Public Health Nursing in Ireland: The General Practitioners' View C. H. Hayes, M. Hynes, B. O'Herlihy.
Eastern Health Board, Community Care Area 8, Dublin, Ireland. Abstract Present health policy in Ireland is directed towards a shift in emphasis from the provision of services on a hospital inpatient basis to a community or outpatient basis. This study set out to elicit views of general practitioners (GPs) in relation to the home visiting activities of the nursing services in the community. Ofthe thirty-five (76 %) GPs whose questionnaires were included in the analysis, 88 % were satisfied with the quality of nursing services provided by the public health nurse (PHN) but were dissatisfied with access to service (37%), out of hours service (48%) and communication with PHNs (25%). Eight GPs had contact with public health nurses on a weekly basis, 11 had contact monthly and 14 had contact three monthly or less frequently. For chronic conditions requiring dressings, over 70% of GPs refer to the PHN and when given a choice, 25% of GPs would refer these conditions to a registered general nurse (RGN). Care by an RGN or nurses' aide for conditions such as monitoring of vital signs, continence care and administration of enemas, was found acceptable by 50% of GPs. The findings indicate that there is need for review of the structure of the nursing services in the community. Introduction In Ireland the public health nurse (PHN), who is a highly trained individual, carries out all the nursing duties in the community except those associated with psychiatric care. This contrasts with the situation in the United Kingdom. The structure of the present community nursing service in Ireland dates from the mid-1960's. At that time, the Department of Health outlined the service as including domiciliary midwifery services, general domiciliary nursing and public health care of children up to the end of national school 1. Integration of the nursing service with general practice was stressed. The consultative Council on General Medical Practice went as far as to say that an adequate domiciliary nursing service in close co-operation with general practitioners (GPs) could keep old and disabled people out of institutions and facilitate earlier discharge from hospital. However following a reorganisation of the general practitioner service in the 1970's, with the introduction of a choice of doctor scheme for the 38% (approximately) of the population who are covered for free general practitioner services, the ties between general practitioners (GPs) and public health nurses (PHNs) became considerably less and this resulted in the GP and PHN working, to a large extent, independently in the community. The declaration of the World Health Organisation at Alma Ata in 1978, committed member states to the primary health care approach to achieve health for all by the year 20002. The GP and public health nurse are seen in Ireland as core members of the team delivering primary health care services and liaison between them is essential for effective delivery of these services. Liaison between the GP and public health nurse is especially important as it has been suggested that 80% of
referrals to PHNs come from GPs 3. The view was expressed in the Irish College of General Practitioners's policy document on the future Organisation of General Practice that there was a widening communication gap between GPs and PHNs due, it was felt, to a mismatch between the GP practice population and the patient population of the PHN 4. In an attitude survey of PHNs more than half of the nurses felt that doctors did not make sufficient effort to discuss cases with them 5. The objectives of our study were:- to,document referral patterns from GPs to public health nurses in relation to their nursing duties. - to document the attitudes of GPs to the community nursing service. Method The study was carried out in one Community Care Area in the Eastern Health Board with a mixed urban/rural population of approximately 200,000 people. A postal questionnaire was sent to a 50% random sample of GPs (n=46) known to have patients in the Community Care Area. The questionnaires were sent with a freepost addressed envelope. The non-responders were contacted by telephone to maximise the response rate. The questionnaires were designed to obtain information on the frequency of contact with the PHN service and referral pattern of GPs. An opinion was sought as to whether, if given a choice, specific disorders would be referred to a PHN, a registered general nurse (RGN) or to a nurses' aide*. An assessment of the satisfaction with * A nurses' aide is a person without nursing qualification who carries out basic nursing care in the community under the direction of a public health nurse. 105
I.J.M.S. April, 1992
106 Hayes et al TABLE I Conditions referred to public health nursing service by general practitioners in the study (35). Always/ Usually No. Dressing of PS.* Prevention of PS.* Varicose ulcer Gangrenous areas Burns Post op wounds Removal of sutures Washing/hygiene Continence care Stoma care Enemas Catheterisation Diabetic injections B12 injections Urine testing Temp./pulse BP measurement
29 28 26 17 12 17 4 26 27 24 25 12 12 10 5 3 2
Rarely/ Never
%
No.
82.9 80.0 74.3 48.6 34.3 48.5 11.4 74.3 77.1 68.6 71.4 34.3 34.3 28.5 14.3 8.5 5.7
6 6 7 13 17 14 28 9 7 10 10 20 18 22 27 28 30
% 17.1 17.1 20 37.1 48.6 4..0 80 25.7 20.0 28.5 28.6 57.1 51.4 62.9 77.1 80.0 85.7
Total 35 34 33 30 29 31 32 35 34 34 35 32 30 32 32 31 32
% 100.0 97.1 94.3 85.7 82.9 88.5 91.4 100.0 97.1 97.1 100.0 91.4 85.7 91.4 91.4 88.5 91.4
*PS = Pressure scores communication, access to service, quality o f care and out o f hours service, was included.
Results Thirty-eight o f the 46 G P s in the study replied giving a response rate of 83%. Three GPs indicated that because o f the composition o f their practice, they had little contact
with the Public Health Nursing service and so considered it inappropriate to comment. A n a l y s i s was confined to the remaining 35 (76%) questionnaires. As not all GPs responded to each question not all the numbers in the tables add to the total of 35. GPs were in contact with a m e a n number of only 2.7 PHNs. There was little contact between GPs and PHNs. Eight G P s had contact with P H N s on a weekly basis, 11 had contact monthly and 14 had contact three monthly or less frequently. Contact was mostSrequently by telephone and initiated by the GP. GPs were more likely to refer chronic conditions, e.g. pressure sores and varicose ulcers to the PHN (Table I). In addition, they referred stoma care, enemas, washing of the patient and prevention o f pressure sores to the PHN service. Patients requiring monitoring o f vital signs, urine testing or r e m o v a l o f sutures were rarely referred. Given a choice of referral, G P w o u l d still prefer to refer conditions requiring dressings and s t o m a care to the PHN (Table II). However, a quarter o f these would accept care by a registered general nurse for those conditions. F o r other conditions, e.g. washing o f patients, continence care, administration o f enemas or monitoring o f vital signs almost half o f GPs indicated that they w o u l d find care by an R G N or nurse aide acceptable. Table III highlights the satisfaction o f GPs with the quality o f care given by the P H N service. There was a high level of dissatisfaction with both access to service (35.1%) and communication (25.7%). G r e a t e s t dissatisfaction was expressed with out o f hours service (48%). W h e n invited to comment, a quarter o f GPs indicated that there should be more nursing staff in the c o m m u n i t y and that they would like a nurse o r practice nurse directly
TABLE II Preferred referral of specific conditions if choice of nursing personnel available in the community. Conditions
PHN Number
Dressing of PS.* Prevention of PS.* Varicose ulcer Gangrenous areas Bums Post op wounds Removal of sutures Washing/hygiene Continence care Stoma care Enemas Catheterisation Diabetic injections B12 injections Urine testing Temp./pulse BP measurement *PS = Pressure scores
26 21 23 19 21 19 10 15 18 22 17 15 19 11 10 9 8
% 74.3 60.0 65.7 54.3 60.0 54.3 28.6 42.8 51.4 62.9 48.6 42.8 34.3 31.4 28.6 25.7 22.9
RGN or PHN/RGN Number % 9 11 11 9 12 12 13 8 12 10 13 15 11 13 10 12 12
25.7 31.4 31.4 25.7 34.2 34.3 37.1 22.8 34.3 28.5 37.1 42.8 31.4 37.1 28.6 34.3 34.3
Nurses Aide Number % . 2 1 2 10 5 1 4 1 1 1 5 5 2
.
. 5.7 2.9 5.7 28.6 14.3 2.9 11.4 2.9 2.9 2.9 14.3 14.3 5.7
None Number
%
Total
%
2.9 14.3 2.9 8.5 25.7 2.9 8.6 11.4 20.0 25.7 20.0 31.4
35 34 35 33 34 35 34 34 35 33 34 34 35 32 34 33 33
100.0 97.1 100.0 94.3 97.1 100.0 97.1 97.1 100.0 94.3 97.1 97.1 100.0 91.4 97.2 94.3 94.3
. 1 5 1 3 9 1 3 4 7 9 7 11
Public llealth Nursing 107
vol. 161 No. 4
TABLE ]II Satisfaction with public health nurse service. Communication No. %
Access Quality to service of care
No. %
Very satisfied Satisfied Dissatisfied Very dissatisfied
10 14 4 5
28.8 9 25.7 40.0 12 34.3 11.4 9 25.7 15.3 4 11.4
TOTAL
33 94.3 34
97.1
No. %
Out of hours No. %
17 48.6 4 14 40.0 9 1 2.8 11 6
11.4 25.7 31.4 17.2
32
85.7
91.4 30
reporting to them. Fourteen percent (14%) would like improved means of contacting the PHN and 12% indicated that they would like regular meetings. Discussion This study was prompted by the considerable changes which have taken place in the health services in Ireland in the last 25 years. More recently, it has been suggested that the emphasis on early discharge from hospital and caring for people in the community has led to greater demands on the community nursing service. An increased workload of the district nurse in the United Kingdom has been documented as a result of a similar policy of promoting health care in the community 6. The low level of contact between GPs amd PHNs found in this study is disappointing especially when looked at in the context of the World Health Organisation's aspiration to achieve health for all by the year 2000 through primary health care teams 2. Although a previous survey3 found that 80% of referrals to PHNs originated from GPs, suggesting a high level of communication, our study has shown that this is not the case. This would indicate that GPs and PHNs are working to a large extent independently of each other in the community. The structure of community nursing in Ireland differs from that in the United Kingdom. In that country the primary health care team is normally formed by the "attachment" of district nurses and health visitors to a general practice. This facilitates communication between GPs and community nurses as is evidenced by a study carried out in the United Kingdom, where 80% of nurses in health centres and 78% of nurses based elsewhere made contact with doctors every day 7. Also, in 9 of the 24 health centres and 5 of 13 other premises, doctors and community nurses had formal meetings once a month. As a minimum formal and informal contact between public health nurses in Ireland and general practitioners should be encouraged and methods facilitating contact and cooperation are essential. One of the most striking features of the study is the high level of dissatisfaction with the out of hours service. A limited but successful twilight and night nursing service is being provided by some health boards. A twilight nursing service is available in the Eastern Hcalth Board area mainly
through the District Units which cater for elderly patients. The introduction of a limited out of hours nursing service is to be welcomed, however it needs to be developed further. The PHN is not only a registetred nurse but a person who in addition, has undergone lengthy training in Midwifery and Public Health and is close in status and salary to that of a hospital ward sister. There is acceptance by GPs that many nursing activities carried out by PHNs could be undertaken by persons with lesser qualifications such as registered general nurses or nurses' aides. In Bolton in the United Kingdom, a mix of state registered nurses, state enrolled nurses and nurse auxiliaries was introduced into the Community Nursing Services and their introduction resulted in reducing the cost of the nursing service without a reduction in quality of care 8. A similar mix of community nursing staff could be introduced in Ireland and result in the availability of increased numbers of personnel working in community nursing at no extra cost. It was originally intended that the activities of the PHN, with special reference to the decision making process for admitting and discharging patients from the community nursing service, would form part of this study. Unfortunately, the withholding of cooperation by some PHNs made this impracticable. However it remains an area requiring review. This study has examined some aspects of the PHN's work in one community care area. It highlights issues relating to the functioning of the present public health nursing service. Firstly there is less than optimal contact between the PHN and GP. Secondly there is dissatisfaction concerning the availability of a community nursing service outside normal working hours. In addition, the issue is raised as to whether an enhanced nursing service in the community could be provided for the same cost, if more use were made of registered general nurses and if nurse auxiliaries were introduced. These points indicate an urgent need to examine in detail the wider aspects of public health nursing on a nationwide basis. References
1. Departnment of Health, The ttealth Services and their future development, Dubfin, 1966. 2. World Health Organisation, Alma-Ata 1978: Primary Health Care: Geneva, 1987. 3. Department of Health, Survey of the Workload of Public Health Nurses, Dublin, 1975. 4. Irish College of General Practice Working Group on Standards of Practice and Conditions of Service, Policy Document on the future Organisation of General Practice in Ireland, Dublin, 1986. 5. McGowan, J. Attitude Survey of Irish Nurses, Dublin: Institute of Public Administrtion, 1979. 6. Salter, B., Battle, S., Moran Ellis, J. Where the buck stops. Community Outlook 1986: 19-20. 7. Tamara, K. et al. Cooperation between general practitioners and community nurses based at health centres and other types of premises in the United Kingdom as seen through the eyes of Japanese doctor, 1979. Public ttealth London 1982: 96(2), 79-85 8. Gallagher, ltowe J. E., McNedl, A. W , Richardson, E. M., Ross, A. I. A Study of llealth Visiting and District Nursing in Bolton (1976). The Medical Officer, 161-167.
Eastern Health Board, Community Care Area 8, Dublin, Ireland. Abstract Present health policy in Ireland is directed towards a shift in emphasis from the provision of services on a hospital inpatient basis to a community or outpatient basis. This study set out to elicit views of general practitioners (GPs) in relation to the home visiting activities of the nursing services in the community. Ofthe thirty-five (76 %) GPs whose questionnaires were included in the analysis, 88 % were satisfied with the quality of nursing services provided by the public health nurse (PHN) but were dissatisfied with access to service (37%), out of hours service (48%) and communication with PHNs (25%). Eight GPs had contact with public health nurses on a weekly basis, 11 had contact monthly and 14 had contact three monthly or less frequently. For chronic conditions requiring dressings, over 70% of GPs refer to the PHN and when given a choice, 25% of GPs would refer these conditions to a registered general nurse (RGN). Care by an RGN or nurses' aide for conditions such as monitoring of vital signs, continence care and administration of enemas, was found acceptable by 50% of GPs. The findings indicate that there is need for review of the structure of the nursing services in the community. Introduction In Ireland the public health nurse (PHN), who is a highly trained individual, carries out all the nursing duties in the community except those associated with psychiatric care. This contrasts with the situation in the United Kingdom. The structure of the present community nursing service in Ireland dates from the mid-1960's. At that time, the Department of Health outlined the service as including domiciliary midwifery services, general domiciliary nursing and public health care of children up to the end of national school 1. Integration of the nursing service with general practice was stressed. The consultative Council on General Medical Practice went as far as to say that an adequate domiciliary nursing service in close co-operation with general practitioners (GPs) could keep old and disabled people out of institutions and facilitate earlier discharge from hospital. However following a reorganisation of the general practitioner service in the 1970's, with the introduction of a choice of doctor scheme for the 38% (approximately) of the population who are covered for free general practitioner services, the ties between general practitioners (GPs) and public health nurses (PHNs) became considerably less and this resulted in the GP and PHN working, to a large extent, independently in the community. The declaration of the World Health Organisation at Alma Ata in 1978, committed member states to the primary health care approach to achieve health for all by the year 20002. The GP and public health nurse are seen in Ireland as core members of the team delivering primary health care services and liaison between them is essential for effective delivery of these services. Liaison between the GP and public health nurse is especially important as it has been suggested that 80% of
referrals to PHNs come from GPs 3. The view was expressed in the Irish College of General Practitioners's policy document on the future Organisation of General Practice that there was a widening communication gap between GPs and PHNs due, it was felt, to a mismatch between the GP practice population and the patient population of the PHN 4. In an attitude survey of PHNs more than half of the nurses felt that doctors did not make sufficient effort to discuss cases with them 5. The objectives of our study were:- to,document referral patterns from GPs to public health nurses in relation to their nursing duties. - to document the attitudes of GPs to the community nursing service. Method The study was carried out in one Community Care Area in the Eastern Health Board with a mixed urban/rural population of approximately 200,000 people. A postal questionnaire was sent to a 50% random sample of GPs (n=46) known to have patients in the Community Care Area. The questionnaires were sent with a freepost addressed envelope. The non-responders were contacted by telephone to maximise the response rate. The questionnaires were designed to obtain information on the frequency of contact with the PHN service and referral pattern of GPs. An opinion was sought as to whether, if given a choice, specific disorders would be referred to a PHN, a registered general nurse (RGN) or to a nurses' aide*. An assessment of the satisfaction with * A nurses' aide is a person without nursing qualification who carries out basic nursing care in the community under the direction of a public health nurse. 105
I.J.M.S. April, 1992
106 Hayes et al TABLE I Conditions referred to public health nursing service by general practitioners in the study (35). Always/ Usually No. Dressing of PS.* Prevention of PS.* Varicose ulcer Gangrenous areas Burns Post op wounds Removal of sutures Washing/hygiene Continence care Stoma care Enemas Catheterisation Diabetic injections B12 injections Urine testing Temp./pulse BP measurement
29 28 26 17 12 17 4 26 27 24 25 12 12 10 5 3 2
Rarely/ Never
%
No.
82.9 80.0 74.3 48.6 34.3 48.5 11.4 74.3 77.1 68.6 71.4 34.3 34.3 28.5 14.3 8.5 5.7
6 6 7 13 17 14 28 9 7 10 10 20 18 22 27 28 30
% 17.1 17.1 20 37.1 48.6 4..0 80 25.7 20.0 28.5 28.6 57.1 51.4 62.9 77.1 80.0 85.7
Total 35 34 33 30 29 31 32 35 34 34 35 32 30 32 32 31 32
% 100.0 97.1 94.3 85.7 82.9 88.5 91.4 100.0 97.1 97.1 100.0 91.4 85.7 91.4 91.4 88.5 91.4
*PS = Pressure scores communication, access to service, quality o f care and out o f hours service, was included.
Results Thirty-eight o f the 46 G P s in the study replied giving a response rate of 83%. Three GPs indicated that because o f the composition o f their practice, they had little contact
with the Public Health Nursing service and so considered it inappropriate to comment. A n a l y s i s was confined to the remaining 35 (76%) questionnaires. As not all GPs responded to each question not all the numbers in the tables add to the total of 35. GPs were in contact with a m e a n number of only 2.7 PHNs. There was little contact between GPs and PHNs. Eight G P s had contact with P H N s on a weekly basis, 11 had contact monthly and 14 had contact three monthly or less frequently. Contact was mostSrequently by telephone and initiated by the GP. GPs were more likely to refer chronic conditions, e.g. pressure sores and varicose ulcers to the PHN (Table I). In addition, they referred stoma care, enemas, washing of the patient and prevention o f pressure sores to the PHN service. Patients requiring monitoring o f vital signs, urine testing or r e m o v a l o f sutures were rarely referred. Given a choice of referral, G P w o u l d still prefer to refer conditions requiring dressings and s t o m a care to the PHN (Table II). However, a quarter o f these would accept care by a registered general nurse for those conditions. F o r other conditions, e.g. washing o f patients, continence care, administration o f enemas or monitoring o f vital signs almost half o f GPs indicated that they w o u l d find care by an R G N or nurse aide acceptable. Table III highlights the satisfaction o f GPs with the quality o f care given by the P H N service. There was a high level of dissatisfaction with both access to service (35.1%) and communication (25.7%). G r e a t e s t dissatisfaction was expressed with out o f hours service (48%). W h e n invited to comment, a quarter o f GPs indicated that there should be more nursing staff in the c o m m u n i t y and that they would like a nurse o r practice nurse directly
TABLE II Preferred referral of specific conditions if choice of nursing personnel available in the community. Conditions
PHN Number
Dressing of PS.* Prevention of PS.* Varicose ulcer Gangrenous areas Bums Post op wounds Removal of sutures Washing/hygiene Continence care Stoma care Enemas Catheterisation Diabetic injections B12 injections Urine testing Temp./pulse BP measurement *PS = Pressure scores
26 21 23 19 21 19 10 15 18 22 17 15 19 11 10 9 8
% 74.3 60.0 65.7 54.3 60.0 54.3 28.6 42.8 51.4 62.9 48.6 42.8 34.3 31.4 28.6 25.7 22.9
RGN or PHN/RGN Number % 9 11 11 9 12 12 13 8 12 10 13 15 11 13 10 12 12
25.7 31.4 31.4 25.7 34.2 34.3 37.1 22.8 34.3 28.5 37.1 42.8 31.4 37.1 28.6 34.3 34.3
Nurses Aide Number % . 2 1 2 10 5 1 4 1 1 1 5 5 2
.
. 5.7 2.9 5.7 28.6 14.3 2.9 11.4 2.9 2.9 2.9 14.3 14.3 5.7
None Number
%
Total
%
2.9 14.3 2.9 8.5 25.7 2.9 8.6 11.4 20.0 25.7 20.0 31.4
35 34 35 33 34 35 34 34 35 33 34 34 35 32 34 33 33
100.0 97.1 100.0 94.3 97.1 100.0 97.1 97.1 100.0 94.3 97.1 97.1 100.0 91.4 97.2 94.3 94.3
. 1 5 1 3 9 1 3 4 7 9 7 11
Public llealth Nursing 107
vol. 161 No. 4
TABLE ]II Satisfaction with public health nurse service. Communication No. %
Access Quality to service of care
No. %
Very satisfied Satisfied Dissatisfied Very dissatisfied
10 14 4 5
28.8 9 25.7 40.0 12 34.3 11.4 9 25.7 15.3 4 11.4
TOTAL
33 94.3 34
97.1
No. %
Out of hours No. %
17 48.6 4 14 40.0 9 1 2.8 11 6
11.4 25.7 31.4 17.2
32
85.7
91.4 30
reporting to them. Fourteen percent (14%) would like improved means of contacting the PHN and 12% indicated that they would like regular meetings. Discussion This study was prompted by the considerable changes which have taken place in the health services in Ireland in the last 25 years. More recently, it has been suggested that the emphasis on early discharge from hospital and caring for people in the community has led to greater demands on the community nursing service. An increased workload of the district nurse in the United Kingdom has been documented as a result of a similar policy of promoting health care in the community 6. The low level of contact between GPs amd PHNs found in this study is disappointing especially when looked at in the context of the World Health Organisation's aspiration to achieve health for all by the year 2000 through primary health care teams 2. Although a previous survey3 found that 80% of referrals to PHNs originated from GPs, suggesting a high level of communication, our study has shown that this is not the case. This would indicate that GPs and PHNs are working to a large extent independently of each other in the community. The structure of community nursing in Ireland differs from that in the United Kingdom. In that country the primary health care team is normally formed by the "attachment" of district nurses and health visitors to a general practice. This facilitates communication between GPs and community nurses as is evidenced by a study carried out in the United Kingdom, where 80% of nurses in health centres and 78% of nurses based elsewhere made contact with doctors every day 7. Also, in 9 of the 24 health centres and 5 of 13 other premises, doctors and community nurses had formal meetings once a month. As a minimum formal and informal contact between public health nurses in Ireland and general practitioners should be encouraged and methods facilitating contact and cooperation are essential. One of the most striking features of the study is the high level of dissatisfaction with the out of hours service. A limited but successful twilight and night nursing service is being provided by some health boards. A twilight nursing service is available in the Eastern Hcalth Board area mainly
through the District Units which cater for elderly patients. The introduction of a limited out of hours nursing service is to be welcomed, however it needs to be developed further. The PHN is not only a registetred nurse but a person who in addition, has undergone lengthy training in Midwifery and Public Health and is close in status and salary to that of a hospital ward sister. There is acceptance by GPs that many nursing activities carried out by PHNs could be undertaken by persons with lesser qualifications such as registered general nurses or nurses' aides. In Bolton in the United Kingdom, a mix of state registered nurses, state enrolled nurses and nurse auxiliaries was introduced into the Community Nursing Services and their introduction resulted in reducing the cost of the nursing service without a reduction in quality of care 8. A similar mix of community nursing staff could be introduced in Ireland and result in the availability of increased numbers of personnel working in community nursing at no extra cost. It was originally intended that the activities of the PHN, with special reference to the decision making process for admitting and discharging patients from the community nursing service, would form part of this study. Unfortunately, the withholding of cooperation by some PHNs made this impracticable. However it remains an area requiring review. This study has examined some aspects of the PHN's work in one community care area. It highlights issues relating to the functioning of the present public health nursing service. Firstly there is less than optimal contact between the PHN and GP. Secondly there is dissatisfaction concerning the availability of a community nursing service outside normal working hours. In addition, the issue is raised as to whether an enhanced nursing service in the community could be provided for the same cost, if more use were made of registered general nurses and if nurse auxiliaries were introduced. These points indicate an urgent need to examine in detail the wider aspects of public health nursing on a nationwide basis. References
1. Departnment of Health, The ttealth Services and their future development, Dubfin, 1966. 2. World Health Organisation, Alma-Ata 1978: Primary Health Care: Geneva, 1987. 3. Department of Health, Survey of the Workload of Public Health Nurses, Dublin, 1975. 4. Irish College of General Practice Working Group on Standards of Practice and Conditions of Service, Policy Document on the future Organisation of General Practice in Ireland, Dublin, 1986. 5. McGowan, J. Attitude Survey of Irish Nurses, Dublin: Institute of Public Administrtion, 1979. 6. Salter, B., Battle, S., Moran Ellis, J. Where the buck stops. Community Outlook 1986: 19-20. 7. Tamara, K. et al. Cooperation between general practitioners and community nurses based at health centres and other types of premises in the United Kingdom as seen through the eyes of Japanese doctor, 1979. Public ttealth London 1982: 96(2), 79-85 8. Gallagher, ltowe J. E., McNedl, A. W , Richardson, E. M., Ross, A. I. A Study of llealth Visiting and District Nursing in Bolton (1976). The Medical Officer, 161-167.
