I S S U E S A N D IN N O V A T I O N S I N N U R S I N G P R A C T I C E

Community nursing: health professional and public perceptions

Hugh McKenna
BSc DPhil RGN RMN RNT

Dean, Faculty of Life and Health Sciences, University of Ulster, Newtownabbey, Ulster, UK

Sinead Keeney

BA MRes

Research Fellow, School of Nursing, University of Ulster, Newtownabbey, Ulster, UK

Submitted for publication 12 March 2003 Accepted for publication 23 October 2003

Correspondence: Sinead Keeney, 12JO5b, School of Nursing, University of Ulster, Shore Road, Newtownabbey, Co. Antrim BT37 0QB, UK. E-mail: sr.keeney@ulster.ac.uk

M C K E N N A H . & K E E N E Y S . ( 2 0 0 4 ) Journal of Advanced Nursing 48(1), 1725 Community nursing: health professional and public perceptions Background. Almost 10 years ago senior United Kingdom nurses met at Heathrow Airport to discuss the challenges and opportunities facing nursing. One aspect of this Heathrow Debate was to encourage nurses to work closer with members of the public. The resulting report stated that nurses have not been effective in working outside their professional area and, in particular, they have not been adept at working in partnership with the public. Aim. The aim of this paper is to report a study to obtain the views of general practitioners (GPs), community nurses and members of the public on how the public perceive community nursing. A further aim was to explore the perceptions of senior health care managers and policymakers about public involvement in primary care. Methods. A two-stage Delphi investigation was undertaken with community nurses (n 38), GPs (n 14) and members of the public (n 8). In addition, one-to-one interviews were carried out with 34 senior health service managers and policymakers. Findings. There was agreement on the following issues: community nurses must work more closely with members of the public; there is a lack of public understanding on the roles of community nurses and specialist nurses; there is public support for nurse prescribing; there is a preference for seeing the community nurse as opposed to the GP; and people prefer one nurse to care for them rather than a variety of nurses. Comments from managers and senior policymakers showed agreement on the public being involved in primary care, but an acknowledgement that this was problematic. A number of recommendations are outlined.

Keywords: primary care, community nurses, general practitioners, service users, Delphi Furthermore, skills relating to community development, community empowerment and public health perspectives were weak and needed to be an integral part of education at preregistration and postregistration levels (Jowett & Walton 1995). Trnobranski (1994) emphasizes that the concept of service user involvement in planning, delivering and evaluating care is an essential component of health care philosophy. This has been a matter of UK policy since the early 1990s (DoH 1990,
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Background
A core element of the United Kingdom (UK) governments health and social care strategy is involvement of the public in decisions about the planning and delivery of services (DHSS 1990, 1996, DoH 1992, 1997). In 1994, UK nurses met at Heathrow Airport to discuss the challenges and opportunities facing nursing. They agreed that nurses have not been effective in working closely with the public (DoH 1994a).
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H. McKenna and S. Keeney

1992, 1994b, 1997, 1999, DHSS 1996, 1999). Studies in Britain (Robinson & Stalker 1993, Thornton & Tozer 1994) and Scotland (Myers & MacDonald 1996) have explored initiatives aimed at consulting with service users and their carers. However, while such objectives continue to command widespread support, practice has not always followed the rhetoric (Myers & MacDonald 1996). The 1996 DHSS report Working together: a focus on health and well-being states that:
The building of healthy alliances with service users and all involved in the provision of health and social care is necessary for needs to be addressed appropriately and equitably (p. 37).

Empowerment

Participation

Consumer satisfaction Consultation Health education

It further asserts that all primary care professionals should provide person focused services which value the expectations, needs and views of patients/clients while protecting their rights and dignity (p. 37). Poulton (1997) outlines a model of user involvement (Figure 1). It can be seen that the lowest level of user involvement is information-giving. However, there is evidence that community nurses have not even reached this level. Most members of the public lack information on what nurses do (Furlong & Glover 1998). There is also much confusion about the plethora of specialist roles currently making up community nursing (Adams et al. 2000). One way to address this is the introduction of a generalist community nurse. A leading gure in the World Health Organization has called for the introduction of The Family Nurse (Fawcett-Henesy 1999. This nurse would be a generalist, a key professional to whom patients and their families could relate. The importance of developing real partnerships between service users and service providers has been highlighted by Twigg and Atkins (1994). In addition, higher public expectations are generally regarded as one of the key drivers of change in public health care provision (see Harrison & Pollitt 1994), as service users tend to become more assertive as they gain more knowledge. This can be seen as a power shift away from the health professional towards the consumer that is characterized by: choice as a fundamental political ideology; an increase in well-informed, assertive consumers; an increase in perceptive questions from the public about provision of health and social care; increasing individual access to health information that was previously held by professional gatekeepers; the challenging of professional autonomy and increasing empowerment of consumers; and increased access to best evidence through the Internet and other media.
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Information-giving
Figure 1 Levels of user involvement.

However, there is very little published research on the perceptions of health professionals about public involvement in primary care or the perceptions of the public about community nurses and their roles.

The study
Aim
This paper reports part of a large study that reviewed the role and function of community nursing with reference to developments in practice, education, research and policy. The aims of this part of the study were: to obtain the views of general practitioners (GPs), community nurses and members of the public on how the public perceive community nursing, and to explore the perceptions of senior health care managers and policymakers about public involvement in primary care.

Design
The Delphi technique and semi-structured interviews were used in this study. The Delphi technique is a structured process that uses a series of questionnaires, or rounds, to gather information and continues until group consensus is reached (Beretta 1996, Green et al. 1999, Hasson et al. 2000). It is growing in popularity, especially for nurse researchers and for health research in general (McKenna 1994, Keeney et al. 2001). This growth centres on the fact that it allows the inclusion of a large number of individuals

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Community nursing Table 1 Community nursing specialties represented in the study Community nursing specialty Practice nurses Health visitors District nurses Community midwives Community psychiatric nurses Public health nurses Community learning disability nurses Specialist community nurse Palliative care Diabetes Child protection Community paediatric nurse Challenging behaviour Macmillan nurse Treatment room nurse Nurse practitioner Number 9 5 4 4 3 3 2 2 2 1 1 1 1 1 1

across diverse locations and with a variety of expertise, and avoids a situation in which a specic expert might dominate the consensus process (Jairath & Weinstein 1994). We considered the level of consensus that would be judged adequate during our use of the Delphi technique. A universally agreed level does not exist as it depends on sample numbers, the aim of the research and resources. Loughlin and Moores (1979) work suggests that consensus should constitute 51% agreement amongst participants; Sumsion (1998) recommends 70%, while Green et al. (1999) opt for 80%. Alternatively, Crisp et al. (1997) question the value of using percentage measures, suggesting that the stability of the response through a series of rounds is a more reliable indicator of consensus. For the purpose of this study, we used a consensus level of 55%.

Participants
The purposive sample for the Delphi survey consisted of 38 community nurses, 14 GPs and eight members of the public. Purposive sampling means that participants were selected to suit the purpose of the study, because it was felt that they possessed the appropriate background to contribute to the discussion (Parahoo 1997). Thirty-seven community nurse participants were female and one was male. Nine had been in practice for more than 20 years; seven for between 16 and 20 years; eight for between 11 and 15 years; nine for between 6 and 10 years and three for between 1 and 5 years. Two did not specify their length of time in practice. Qualications held by the community nurse sample included Registered General Nurse, Registered Mental Nurse, Registered Midwife, Registered Health Visitor, in addition to diplomas in specialist areas such as diabetic care and challenging behaviour, and certificates in areas such as community nursing and mental health. Several participants had primary degrees and Masters degrees. Several others held teaching qualications. Their specialties are shown in Table 1. There are four Health and Social Services Boards in Northern Ireland which are responsible for planning and commissioning Northern Irelands health and social services. The 14 GPs in the sample were accessed through Senior Nurses at these Health and Social Services Boards. Twelve of the GP participants were male and the remaining two were female. Four GP participants had been in practice for over 20 years, four for between 16 and 20 years, three for between 11 and 15 years and three for between 6 and 10 years. Members of the public were recruited through the Health and Social Services Councils, which are formal pressure groups for service users. The participants were not Council members but members of the public who agreed to take part in the study. Seven were female and one was male. They had been in contact with a range of primary care services, including midwifery services, health visitor services, social workers, occupational therapists and speech therapists.

Data collection
Delphi technique The literature and the views of an expert steering group formed the basis for the formulation of the initial Delphi questionnaire. Participants were asked to circle a response on a ve-point scale from strongly agree to strongly disagree. Space was also provided under each statement for participants to write qualitative comments if they wished; several participants did take this opportunity. Round one secured a response rate of 100%. Data were analysed using SPSS (Version 10.0). The round 2 questionnaire, which included written feedback from round 1, was mailed to the sample. The response rate was 97% (n 58). One GP dropped out as he had moved out of the country and one member of the public did not return the second round. The reason for this is unknown. While sample size overall was high for a Delphi panel, the number of members of the public was small (round 1: n 8; round 2: n 7). Semi-structured interviews Following the Delphi survey, individual interviews were undertaken with senior health service managers and policymakers. A purposive sample of 34 respondents was
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H. McKenna and S. Keeney

interviewed. This included chief executives of Health and Social Services Boards, chief nurses, Department of Health nursing ofcers, heads of university nursing departments and other senior managers. A semi-structured interview schedule was used for each interview, the questions for which were formulated from the literature and the results of the Delphi survey. Interview schedules were designed according to the accepted rules of topic guide construction (Rubin & Rubin 1995, Morgan & Krueger 1998). Interviews lasted between half an hour and one hour and were audio-taped with the consent of the participant. Data were transcribed and entered into the NUD*IST package for qualitative data analysis.

Perceptions of GPs and community nurses

In the Delphi study, GP and community nurses were asked to agree or disagree with a number of statements about primary care and the public. Table 2 shows round 2 Delphi responses to these statements. It is clear from Table 2 that the majority of both GPs and community nurses agreed that community nurses of the future have to work in close partnership with members of the public. However, both GP and community nurse responses to the statement there is no clear understanding of the role of the community nurse among members of the public varied.. Responses to the statement members of the public feel more comfortable dealing with the community nurse than their GP were also split. It is interesting to note that, while a high percentage of GPs and community nurses agreed with the statement, sizeable proportions of GPs were either unsure or disagreed, and many community nurses were unsure. Only a small percentage of community nurse respondents disagreed with the statement. The majority of both GPs and community nurses agreed with the statement members of the public prefer one type of nurse to visit them at home rather than a variety of different nurses but, again, substantial proportions of each type of respondent disagreed or were unsure. The statement members of the public feel more condent if they are treated by a specialist nurse produced a departure from the previous trend; many GPs were unsure about the statement and most community nurses agreed with it. A sizeable proportion of GPs disagreed with the statement while disagreement was expressed by only a small percentage of community nurses. A large percentage of GPs disagreed with the statement the concept of the nurse being able to prescribe medication within

Ethical considerations
Research ethics committee approval was not required at the time of the study as patients were not being included. Informed consent was obtained from all participants and each was informed that they could leave the study at any stage without prejudice. While true anonymity could not be assured because we could link responses to specic participants, condentiality was guaranteed. Participants were informed that only we would have access to the data, that tapes and transcripts would be destroyed after analysis, and that no participant would be recognizable in any report or publication derived from the study.

Findings
The ndings are presented in four sections: perceptions of GPs and community nurses; perceptions of members of the public; overall Delphi ndings; and perceptions of senior health care managers and policymakers.

Table 2 Perceptions of general practitioners and community nurses (round 2 responses) General practitioner responses Statement Community nurses of the future have to work closely in partnership with members of the public There is no clear understanding of the role of the community nurse among members of the public Members of the public feel more comfortable dealing with the community nurse than their GP Members of the public prefer one type of nurse to visit them at home rather than a variety of different nurses Members of the public feel more condent if they are being treated by a specialist nurse The concept of the nurse being able to prescribe medication within a GP practice is very appealing to members of the public Community nurse responses

Agree (%) Unsure (%) Disagree (%) Agree (%) Unsure (%) Disagree (%) 14 (100) 0 0 7 (538) 4 (308) 2 (154) 4 (308) 0 37 (974) 21 (553) 0 6 (158) 1 (26) 11 (289) 3 (78) 5 (131) 3 (78) 2 (53)

2 (154) 4 (308) 6 (462) 3 (231) 8 (615) 3 (231) 2 (154) 7 (538) 4 (308) 9 (692)

20 (526) 15 (396) 21 (553) 12 (316) 23 (606) 12 (316) 20 (526) 16 (421)

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Community nursing

a GP practice is very appealing to members of the public, while most community nurses agreed with it. However, many community nurses were unsure, as were most GPs.

Perceptions of members of the public

Members of the public were asked to agree or disagree with the same statements about primary care and the public. Table 3 shows their round 2 responses to these statements. It is clear from Table 3 that all members of the public agreed that community nurses of the future would have to work in close partnership with members of the public. While four of them agreed that there is no clear understanding of the role of the community nurse, it is interesting to note that two were unsure and one disagreed. Three agreed with the statement members of the public feel more comfortable dealing with the community nurse than their GP, two were unsure and a further two disagreed. As Table 3 illustrates, most members of the public agreed with the statements members of the public prefer one type of
Table 3 Perceptions of members of the public (round 2 responses)

nurse to visit them at home rather than a variety of different nurses, members of the public feel more condent if they are being treated by a specialist nurse and the concept of the nurse being able to prescribe medication within a GP practice is very appealing to members of the public.

Overall Delphi ndings

Table 4 outlines which statements gained consensus and which did not. It also shows the level of consensus gained overall for all statements. Consensus was gained on the statement community nurses of the future have to work closely in partnership with members of the public. The vast majority of respondents agreed with the statement, giving an overall sample consensus of 983% agreement. Participants were asked to consider the statement There is no clear understanding of the role of the community nurse among members of the public. No overall consensus was gained after two rounds of the Delphi questionnaire.

Responses Statement Community nurses of the future have to work closely in partnership with members of the public There is no clear understanding of the role of the community nurse among members of the public Members of the public feel more comfortable dealing with the community nurse than their GP Members of the public prefer one type of nurse to visit them at home rather than a variety of different nurses Members of the public feel more condent if they are being treated by a specialist nurse The concept of the nurse being able to prescribe medication within a GP practice is very appealing to members of the public Agree (%) 7 (100) 4 (571) 3 (428) 5 (714) 6 (857) 6 (857) Unsure (%) 0 2 (286) 2 (286) 1 (143) 0 1 (143) Disagree (%) 0 1 (143) 2 (286) 1 (143) 1 (143) 0

Table 4. Overall levels of consensus Statement Community nurses of the future have to work closely in partnership with members of the public There is no clear understanding of the role of the community nurse among members of the public Members of the public feel more comfortable dealing with the community nurse than their GP Members of the public prefer one type of nurse to visit them at home rather than a variety of different nurses Members of the public feel more condent if they are being treated by a specialist nurse The concept of the nurse being able to prescribe medication within a GP practice is very appealing to members of the public Consensus gained Yes No No Yes No No Level of consensus 983% agreed with statement 466% agreed with statement 535% agreed with statement 587% agreed with statement 534% agreed with statement 517% agreed with statement

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Overall, 535% (n 31) of the sample agreed that members of the public feel more comfortable dealing with the community nurse than their GP. As it is over half the sample, this percentage could be considered to represent consensus on the issue. However, in our study it did not constitute consensus as it did not reach the level of 55%. It is interesting that six (462%) of the GP respondents agreed with the statement as did 20 (526%) of the community nurses. Overall, 587% (n 34) of the total sample agreed that members of the public prefer one type of nurse to visit them at home rather than a variety of different nurses. This percentage was just over the consensus level. In relation to the statement members of the public feel more condent if they are being treated by a specialist nurse, only two (154%) GPs agreed, but 23 (606%) community nurses and six (857%) members of the public agreed. While the majority of community nurses and members of the public agreed with this statement, the very low percentage of GPs who agreed resulted in agreement by just over half the overall sample (534%). This is not high enough to be considered a consensus. The concept of nurses being able to prescribe medication within a GP practice is very appealing to members of the public was the next statement that the sample were asked to consider. Six (857%) members of the public agreed with the statement; one was undecided and none disagreed. Over half the community nurses (526%, n 20) agreed with the statement and four (308%) of the GPs agreed, with the remainder undecided. No GPs disagreed with the statement. Overall, over half the sample (517%, n 30) agreed with the statement but no consensus was gained.

There is a role but it is not clearly dened

It is very important that we have government policy to engage the public and seek their views on how the service should be provided. We always said we knew what the public need and wanted, but I dont know that we ever actually asked them. (Director of Nursing) We are not innovative enough or creative enough to organize ourselves in a way that makes our service amenable and accessible to the most vulnerable in our community. The only way to engage these communities is to make them active partners in these processes, and so community development is a concept, which is easy to say but very difcult to do. (Chief Executive, Health & Social Services Board) The answer, of course, is that they should be involved, but the real question is: How do we involve them? (Director of Nursing) What we really have to do is ensure that the publics voice is heard. This hasnt really been worked out yet. There are issues to do with public representation, community representation, PCGs in primary care, the Health and Social Care partnerships. But there is a commitment to ensuring that the public voice is heard. (Senior Nurse Manager)

There is a clear role for the public at present

There is a clear role for the public in primary care at present and it is beginning to work very well. It has to be a partnership, and we have begun that process. (Director of Nursing)

Limitations
This study was conned to purposive samples in Northern Ireland and a small sample of members of the public was used. While every effort was made to ensure a rigorous and systematic study, the ndings are not generalizable to similar groups of participants outside this setting. Nonetheless, the ndings do mirror those of other international research studies on this topic. In addition, there are many critiques of the Delphi technique as a research method (see Keeney et al. 2001). However, it remains one of the most popular methods of achieving consensus on difcult issues.

Perceptions of health care managers and policymakers

The involvement of members of the public in primary care was explored in the interviews with 34 senior health managers and policymakers. They were asked what role they believed that the public should play in the development of primary care services. Responses were categorized and three clear themes emerged: There is no role for the public at present, There is a role but it is not clearly dened, There is a clear role for the public at present. The second theme was by far the most predominant. Examples of interviewees comments follow. There is no role for the public at present
[I am] not sure that they have any role at present. They could have a big role, but not at present. I think we should be seeking the view of the public on this. Efforts should be made independently to assess what is thought of community nursing in Northern Ireland. (Director of Nursing) 22

Discussion
One of the main ndings suggests that community nurses must work more in partnership with the public. This is something which has been policy-driven for the last decade (DoH 1992, 1994b, 1997, 1999) and it is interesting to see that GPs, community nurses and members of the public were all in agreement.

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Community nursing

The ndings show no overall consensus among participants on there being a misunderstanding of community nurses roles among members of the public. However, closer examination indicates that the views of GPs and the other participants were polarized. Most nurses agreed that there was misunderstanding among members of the public about their role. This suggests that, unlike GPs, nurses recognize that there is a problem. This would support the views of Furlong and Glover (1998). Further to this, it is interesting that 58% of all participants agreed that members of the public prefer one type of nurse to visit them at home rather than a variety of different nurses. This is not a surprising nding, but it does show a lack of understanding about the contemporary role of community nursing. It intimates that there is a preference for generalism rather than specialism and that one community nurse, rather like one GP, can deal with all their community nursing needs. This is coherent with Fawcett-Henesys (1999) family nurse initiative. In contradiction to the previous nding, over 85% of the members of the public agreed that they felt more condent when being treated by a specialist nurse. This suggests confusion about the community nurses role. It is inconsistent to be a supporter of specialist nursing practice and yet wish to be visited by a generalist nurse. What is most surprising is that community nurses themselves appear to be torn between desiring specialization and realizing that clients can best interact with one key visiting nurse. Perhaps the best way to interpret this is that nurses and members of the public want a balance between high quality expertise and as few visiting nurses as possible. This seems to echo the conclusions of the National Public Health Nursing Committee (1995), which state that, while increased specialization is inevitable, there is no agreement on how all-embracing it should be. Over half of the participants agreed that members of the public would feel more comfortable dealing with a community nurse than their GP. Interestingly, just under half of GPs and members of the public, and over 50% of community nurses agreed with this statement. This reects the contemporary expansion of nurse practitioner and practice nurse roles (Hicks & Hennessy 1999). It suggests that nurses can take on roles that were previously the remit of doctors, and that many of them have the expertise and time to give to patients who present with a variety of problems, as Adams et al. (2000) also concluded. This expansion of the community nurse role is also supported by the responses of members of the public to community nurse prescribing. Interestingly, GPs seemed less convinced that this was a good idea. This could be a form of territorialism, and of GPs seeing their independent role being

eroded by community nurses. Over 40% of the community nurses also disagreed with nurses being allowed to prescribe. This seems to be a rejection of a key recommendation of the Crown Report (1999): extension of the scope of nurse prescribing in the UK to a wide range of medicines which at present require a doctors prescription. Almost all of the 34 senior managers and policymakers gave responses supportive of a greater involvement of members of the public in health care planning and provision. This is in line with a large number of UK government reports (DHSS 1990, 1996, DoH 1992, 1997). However, there was a distinct impression from the participants that they were unclear as to how this wish could be turned into meaningful reality, a perspective echoing that of Myers and MacDonald (1996).

Conclusions
The study highlights the views of a sample of GPs, community nurses and members of the public on public perceptions of community nursing, and senior managers and policymakers views on user involvement in primary care planning and delivery. Findings indicate agreement on community nurses working in partnership with the public, but also a lack of clear understanding of the roles of community nurses and specialist nurses. There were positive views on nurse prescribing and it was thought that members of the public often prefer to see a community nurse rather than the GP. Members of the public highlighted their preference for having one nurse care for them, as opposed to a variety of nurses. Comments from senior policymakers suggest that the public should be involved in primary care but acknowledge that this is problematic. In light of this, the following recommendations are proposed: Nurses should promote and encourage the public to be involved in the planning and delivering of services. Community nurses must also involve consumers of health and social services in ways that increase their resources, promote their capacity and power to inuence factors affecting their health and well-being, and enhance their understanding of community nurse services. Nurses have a special relationship with the public and this demands a readiness to ask people about their experiences of health and how they want their care needs met. Commissioners and trusts must create a climate and culture that is responsive to public involvement, and this must be reected in the resources, timescales, information exchange and willingness to support individual practitioners in their public engagement.
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H. McKenna and S. Keeney DoH (1994b) Working in Partnership? A Collaborative Approach to Care. Department of Health, London. DoH (1997) The New NHS: Modern and Dependable. Department of Health, London. DoH (1999) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. Department of Health, London. Fawcett-Henesy A. (1999) Presentation Given at an All-Ireland Seminar on Public Health Nursing. Canal Court Hotel, Newry, Co. Down. Furlong S. & Glover D. (1998) Confusion surrounds piecemeal changes in nurses roles. Nursing Times 94(37), 5456. Green B., Jones M., Hughes D. & Williams A. (1999) Applying the Delphi technique in a study of GPs information requirements. Health and Social Care in the Community 7(3), 198205. Harrison S. & Pollitt C. (1994) Controlling Health Professionals. Open University Press, Buckingham. Hasson F., Keeney S. & McKenna H.P. (2000) Research guidelines for the Delphi survey technique. Journal of Advanced Nursing 32(4), 10081015. Hicks C. & Hennessy D. (1999) A task based approach to defining the role of Nurse Practitioner; the views of UK acute and primary sector nurses. Journal of Advanced Nursing 29(3), 666 673. Jairath N. & Weinstein J. (1994) The Delphi methodology (Part 1): a useful administrative approach. Canadian Journal of Nursing Administration 7(3), 2940. Jowett S. & Walton I. (1995) Challenges and Changes in Nurse Education: a Study of the Implementation of Project 2000. NFER, London. Keeney S., Hasson F. & McKenna H.P. (2001) A critical review of the Delphi technique as a research methodology for nursing. International Journal of Nursing Studies 38, 195200. Loughlin K. & Moore L. (1979) Using Delphi to achieve congruent objectives and activities in a paediatric department. Journal of Medical Education 54, 101106. McKenna H.P. (1994) The Delphi technique: a worthwhile technique for nursing? Journal of Advanced Nursing 19, 12211225. Morgan, D.L. & Krueger, R.A. (1998) The Focus Group Kit. Sage, London. Myers F. & MacDonald C. (1996) Power to the people? Involving users and carers in needs assessments and care planning views from the practitioner. Health and Social Care in Community 4(2), 8695. National Public Health Nursing Committee (1995) A Service without Walls an Analysis of Public Health Nursing. Department of Health, Dublin. Parahoo A.K. (1997) Nursing Research: Principles, Process and Issues. Macmillan, London. Poulton B. (1997) Consumer feedback and determining satisfaction with services. In Achieving Quality in Community Health Care Nursing Services (Mason C., ed.), Macmillan Press, London, pp. 3153. Robinson C. & Stalker K. (1993) Patterns of provision in respite care and the Childrens Act. British Journal of Social Work 23(1), 4563. Rubin H.J. & Rubin I. (1995) Qualitative Interviewing: the Art of Hearing Data. Sage, London.

What is already known about this topic

The importance of developing partnerships between service users and service providers has been highlighted. Nurses have not been effective in working closely with the public. There has been very little research on the publics view of community nursing.

What this paper adds

The views of general practitioners and community nurses on public perceptions of community nursing. The views of members of the public on issues in community nursing and primary care. The views of senior health managers and policymakers on public involvement in primary care.

Senior nurses at management, planning and commissioning level should invest in developing strategies for involving the public in service planning and provision.

Acknowledgements
The study was funded by the Southern Health and Social Services Board and the Western Health and Social Services Board in Northern Ireland, and Co-operation and Working Together (CAWT).

References
Adams A., Lugsden E., Chase J., Arber S. & Bond S. (2000) Skill-mix changes and work intensification in nursing. Work, Employment and Society 14(3), 541555. Beretta R. (1996) A critical review of the Delphi technique. Nurse Researcher 3(4), 7989. Crisp J., Pelletier D., Duffield C., Adams A. & Nagy S. (1997) The Delphi method? Nursing Research 46(2), 116118. Crown Report (1999) Review of Prescribing, Supply and Administration of Medicines. Department of Health, London. DHSS (1990) People First: Community Care in Northern Ireland for the 1990s. DHSS, Belfast. DHSS (1996) Working Together: Action Plan for Community Nurses, Midwives and Health Visitors. DHSS, Belfast. DHSS (1999) Fit for the Future. DHSS, Belfast. DoH (1990) The Care Programme Approach for People with a Mental Illness Referred to the Specialist Psychiatric Services. Department of Health, London. DoH (1992) The Patients Charter. Department of Health, London. DoH (1994a) The Heathrow Debate: the Challenges for Nursing and Midwifery in the 21st Century. HMSO, London.

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Issues and innovations in nursing practice Sumsion T. (1998) The Delphi technique: an adaptive research tool. British Journal of Occupational Therapy 61(4), 153156. Thornton P. & Tozer R. (1994) Involving Older People in Community Care Planning: A Review of Initiatives Social Policy Research Unit. University of York, York.

Community nursing Trnobranski P. (1994) Nursepatient negotiation: assumption or reality? Journal of Advanced Nursing 19, 733737. Twigg J. & Atkins K. (1994) Carers Perceived: Policy and Practice in Informal Care. Open University Press, Buckingham.

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