Using the Donabedian framework to examine the quality and safety of nursing service innovation

J Clin Nurs. 2014 Jan;23(1-2):145-55. doi: 10.1111/jocn.12146. Epub 2013 Jul 3.


Aims and objectives: To evaluate the safety and quality of nurse practitioner service using the audit framework of Structure, Process and Outcome.

Background: Health service and workforce reform are on the agenda of governments and other service providers seeking to contain healthcare costs whilst providing safe and effective health care to communities. The nurse practitioner service is one health workforce innovation that has been adopted globally to improve timely access to clinical care, but there is scant literature reporting evaluation of the quality of this service innovation.

Design: A mixed-methods design within the Donabedian evaluation framework was used.

Methods: The Donabedian framework was used to evaluate the Structure, Process and Outcome of nurse practitioner service. A range of data collection approaches was used, including stakeholder survey (n = 36), in-depth interviews (11 patients and 13 nurse practitioners) and health records data on service processes.

Results: The study identified that adequate and detailed preparation of Structure and Process is essential for the successful implementation of a service innovation. The multidisciplinary team was accepting of the addition of nurse practitioner service, and nurse practitioner clinical care was shown to be effective, satisfactory and safe from the perspective of the clinician stakeholders and patients.

Conclusions: This study demonstrated that the Donabedian framework of Structure, Process and Outcome evaluation is a valuable and validated approach to examine the safety and quality of a service innovation. Furthermore, in this study, specific Structure elements were shown to influence the quality of service processes further validating the framework and the interdependence of the Structure, Process and Outcome components.

Relevance to clinical practice: Understanding the Structure and Process requirements for establishing nursing service innovation lays the foundation for safe, effective and patient-centred clinical care.

Keywords: audit; health service innovation; health services research; nurse practitioner.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Humans
  • Models, Nursing*
  • Nursing Homes / organization & administration*
  • Nursing Homes / standards
  • Organizational Innovation*
  • Patient Care Team
  • Patient Safety*
  • Patient Satisfaction
  • Quality of Health Care*