An examination of primary health care nursing service evaluation using the Donabedian model: A systematic review

Abstract Nurses are key to the delivery of global primary health care services. However, there appears to be a lack of evaluation of primary health care nursing delivery models in the published literature. This evaluation is vital to the improvement of patient experiences, national and global health outcomes, and the justification of future investment in primary health care nursing services. The purpose of this review was to explore and analyze the literature that reports on the evaluation of primary health care nursing services, to ascertain the nature and utility of these evaluation methods, and identify opportunities for future research in this area. A systematic review of the published literature was conducted following PRISMA guidelines, using the databases CINAHL, Joanna Briggs Institute, MEDLINE, and Proquest. Thirty‐two articles published between 2010 and 2022 were selected. Results were organized using the Donabedian model. A paucity of research into the evaluation of nurse‐led primary health care services was noted. Where evident, evaluation of primary health care nursing services tended to reflect the medical model. Medical outcomes measures dominated evaluation criteria including diagnosis rates, prescription costs, and disease outcomes. Primary health care principles such as service accessibility, cultural appropriateness, and availability were rarely used. The perspectives and experiences of nurses were not sought in service evaluation, including most of the nurse‐led services. Development of an evidence‐base of nursing primary health care services that are informed by the nursing experience and apply a framework of universal primary health care principles across the structure, process, and outcomes aspects of the service is recommended.

The concepts of primary care and PHC are often used interchangeably by practitioners, politicians, and scholars (Keleher, 2001). In essence, primary care is a component of PHC. Defined as the first level of contact for individuals seeking help in the community (usually the general practitioner setting), primary care is based on the biomedical model of health and usually involves a "one-off" intervention where the patient seeks a treatment or cure for an existing condition (Keleher, 2001). Often the first point of contact in primary care in Australia is the general practitioner (physician), but this can also be the pharmacist, allied medical professional, or nurse (general practice nurse, nurse practitioners, or community nurse) (Australian Institute of Health and Welfare, 2020).
In contrast, PHC is a population level service informed by a socioecological model of health that seeks to address health inequities (unfair differences in health) and the social determinants of health that create this inequity, such as poverty, unemployment, transport issues, political structures, and geo-

| The nurse's role in PHC service provision
PHC is delivered by a range of health practitioners in addition to the nurse and general practitioner, including community health workers, Aboriginal and Torres Strait Islander health practitioners, and other allied health professionals. The general practitioner is not necessarily the dominant practitioner leading and delivering these services. Indeed, nurses are the most widely distributed and accessible healthcare providers in PHC settings (World Health Organization, 2022). The nurse has a central and unique PHC role that incorporates personal care with health promotion, community empowerment, and participation. It is underpinned by the PHC principles of social justice, equity, access, and empowerment, and is informed by an understanding of social determinants of health (Australian Primary Health Care Nurses Association, 2022).

| PHC and population health
In 2015, the United Nations developed the Sustainable Development Agenda 2030, a global blueprint to improve people's lives and protect the environment underpinned by 17 Sustainable Development Goals including "good health and well-being" (goal 3), and "reduced inequalities" (goal 10) (United Nations, n.d.) to which Australia is invested (Australian Government, 2018). PHC services are a critical mechanism for achieving these goals (World Health Organization & United Nations Children's Fund, 2018). Countries with strong PHC systems "provide more efficient care, have lower rates of hospitalization, fewer health inequalities, and better health outcomes including lower mortality" (Standing Council on Health, 2013;p. v).
The evaluation of PHC quality across service structures, processes, and outputs/outcomes is integral to this achievement (Veillard et al., 2017; World Health Organization and the United Nations Children's Fund, 2022).

| PHC evaluation
Evaluation of quality of care is vital in improving health outcomes and assessing the effectiveness of health care services (Australian Institute of Health and Welfare, 2018). Rigorous evidence of the quality of care is needed if policy makers are to make informed decisions about health care delivery models (Laurant et al., 2018).
Whilst many reliable measures exist to evaluate quality of individual medical care in acute care hospital settings (Bastemeijer et al., 2019) these are more limited in the PHC environment.
The Australian Government has recently released guidelines to resolve this discrepancy. The National Safety and Quality Primary Health Care standards, published in 2021 (Australian Commission on Safety and Quality in Health Care, 2021) aim to protect the public from harm and improve the quality of PHC delivered to patients and consumers. This document had three standards. The first "Clinical Governance Standard" outlines the responsibility of primary care and PHC practitioners to deliver safe, quality, and effective services that are continuously evaluated and improved. The standard also refers to the recognition of social determinants in this delivery of safe and effective care and outlines the importance of a service that engages in continuous quality review and improvement. Aspects of this standard cover structure, process, and outcomes of quality PHC, aligning with the Donabedian (2005) model used to organize findings in this review.

| Purpose of the review
The purpose of this review was to explore and analyze the literature that reports on the evaluation of PHC nursing services. The review question asked, "What evaluation frameworks have been used to assess PHC nursing services and how useful are they in the Australian PHC context?"

| The Donabedian model
The Donabedian model (Donabedian, 2005) continues to be a leading instrument in the evaluation of care quality in health services (Berwick & Fox, 2016). This model situates care within three areas: the structure in which care delivery is provided, the process in which engagements between patients and caregivers occur, and outcomes, which refer to the impact of care on the health status of the patient or the population (Donabedian, 2005) (Figure 1).
Structure measures (also known as input measures) consider attributes of the service/provider including staff: patient ratios, ethical approaches, times of service operation that influence service accessibility, and availability. Process measures encompass the elements of the running of the service that influence the desired outcome. For example, waiting time to be seen by a health care practitioner, staff hygiene standards, correct record keeping. Outcome measures reflect the impact of the service on patient health outcomes, and whether the desired outcomes have been met. These outcomes may include reduced mortality and morbidity, reduced hospital admissions, lifestyle and medication compliance, and improved patient experience (Donabedian, 2005). The Donabedian model is used as a framework to organize the review findings according to the area of health care assessed. The methods of evaluation used within each stage of the model are explored and examined in this review.

| METHODS
The study comprised a systematic review of the literature. The protocol was informed by guidelines from Bettany-Saltikov (2010a, 2010b).

| Search strategy
This systematic review was initially focused on the exploration of the provision of PHC services to small, geographically isolated communities in Australia, where health services are often limited to nurse-led PHC clinics (Muirhead & Birks, 2020). The lack of articles in the rural/ remote context however meant this initial focus was abandoned. The limited availability of Australian studies also led to the inclusion of international studies in the review. Databases searched were the Joanna Briggs Institute database, MEDLINE, Proquest, and CINAHL.
Because of the confusion of terminology usage around primary care and PHC, this systematic review sought and considered articles that used the terms "primary care" or "primary health care" as potential studies relevant to the review's purpose. Those that on later examination were found not to discuss PHC (as defined in this article) were removed. The following search terms (and synonyms) were used: "primary care" OR "primary health care" OR "primary healthcare" AND nurs* AND "quality care" OR "quality eval*" OR "quality measur*" OR "quality indicator.*" The search strategy was repeated across databases. All searches were conducted in June 2020 and again in May 2022.

| Inclusion/exclusion criteria
Papers were included if they discussed PHC services, nursing, and quality and were published between 2010 and 2022. Papers were excluded if they omitted nursing, were not in English, did not relate to quality care or if the paper was an abstract only. As the review purpose was to explore and analyze primary research that evaluated PHC services, review articles were also excluded. Three authors reviewed the articles according to the inclusion criteria and any disagreements were resolved by the entire authorship panel ( Figure 2).

| Quality appraisal
The Mixed Method Appraisal Tool (MMAT) version 2011 (Pluye et al., 2011) was used to assess the quality of research studies included in the review. Two authors applied the MMAT tool to the selected articles to ensure quality and consistency of assessment (A. G. and M. D.). The tool assesses both qualitative and quantitative research and scores each from 20% to 100% depending on the number of criteria met. These ratings were converted to a star ranking of 1 to 5 stars for ease of use (Table A1, Appendix).
The initial search from four databases resulted in 800 references.
After duplicates were removed, 547 titles were assessed for eligibility. Papers meeting the inclusion criteria are presented in Appendix A as a data extraction table (Table A1, Appendix).
F I G U R E 1 Donabedian model of quality in health care

| RESULTS
Thirty-two studies that evaluated nursing services based in a PHC setting were included in the review. Full details are provided in Table A1 (Appendix). The date of their publication ranges from 2011 (Coddington et al., 2011;Stenner et al., 2011;Wenger et al., 2011) to 2021 (Farford et al., 2021).

| Study design and rigor
Three studies used qualitative data informed by interviews and focus groups (Fischer et al., 2015;McCullough et al., 2020;Stenner et al., 2011). Harris et al. (2015) used a mixed-methods approach and the remaining articles used quantitative methods analyzing data from surveys, patient records, and quality audit databases. The MMAT score was applied to the research design of each article. Fifteen articles were rated as 5 star, 7 achieved 4 stars, 4 achieved 3 stars.
More commonly, evaluated PHC services included the nurse as a member of the multidisciplinary team. Often, studies aimed to evaluate nursing care by making comparisons between the care provided by nurses and that of other health professionals, most commonly a comparison between nurse practitioners and physicians (Buerhaus et al., 2018;Christiansen et al., 2016;Gysin et al., 2020;Iles et al., 2014;Jennings et al., 2016;Karnon et al., 2013;Klemenc-Ketis & Poplas-Susič, 2017;Kurtzman & Barnow, 2017;Lawson et al., 2012;Mitchell et al., 2019;Prestes et al., 2017;Reuben et al., 2013;Vestjens et al., 2019;Wenger et al., 2011). 3.5 | Structure, process, and outcome evaluation  Just 7 studies considered process. Examples included continuity of care in community health centers (Christiansen et al., 2016) and the mentoring process and quality of care (Fischer et al., 2015). Most commonly, the outcome of the service was evaluated (24 studies).
Patient health outcomes were commonly used to measure service outcomes (see "quality indicators").
Nine studies examined more than one aspect of the service (bold in Table 1) (Buerhaus et al., 2018;Fischer et al., 2015;Harris et al., 2015;Klemenc-Ketis & Poplas-Susič, 2017;Lawson et al., 2012;McCullough et al., 2020;Mitchell et al., 2019;Reuben et al., 2013;Wenger et al., 2011). Mitchell et al. (2019) for example, evaluated a primary care model in Minnesota USA, which considered staff quality of life and safety culture within the team (process), and patient experience, cancer screening targets, and care costs (outcome). Just 1 study (Harris et al., 2015) measured all three aspects of their primary care walking intervention service. This nurse-led service was evaluated across structure (nurse and patient perceptions of equipment used), process (nurse perception of time and quality of consultations, including holistic approach), and outcomes (patient health outcomes including increased exercise duration and intensity, changes in obesity, and blood pressure).

| Quality measures
Measurement of quality in services were carried out across two broad approaches: objective quality indicators and perceptions and | 163 experiences of services (Table 1). Just 3 studies evaluated their service using both approaches (Faulkner et al., 2016;Harris et al., 2015;Mitchell et al., 2019).

| Objective quality indicators and measurement tools
Indicators chosen to assess service quality varied. For example,

| Service perspectives and experiences
Thirteen studies analyzed perspectives of service quality. Eight of these asked the patient/consumer (Abrahamsson et al., 2015;Faulkner et al., 2016;Harris et al., 2015;Kinder, 2016;Mitchell et al., 2019;Rawat et al., 2018;Stenner et al., 2011;Vestjens et al., 2019). Patients were asked to report on a range of service factors. For example, Kinder (2016) assessed patient satisfaction of pediatric nurse practitioner care outcomes (perceptions) as well as patient compliance to care regimen (outcome as quality indicator); Stenner et al. (2011) asked patients about the diabetic care they received from nurse prescribers in semistructured interviews.

| Capturing the nurse perspective
The comparatively high number of studies that included the patient voice in service evaluation is to be commended, aligning well with the PHC principle of patient participation in health service development and provision (World Health Organization and the United Nations Children's Fund, 2022). The finding that nurses were less frequently asked to contribute their perspectives and experiences within the evaluation of the care they provide concurs with a previous literature review (Ryan et al., 2017). This oversight is concerning. Already a relatively disempowered health profession (Burton, 2020), this further disenfranchises the nurse as an autonomous leader and decision maker in health. It also diminishes the nurse's role as patient advocate and their capacity to apply their holistic knowledge of community to inform the development of an accessible and acceptable PHC service model.

| A structure-process-outcome focus
PHC scholars argue that quality measurement of a PHC service must involve the interplay between service structure, process, and outcome (Arvidsson et al., 2019;Berwick, 1989;Berwick & Fox, 2016). Many of the studies in this review limited their PHC service evaluation to the outcome section of the Donabedian (2005) model. This focus, to the exclusion of structures and processes, appears common in PHC service evaluation literature (see Lukewich et al., 2022;Simou et al., 2015). Studies that consider patient health outcomes but not service structure and processes ignore the holistic nature of services and the association between these factors and service outcomes. The outcome of a screening service uptake is, for example, greatly influenced by the service structure (accessibility) and process (acceptability). Ignoring factors such as the cultural appropriateness, cost and setting of a screening service limits the usefulness and meaningfulness (the why?) of the outcome findings (Penchansky & Thomas, 1981).

| Shifting away from the medical lens
Although study designs and evaluation tools were generally acceptable in terms of rigor, the lens through which many services were assessed for quality was less ideal. Many of the quality criteria used appeared to be highly medical in nature (such as diagnosis rates, diagnosis accuracy, and pain outcomes). The ANCOVE measure, for example, whilst validated and widely accepted in the acute medical setting, is an individualized disease-centered tool with limited applicability in the PHC environment.
This disconnect with PHC principles reduces the applicability of these evaluation approaches to PHC services. One study in the review that demonstrated a contrasting approach was Kosteniuk et al. (2017) who developed a tool to measure nurses' perspectives of their organization's PHC service and its alignment with PHC principles. The evaluation was underpinned by principles of PHC including service accessibility/availability, holism, comprehensiveness, and a multidisciplinary team approach. This approach provided a way of assessing many aspects of structure and process quality of PHC services, although not outcomes, using PHC concepts that are transferable across national and cultural divides.
The setting of the majority of the reviewed PHC service evaluations also reflected the medical model, being set in the primary care environment, in particular in general practice (community physician setting). Often based on private business models, general practitioner-led primary care services tend to lack service integration, carry out insufficient levels of prevention work and may lack accessibility to poorer people, reducing their potential for equity (Swerissen et al., 2018). As such, by their very nature, they are unable to provide a base for quality PHC service delivery.

| Implications for practice
Without an accepted PHC nursing service evaluation approach, the quality of equity focused service provision cannot be ascertained.

| LIMITATIONS
This review was limited to peer-reviewed academic literature and as such did not consider studies found in the gray literature. Expert opinion pieces or articles published in a language other than English were also not considered. A further limitation of this review is variation in the way primary care and PHC may be interpreted. While the initial inclusion of the search term "primary care" ensured "mistermed" PHC studies were not excluded for review, it is reasonable to assume that some PHC articles were missed in cases where other terminology has been used to describe these services.

| CONCLUSIONS AND RECOMMENDATIONS
The Australian Government's National Safety and Quality Primary Healthcare Standards (ACSQHC, 2021) has recently called for PHC providers to evaluate their services for quality and governance standards.
This review has demonstrated that, in contrast with the acute medical setting, there is a paucity of approaches designed to measure this, especially those led by the nurse. An examination of the existing approaches reveals many researchers have applied a medical model approach, including medical indicators and a limited focus on patient disease outcomes to understand the quality of PHC nursing services.
Few have approached their evaluation through the lens of PHC principles, or have involved the nurse experience, and many lack a holistic structure-process-outcome approach to their evaluation. The usefulness of these models as tools to evaluate PHC services tasked with the achievement of national and international population health goals is therefore questionable.
A coordinated approach is required, based on PHC principles to understand the unique contribution of the nurse to PHC population health in Australia. This requires a mind-shift in which nurses are consulted and trusted to lead services and the process of service evaluation that is based on a holistic approach to this evaluation based on a framework of PHC principles.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
This is a systematic literature review. Data are drawn from published research articles.

PEER REVIEW
The peer review history for this article is available at https://publons. Frail community-dwelling older persons' perspectives on quality of primary care were associated with their perceptions of interactions with the general practitioner and practice nurse in both groups.
There were no significant differences in overall perceived quality of care between groups and at follow-up. Addition of nurse practitioner to special needs plans, recommended care adherence increased to 69% (compared to 53% for GP only). N *****

Note:
Asterisk in last column indicate that the scale is from 1 to 5 *. Only articles with 3 and above * were included in the study. Abbreviations: ACOVE, assessing care of vulnerable elders; MMAT, mixed method appraisal tool; PHC, primary health care.