termed nursing's historical position at the intersection of duty and paid labor—perpetually required to prove worth within frameworks that simultaneously limit the capacity to do so.

The narrow economic perspectives dominating included studies—focusing on direct healthcare costs while omitting indirect costs, productivity impacts, and social reproduction labor—reflect gendered assumptions about which forms of work merit economic recognition. When studies fail to quantify family caregiver time savings (Zhang et al. 2018; Madrigal et al. 2023) or patient productivity gains (Huang et al. 2022; Odom et al. 2024), this absence reflects deeper societal devaluation of reproductive and care labor, predominantly performed by women. As Folbre (2006) argues, conventional economic frameworks systematically render invisible precisely the forms of work—emotional labor, coordination, and health education—at which nursing excels.

The historical feminization of nursing provides an additional lens through which these findings can be interpreted. Feminist scholars have long argued that forms of labor associated with care, relational continuity, emotional support, and social reproduction are systematically undervalued within economic systems that privilege productivity, technical intervention, and measurable outputs (Fraser 2016). From this perspective, the persistent requirement for nursing to demonstrate its legitimacy through economic evaluation may reflect broader gendered patterns of recognition in which care work is expected, but not fully valued. The limited attention paid to indirect costs, caregiver burden, and relational outcomes in the reviewed studies may therefore represent not only methodological shortcomings but also deeper assumptions about which forms of healthcare work are considered economically and politically visible—what Tronto (1993) termed the marginalization of care as a political practice rather than a technical function.

Notably absent are assessments of how cost savings are redistributed. When Gosselin et al. (2017) documented progressive cost reductions from $430.56 to $125.06 per catheter over 6 years, no mechanism ensured savings would fund expansion of nursing roles rather than substitute for existing resources. Cost‐effectiveness evidence may thus paradoxically undermine nursing's position: by demonstrating that nursing produces more for less, it provides rationale for intensifying workloads without proportional resource allocation.

The absence of standardized frameworks such as CHEERS (Husereau et al. 2022) and comprehensive cost perspectives incorporating productivity losses, caregiver burden, and societal impacts leads to systematic underestimation of nursing's true organizational and societal value (Drummond 2016).

5.5. Limitations and Implications for Research and Practice

The methodological limitations characterizing this evidence base may reflect unresolved questions regarding the nature and boundaries of nursing authority. The near‐complete absence of studies examining power dynamics, decision‐making authority, or organizational influence—rather than clinical outcomes—is itself analytically significant. The predominance of time‐limited programs (82% ≤ 12 months) rather than examinations of nursing's structural position suggests nursing leadership is conceptualized as innovation to be implemented, not fundamental reorganization of authority. Building on institutional theory (Powell and DiMaggio 1991), organizations often adopt nurse‐led initiatives to demonstrate legitimacy. However, this process typically involves a ceremonial adoption that preserves existing power structures, without resulting in meaningful redistribution of authority.

The fragmented evidence base reflects nursing's ambiguous professional status. Established professions command theoretical frameworks guiding research agendas; nursing's portfolio remains oriented toward demonstrating value within others' frameworks—medical effectiveness, managerial efficiency—instead of developing autonomous theoretical traditions which still lack practice (Botana Gronek et al. 2025). These methodological limitations reinforce the need for more comprehensive economic evaluation frameworks capable of informing policy and resource allocation decisions.

A critical research agenda would interrogate conditions under which nursing leadership challenges rather than accommodates existing hierarchies: how nursing authority is enacted and contested in governance; whether nurse‐led models redistribute or concentrate power; and how financial constraints shape nursing autonomy. Critical organizational methods—ethnographic observation of decision‐making, discourse analysis of policies, and participatory action research—would illuminate dynamics invisible in effectiveness trials. Future research must adopt longer follow‐up, multi‐site designs, and comprehensive economic evaluations incorporating a societal perspective. Beyond individual studies, there is a pressing need to establish a systematic agenda for efficiency analysis in nurse‐led interventions—one that moves from fragmented, opportunistic economic reporting toward institutionalized evaluation frameworks embedded in nursing research programs. This agenda is particularly urgent in the context of nursing leadership, where the economic value of governance, workforce development, and structural authority remains almost entirely unevaluated. Without such an agenda, the evidence base will continue to reflect the marginal position of nursing within research hierarchies rather than the actual economic contribution of nurse‐led care. Core competencies set (Hughes et al. 2022) should include not only clinical and economic indicators but measures of actual authority: budget control, strategic participation, policy influence, and collective professional power.

For practice, organizations must create conditions for substantive nursing leadership: (1) structural authority with budget control and decision‐making participation; (2) protected resource commitment for nursing innovation; (3) epistemological legitimacy recognizing nursing knowledge without medical validation; (4) accountability mechanisms assessing authority distribution, not merely leader presence; and (5) support for collective professional power through unions and collaborative governance. While transformational leadership development and financial literacy remain tactically necessary (Ferreira et al. 2022; Gebreheat et al. 2023), individual competency without structural transformation risks reproducing subordination.

The persistence of methodological limitations despite decades of research suggests these are not correctable technical problems but manifestations of nursing's contested professional status, requiring fundamental interrogation of whose questions get asked, whose knowledge gets valued, and whose interests research agendas serve.

6. Conclusion

This systematic review provides consolidated evidence that nursing‐led interventions are associated with improvements in healthcare quality and professional well‐being. Nurse‐led appear to enhance patient outcomes through education and care coordination, while leadership interventions strengthen workforce satisfaction and retention.

However, a critical evidence gap remains regarding their economic value. There is insufficient evidence to determine whether nursing‐led interventions are cost‐efficient. Full economic evaluations are scarce, and existing partial economic evaluations and cost comparison studies frequently lack methodological rigor and incremental comparative approaches, limiting robust conclusions about efficiency.

Developing leadership competencies remains important; however, the findings suggest that competency development alone is insufficient without corresponding meaningful participation in governance and resource allocation.

Healthcare organizations must move beyond symbolic recognition and structurally empower nurses to design, implement, and rigorously evaluate innovative care models, integrating financial authority into nursing leadership roles. Investment in evidence‐based succession planning and transformational leadership development is vital to ensure workforce continuity and long‐term organizational capacity.

Future research should prioritize addressing critical methodological and conceptual gaps through longitudinal studies of at least 3–5 years, multi‐site designs, and robust full economic evaluations conducted according to internationally recommended standards, incorporating societal perspectives and indirect costs. The development of standardized core outcome sets would facilitate comparability, evidence synthesis, and successful scale‐up.

In conclusion, nursing leadership represents an underleveraged strategic driver of professional well‐being, workforce sustainability, and organizational efficiency. Strengthening leadership competencies across nursing roles—from frontline clinical nurses to executive leaders—is essential to building resilient, high‐performing, and value‐based healthcare systems.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Disclosing the Use of Artificial Intelligence (AI)

Artificial intelligence (AI) tools were used in a limited and supervised capacity during the preparation of this manuscript, specifically to assist with translation of non‐English language materials during the screening process. No AI tools were used for data extraction, analysis, interpretation, or writing of the manuscript. All authors take full responsibility for the integrity of the content.

PROSPERO and OSF Full Identification After Blinding

PROSPERO: CRD42023469656. OSF: doi:10.17605/OSF.IO/J82M5.

Supporting information

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Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.