'Implementation deficit' and 'street-level bureaucracy': policy, practice and change in the development of community nursing issues

The present paper examines the mechanisms by which health and social care policies put forward by the Government may be translated into community nursing practice. Data from a research project on community nurse case managers were re-examined in the light of two classic theories often cited by policy analysts (i.e. implementation theory and 'street-level bureaucracy'). It was found that the extent to which nurses adopted the case management role, and the model of choice, depended on four major interrelated variables, namely: (1) the clarity of policy guidance; (2) the extent to which it coincided with professional (nursing) values; (3) local practices and policies; and (4) the personal vision of the community nurse. It is argued that this framework may have wider relevance, and this was tested out in two ways. First, major change in one of these variables (Government policy) over time was analysed for its effect on case management practice via the remaining variables. Secondly, an unrelated, but policy-initiated, nursing issue (nurse prescribing) was briefly examined in the light of the framework. It is suggested that this framework may be of some use when considering the likely practice response to policy-related changes in community nursing.