Evaluation of Process examines the provision of care,
and Process characteristics are considered to have the most
influence on quality outcomes (Smitz Naranjo & Viswanatha
Kaimal 2011). The nurse practitioner interviews indicated
that most practise according to established evidencebased
clinical guidelines for patient care in their specialty.
Furthermore, many of the nurse practitioner participants
reportedly were involved in some form of regular review or
audit of clinical practice. Audit of the patients’ health
records in this study showed that nurse practitioners were
judicious in the use of diagnostic resources and conservative
in prescribing practices. The MDT agreed or strongly
agreed that the nurse practitioner role is valuable in
meeting patient and service needs.
Results indicated that an area in need for improvement
was duplication of nurse practitioner care activities and the
perceptions of the MDT were less positive on this Process
issue. Previous writers (Smitz Naranjo & Viswanatha Kaimal
2011) claim that whilst Process elements have most
influence on Outcomes, they in turn rely on Structure attributes
to be successful. This audit of a service innovation
validates and supports the Donabedian framework and
Smitz Naranjo et al.’s interpretation of this framework.
Nurse practitioners in Australia have legal authority to prescribe,
refer and request diagnostics. However, those who
practise within a state government–funded public health
facility do not have provider status for their prescriptions,
their referrals to medical specialists nor for diagnostic
investigations that are activated outside the specific public
health facility. This means that patients who have nurse
practitioner prescriptions, referrals and diagnostic investigation
requests are not eligible for Commonwealth Government
subsidies. Hence, the nurse practitioners in this audit,
and indeed in all state-funded public health facilities in
Australia, need to garner the cooperation of a medical
colleague to initiate these clinical functions for their
patients. This was clearly perceived by medical clinicians as
duplication of service. This anomaly is a Structural element
that has a direct effect on the success of Process in nurse
practitioner service.