Open Journal of Nursing, 2013, 3, 472-480 OJN
http://dx.doi.org/10.4236/ojn.2013.37064 Published Online November 2013 (http://www.scirp.org/journal/ojn/)
Challenges and facilitators for patient and public
involvement in England; focus groups with senior nurses
Markella Boudioni1, Susan McLaren2
1Institute for Leadership and Service Improvement, Faculty of Health and Social Care, London South Bank University, London, UK
2Faculty of Health and Social Care, London South Bank University, London, UK
Received 2 October 2013; revised 22 October 2013; accepted 30 October 2013
Copyright © 2013 Markella Boudioni, Susan McLaren. This is an open access article distributed under the Creative Commons Attri-
bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
ABSTRACT
The concepts of patient and public involvement (PPI)
have been recognized and linked with quality in
health services internationally and in Europe. In
England, for more than a decade, NHS policies have
increasingly quoted patient-centred services. Limited
evidence exists about the implementation of PPI poli-
cies and strategies within organisations; three studies
only have explored health professionals’ perceptions
of PPI. Although nurses’ positive support for patient
and public involvement has been noted, compara-
tively little is known about senior nurses’ experiences
of embedding PPI. A national consultation utilising
three focus groups aimed to explore senior nurses’
perceptions of challenges and facilitators for PPI im-
plementat ion. Four Strateg ic Health Authorities (SHAs)
and eleven Primary Care Trusts (PCTs) in England,
with fifteen senior nurses with leadership roles and
direct PPI experience, participated. Nurses’ percep-
tions on patient and public involvement, challenges
and facilitators for its implementation were discussed.
Focus groups were digitally recorded and transcribed
verbatim; anonymised transcripts were validated by
participants and analysed with thematic analysis.
Limited resources, patient representation and re-
cruitment, complexities of implementing PPI and na-
tional policy changes were challenging. Commission-
ing limitations, lack of feedback on patient experience,
limited staff awareness, negative attitudes, manage-
ment of patients and public expectations constituted
further challenges. Nursing role characteristics and
informal involvement activities, PPI policy and cul-
tural change, commissioning PPI competencies, re-
lated service frameworks, providing feedback on pa-
tient experiences to staff and recognition of involve-
ment benefits were recognised as facilitators. Find-
ings provided new insights into senior nurses’ ex-
periences and evidence that progress towards mean-
ingful, effective PPI remains slow. However, recogni-
tion of existing nursing role characteristics and po-
tential delivery problems created by expanded nurs-
ing roles, informal PPI practice and internal organ-
isational sharing of patient feedback may bring an
“emerging productive partnership” with nurses ena-
bling and contributing to effective PPI.
Keywords: Nursing; Patient and Public Involvement;
Challenges and Facilitators; Focus Groups;
Patient-Centred Care
1. INTRODUCTION
The concepts of patient and public involvement (PPI)
and empowerment have been recognized and linked with
quality in health services internationally and in Europe
[1,2]. Countries have implemented a wide range of
patient empowerment measures, including patients’ rights
legislation (Netherlands, Greece), introducing ombuds-
person services (Austria, Finland, Hungary, No rway, Greece)
and increasing patients’ involvement and participation in
care decision-making (England) [3,4].
In England, for more than a decade, NHS policies
have increasingly quoted patient-centred services. Not-
able drivers h ave been the legal duty to involve and con-
sult the public [5] and the increasing body of inter-
national ev idence for involving peop le in health care and
its benefits [6-8]. Most recently, the PPI agenda has
permeated the World Class Commissioning vision, stat-
ing that “to be world class commissioners we need to
know the needs and preferences of our local com-
munities, work with our partners on the health and
well-being agenda and work with local people to tackle
health inequalities”. Specific emphasis was placed on
“building continuous and meaningful engagement with

M. Boudioni, S. McLaren / Open Journal of Nursing 3 (2013) 472-480 473
patient and public to shape services”, as one of its
competencies [9]. Furthermore, the “High Quality Care
for All” [10] called for an NHS “that gives patients and
the public more information and choice, works in part-
nership and has quality of care at its heart”.
Many definitions exist for involvement; INVOLVE
[11] summarised this as “everything that enables people
to influence the decisions and get involved in the
actions that affect their lives”. To enable policy im-
plementation, the English NHS has adopted the “In-
volvement Continuum” [12], encompassing giving and
getting information, forums for debate and partici-
pation (Figure 1).
Although the research evidence supporting PPI varies
in quality, benefits identified in systematic reviews have
included improvements in health literacy, clinical de-
cision making, self-care, chronic disease management
and patient safety [13,14]. Others have also demonstrated
improvements in the information clarity provided and
patients’ knowledge [15]. However, limited evidence
exists about the implementation of PPI policies and
strategies within organisations [16]. National surveys
found that although health services were putting systems
in place to involve people in planning and improving
services, many challenges remained. Barriers included
lack of commitment by senior managers or clinicians,
inadequa te resources, lack of incentives and poor quality
of interpersonal care [17-20]. Other studies have also
found that health services staff were often the most
important change drivers, but strong management and
leadership, acting on patient feedback and streng-
thening an open and transparent culture were also vital
[21].
Only three studies have explored health professionals’
perceptions of PPI [22-24] showing that progress to-
wards achieving meaningful and effective PPI was slow.
Deficiencies in financial and human resources, orga-
nisational capacity, lack of relevant data, difficulties in
supporting the public and accessing seldom heard groups
were identified as barriers. Significant changes to the
way that PCTs organised PPI in commissioning, indi-
cated the start of a cultural shift; however, engaging
beyond the ‘easy to reach’ was cited as a barrier [23,24].
An ethnographic study [23] found that health profes-
sionals determined areas for service user participation,
which covered a wide range of activities; understanding
and practice relating to this varied according to pro-
fessional ideologies and circumstances. An interesting
finding was the challenge embedding user involvement
across work streams and authority issues raised.
Comparatively little is known about senior nurses’
experiences of embedding PPI, although nurses’ positive
PPI support has been noted [6]. Nurses are key NHS
frontline staff in terms of direct patient care; they also
Figure 1. The involvement continuum.
hold key management positions which require an
understanding of PPI and its policy implementation chal-
lenges. This article reports on a national consultation
exercise commissioned by the Royal College of Nursing
(RCN) to explore senior nurses’ perceptions of PPI
challenges and facilitators in England. Further details of
the project can be foun d in the full report [25].
2. METHODS
A qualitative exploratory design utilising focus groups
with senior nurses—nurses with leadership roles—across
England, was employed. Focus groups have the ad-
vantage of making use of group dynamics to stimulate
discussion, gain insights and generate ideas to pursue a
topic in greater depth. It is a useful technique for ex-
ploring values and beliefs about health, disease and
systems; they are popular in health promotion and action
research, organisational research and development [26].
Being relatively economic and gathering views of many
in a relatively short space of time were additional reasons
for choosing focus groups [27].
SHAs in England were selected as the first points of
contact, having the advantage of being able to access all
PCTs and a range of senior nurses across England. All
nine SHAs were invited to send representatives to par-
ticipate in focus groups. Letters informing and inviting
senior nurse managers were sent directly from the RCN
to Chief Executives for approval; they allocated a key
stakeholder to co-ordin ate and explore the feasib ility of a
focus group locally. Stakeholders invited senior nurse
managers to participate voluntarily. Recruitment was very
slow, although the Chief Executives and key stake-

M. Boudioni, S. McLaren / Open Journal of Nursing 3 (2013) 472-480 474
holders were reminded with second letters and follow-up
phonecalls; reasons given were work overload and other
priorities. All communication regarding recruitment and
selection took place between June 2008 and October
2008. Ethical approval from a Trust or an external body
was not required; the University Ethics Committee was
informed for this national consultation.
All participants were given an information sheet and
consented in writing to participation and digital recor-
ding of the focus group. Confiden tiality was ensured and
all participants were aware of their right to withdraw. A
semi-structured topic guide was drafted in collaboration
with RCN and used for all focus groups; they were fa-
cilitated by MB, a university researcher, independent
from the RCN, SHAs and PCTs. They lasted between 80
and 120 minutes and took place in private meeting rooms
at SHAs’ premises.
Digital recordings were transcribed verbatim by pro-
fessional transcribers. Data was analysed manually by
MB using the principles of thematic analysis, thus coding
data line by line and forming codes, categories and
themes [28,29]. Fifteen sub-themes emerged within the
main themes comprising challenges (9 sub-themes) and
facilitators (6 sub-themes).
Transcripts were checked against recordings for relia-
bility. Anonymised summaries of the individual focus
groups findings were sent to participants of each group
for participant validation. Only two participants res-
ponded citing no comments; one of them reinforced a
suggestion already made at the group.
3. RESULTS
Fifteen senior nurses, with leadership roles and direct
PPI experience, employed in eleven PCTs from four
SHAs participated. Participants, all RCN members with a
variety of roles (Table 1), took part in three focus groups
at north, west central and south England locations, con-
ducted between September and October 2008.
3.1. Challenges for Effective PPI Nursing
Practice (Figure 2)
3.1.1. Limited Resources, Capacity and Time
The importance of resources was highlighted among all
groups. On one hand, the organisational rationing of
general resources allocated to specific projects and
events including PPI, was discussed. On the other, al-
located PPI resources, capacity and time for PPI activi-
ties were also recognised as limited. These limitations
also affected the time for change implementation emerg-
ing from PPI; in one case, it had taken three to four year s
for the recommendations to be implemented. Addi-
tional PPI capacity for specific services and subgroups of
service users, i.e. children, was also needed.
Figure 2. Challenges for patient involvement.
Table 1. Professional roles of participants.
Focus Group 1 Focus Group 2 Focus Group 3
Director of Quality and
Performance
(Executive Nurse) Clinical Audit Manager Lead Infection
Policy Chief Nurse
Head of Service
Development
(Children Services)Lead Educator Director of Nursing
(Executive Nurse)
Head of Clinical
Strategy Director of Nursing Head of Clinical
Governance and
Effectiveness
Head of Infection
Prevention and ControlHead of Clinical Services Head of Service Reform
Commissioning
Manager
(Sexual Health)
Matron
(Senior Clinical Nurse)
Public Involveme nt Lead and Health Improvement
Manager
Participants spoke extensively about availability of
resources, capacity and time at a workforce planning
level especially at the initial PPI stages and dev elopment,
and also through the different levels of the involvement
continuum. Resources were also important when “real”
involvement and partnership had been “achieved”, for
sustainability, as patients’ expectations from the services
might have been increased.
Well as you work up the continuum again, if you’re
working towards real involvement and real partnership,
it takes time and to go out to community groups, to link
with Sure Start, to set up your days, to… The maternity

M. Boudioni, S. McLaren / Open Journal of Nursing 3 (2013) 472-480 475
services are like the Mental Health Services, they’ve got
a long history of involvement, haven’t they? And it takes
time to work in partnership with the public in whatever
way is appropriate for that particular issue or service.
(FG2, P4, p24, 19-25)
Effective management, setting up and maintenance of
memberships, i.e. of Patients Forums, and involving
everyone individually also required staff time and re-
sources. These elements should also be seen in con-
junction with the other responsibilities of nurses, espe-
cially when staff shortages were considered. The ad-
ditional nursing roles and absorbing different roles with
various deliverables could be challenging for PPI.
I mean as nurses have taken on more and more of the
medics roles, which they have but actually even with
skilled nurses, they still haven’t dropped a lot of the
other roles that they had… And to a certain extent I think
a lot wouldn’t want to as well, it comes to a point where
the NHS has worked on goodwill for years, hasn’t it?
We’ve all done it but this, you start to get to a point
where sometimes it’s just that bit too much and people
are starting to get a bit more protective of their time.
(FG1, P3, p27, 24-34)
3.1.2. Representation and Recruitment of Patients
and the Public
High representation of people with certain characteristics
in conjunction with their self-selection, were discussed
extensively. Patient representatives were often people
who had time, were more vocal and active, and perhaps
had an interest in specific issues. Other people were less
represented, i.e. those who could not read English, were
less educated or illiterate, less well off, employed or with
childcare issues. Thus, as a result the same patients were
involved in all activities creating “real” representation
challenges.
I’m just thinking about some of the parents we’ve got
who can barely read, who are very hard to reach and
who would be completely fazed by having to go through
that kind of process but probably wouldn’t go through it
anyway, we already know that those who are not so well
off are less likely to attend because either they’re work-
ing or they’ve got issues of, childcare issues or this, that
and the other. (FG1, P3, p27, 24-34)
Recruiting and influencing people to participate using
a variety of approaches were also challenging. Lack of
guidelines for getting a wide range of people was high-
lighted. Involving the public, “the man in the street” in
particular, presented a challenge for many participants.
Involving certain population groups and its organi-
sational challenges were also discussed. For example, the
difficulties and time required for children and young
people’s involvement may be challenging to particular
groups of professionals, i.e. children’s nurses. Additional
challenges were associated with staff being equipped and
trained to deal with black and ethnic minorities (BME)
and the disabled, i.e. answering telephone lines appro-
priately and presentations with interpreters were cited.
I think a couple of challenges from my perspective, the
BME community and the deaf, the hard to reach com-
munities, because there’s nothing more terrifying than
standing up doing a presentation, seeing it sign lang-
uaged, hearing it being interpreted in Cantonese and
seeing somebody else, you know, and are we equipped
and trained to do that? (FG3, P1, p17, 6- 10)
3.1.3. Complexity of PPI Implementation
The plethora of complex dimensions and involvement
areas, i.e. many clinical practices, various professional
cultures and subsequent organisational issues created
additional difficulties. It was recognised that ch ang es and
development had to be implemented across the spectrum
of clinical services and professions, so cultural change
could be facilitated. The additional complexity of PPI
being linked with people’s immediate personal exper-
iences, sometimes with unpredictable events, was also
recognised.
Set up a consultation event, here’s the ground rules,
here’s the parameters, here’s what we will do with your
information, here’s what we (it is easy), but we’re talking
about day to day lived experiences that pop up when you
least expect them, or you get put in a situation where you
hear something. (FG3, P1, p17, 6- 10)
3.1.4. National PPI Policy and Changes in Structures
Additionally, concerns were expressed that changes in
national PPI policies and bodies, notably, the abo-
lishment of Community Healt h Cou ncils and PPI Fo ru ms
and the creation of LINKs, had temporarily brought
wider engagement to a halt.
…because we had a very active Patient and Public
Involvement Forum, the LINKs host wasn’t appointed
until the beginning, their contracts started at the be-
ginning of August, then the manager within the host…
host organisation was identified to start the work went
off sick, you know, and now we’re here into September
and really, and there’s a sense of frustration building
amongst particularly the old PPI forum members, so
here we are six months on from the abolishment of the
forum and they still haven’t got an engagement group.
(FG2, P2, p20, 44-51 and p21, 1-4)
NHS structural changes also affected the implemen-
tation of the world class commissioning competencies, as
potential co llaborations with patient representatives were
interrupted. These changes had also led to organisational
and team changes that subsequently had a PPI impact, i.e.

M. Boudioni, S. McLaren / Open Journal of Nursing 3 (2013) 472-480 476
amalgamation or restructuring of teams impacted on PPI.
Additionally, the Patient Advice and Liaison Services
(PALSs) were not considered well-integrated within the
whole NHS system; dealing with patients with specific
issues was considered to limit PALS’ objectiveness of
feedback.
3.1.5. Commissioning Limitations: Organisational
Issues
It was believed that PPI projects were still very tokenistic;
there were some good examples, but the world class
commissioning PPI competencies, had not yet been reach-
ed. If the organisational participation culture, as revealed
from the organisational strategy and actions, was not
open and transparent, then PPI was not perceived to be
effective. Control and representativeness were other
issues to be considered. PPI controlled either by com-
mittees or people, staff or patient representatives was
considered problematic; this might be linked with user
representation issues discussed.
…I think the committees, it’s how the organisation is
set up, you can have co ntrolling PPI, can’t you? You can
have… it was Dignity and Compassionate Care group
we’ve just set up and someone suggested a name and
obviously new into the organisation I didn’t know who
this person was, so I did a bit of, well, you know, she’s
been around a few years, she’s been awarded an OBE
for her contribution to the NHS but, you know, does she
truly represent a user? So, you know, it’s that control,
you can have a control system that says yes we have got
PPI but then when you sort of dig down, you think is that
really Joe Bloggs on the street’s view?
(FG2, P3, p21, 21-33)
3.1.6. Staf f PPI Awareness a nd Negative Atti t ud es
Participants across groups reco gnised low PP I awaren ess
among nurses. This was expressed with nurses per-
forming patient involvement activities, i.e. informing,
sharing and discussing care issues with patients, without
recognising or labeling them as such. They actually wel-
comed the informality and flexibility; th ey were resistant
in such labels.
I would want, not want to label it as I have PPI, you
know, I had a PPI today, I just think that it would be a
complete disaster because we’d lose some of the freedom
but I do think nurses would benefit from understanding
how we could use the information in perhaps a more
beneficial way and they wouldn’t feel like they’re not
doing it but I wouldn’t like to lose that informal…
(FG2, P1, p6, 1-5)
A diversity of medical attitudes, both PPI positive and
negative, was also identified. These attitudes may have
further implications for the PPI nursing practice; for
example more effort may be required for nurses to ensure
PPI good practice.
…some of our consultants are fabulous, absolutely
fabulous and we’ve got certain dynamic groups, diabetes
and various other things but we’ve got others where the
patients would never be, have a voice if it was down to
the doctor. Whereas I don’t think nurses think like that,
so I think it is very relevant about how boards are made
up, where we’re going with all of these new Trusts, who’s
the decision making people and how we involve our
customers, so I do think it’s quite crucial.
(FG2, P1, p19, 40-47)
3.1.7. Lack of Feeding Back Evidence on Patients’
Experience
The mentioned resistance of nurses towards labeling cer-
tain activities as PPI had consequences on capturing and
measuring patient involvement and experience properly.
Thus PPI evidence was not collected; it was difficult to
be identified an d demonstrated, resulting to limited feed-
back to the management. Clinical and other decisions
were based only on demonstrable or available evidence
and not on anecdotal patient experiences; thus the pro-
cess of shaping services accordingly was hindered.
…actually sometimes it’s very hard to find the evi-
dence to actually demonstrate that and say for instance
there might be notice of a meeting but they might not say
“xx is the patient representative”, you know, so it maybe
just had a list of names… You know, how can you de-
monstrate this for your, this particular assessment pro-
cess or that process? Actually because it’s part of what
we do on a day to day. (F G2, P2, p14, 15-24)
3.1.8. Man agement of Patient and Publi c Feedb ack
and Expectations
Effective management of patient and public expectations
was also perceived as difficult, requiring good judgment
and balancing all complexities around them. Ineffective
management could cause delays in resolving issues and
result to patients’ frustration.
…and they’re still at the end of that session frustrated
because we still haven’t worked out how we’re going to
get them their tablets more quickly. And they’ve been
really honest. I’m frustrated because I can see that it
should be simple but I know it isn’t because of all these
other complex things happening, therefore our part-
nership’s thwarted really because we can’t get to where
they want to get to very easily. (FG1, P1, p21, 27-33)
In some occasions, utilising the feedback, expectations
or outcomes from PPI activities to shape services was
difficult. This was due to practical, financial or orga-
nisational reasons. Incapacity to fulfill certain expec-
tations, because they were outside somebody’s juris-
diction was also hig hl i ghted.

M. Boudioni, S. McLaren / Open Journal of Nursing 3 (2013) 472-480 477
P3: My concern is that we can sort them and don’t
necessarily use the information we get to shape the ser-
vice if we’re not careful.
P2: Or that we don’t have the resources to provide.
P3: Yes, which is where the honesty bit comes in.
(FG1, p12, 38-4 4)
3.2. Facilitators for Effective PPI Nursing
Practice (Figure 3)
3.2.1. Nurses ’ Rol e and Informal PPI Ac tivities
The nurses’ skills, their informal caring and interactive
activities-although not labeled as PPI were recognised
as facilitators. General comments were made about
nurses having transferable skills and gaining new skills
all the time. The nursing carin g role included continuous
rapport with patients, engagement and on-going feedback
from them. This feedback, including comments, com-
pliments and complaints—when evidenced—was taken
into account in shaping services.
As a profession I think it is… that caring side of nurs-
ing, that one to one rapport that you get when you’re
caring for a patient and the feedback…, so I still have
that engagement and I know as leaders we’re very con-
scious of the fact that we need to be taking on board
patient stories and we need to be identifying good and
bad comments, you know, that we’re getting back from
the patients and acting upo n them and I think that’s how
we’re going to shape our services. (FG1, P4, p2, 24- 32)
Nurses were considered to conduct PPI in practice, in
every single interaction with patients, even if not reco-
Figure 3. Facilitators for patient involvement.
gnised as such. One to one and non-patronising in-
teraction with patients, listening to communities, indi
vidual patients and working towards their best care and
services were considered to be both PPI and nursing
professionalism elements. They were seen to be integral
to a nurse’s role at different levels and settings, i.e. in
community or acute settings. However, it was recog-
nised that this might vary in different departments,
clinics, or wards. In maternity, for example, involve-
ment might be greater than in other clinics. In addition ,
specific professional roles such as the modern matrons
were considered having a better PPI understanding
than others.
I think if you looked at the, the modern matron role
that was brought in they do have an understanding of
public patient involvement as well as patient safety and
the governance aspects but maybe the frontline nursing
staff, it’s about that one to one interaction for patients.
(FG3, P1, p27, 11-14)
3.2.2. NHS Policy Changes and Subsequent Cultural
Change
It was recognised that most recen t NHS national policies
had been patien t-centred and facilitated a cultural ch ange,
including a focus on self-care and self-management,
both closely related to PPI. Although new developments,
i.e. LINKs at the time, were recognised as capable of
bringing changes and shaping services, lack of clarity
about their processes and membership were also men-
tioned.
3.2.3. Commissioning PPI Competencies
The world class commissioning PPI competencies and
organisational drivers for their implementation had some-
how influenced and facilitated PPI. The push for in-
tegrated services and the recognition of the third sector
also reinforced patient-centred services.
Well, yes, one of the world class commissioning com-
petencies is around Patient Public Involvement… It’s
about your structure as a commissioning PCT and how
you’ve structured yourself and what your hierarchy looks
like and how you’re going to engage the public in, right
at that front end, your health needs assessment works
because at the moment they’re kind of brought in after
that, aren’t they? (FG3, P1, p32, 28-36)
The organisational strategy or requirements-revealing
perhaps a positive pa rticipation culture, i.e. patient repre-
sentatives on the Board-facilitated higher involvement
le vels. Organisational structures might also enable involve-
ment at the higher level.
I mean for instance our Board now has two patient
representatives who are, and their function has evolved
and their participation in that Board has evolved, so for

M. Boudioni, S. McLaren / Open Journal of Nursing 3 (2013) 472-480 478
instance when our new PCT was first set up one of the
early Board meetings, our Chairman made the comment
that said this is a meeting held in public, not a public
meeting. (FG2, P2, p20, 9-13)
3.2.4. Other PPI Supportive Frameworks
Several participants referred to existing frameworks, i.e.
the Essence of Care Standards, the Knowledge and Skills
Framework, the Standards of Nursing, an d customer care
standards. Their relevant to PPI competencies or ele-
ments were identified as helpful for PPI overall. Some
participants also referred to evaluation, monitoring and
appraisal processes, dealing with staff developmental
issues, including PPI, as PPI supportive. The consensus
in one group was that the existing competency frame-
works were sufficient and adding another framework
would make clinicians feel overload ed. A participant felt
that the continuum of involvement could be mapped
through existing frameworks, although its implemen-
tation needed work.
….because you’ve got the continuum of involvement
that is recognised and actually in a sense you could put
your different levels of involvement as with the gradings,
you could make a model basically, you could use the
continuum of involvement and then you’ve got your
essence of care standards, you’ve got your KSF… you’ve
got your customer care standards, which is all integral
into a nurses role at different levels in different ways,
wherever they may be working in the community or in an
acute setting or in a community hospital. So actually
there is a kind of framework there already, it’s how you
apply it. (FG2, P4, p29, 25-36)
3.2.5. Recognition of PPI Benefits
Participants referred to the PPI benefits; notably that it
was powerful, influential and the whole process provided
the argument for cultural and organisational change. The
awareness and recognition of these benefits facilitated
effective PPI further.
P4: And I think nothing’s more powerful is it, than a
patient or a carer challenging a consultant or a doctor
or a nurse or a Social Worker?
P2: It’s very powerful.
P4: To, or the Head of Social Care, it is much more
powerful and it actually speaks volumes, you know, that
they will turn and pull so mething up… (FG3, p4, 36-42)
It was also recognised that the core of true patient care
started with asking p atients’ about individual needs. Real
involvement should also have a re-energising effect for
everybody in the system. Other benefits included better
understanding of the NHS bureaucratic system, chal-
lenging NHS staff, bringing in simple changes, speeding
up procedures, making the NHS more transparent and
accountable.
3.2.6 Organisational Feedback to Staff
Providing feedback to staff on various aspects of patient
experiences and involvement, for example, patient expe-
rience surveys, complaints and various incidents, was
considered another facilitator. Organisational feedback
could be linked with action plans. The feedback provided
to individual nurses could help them recognise the
different aspects’ importance and any actions or reso-
lutions necessary.
Well we do a lot of feeding back to staff on just, of
things that we’ve done, so obviously our satisfaction
surveys, it would, you kno w, it’s a key thing to go back to
staff and involve them in determining an action plan. And
but also things like complaints where we know we’ve
made a change and on a regular basis we’ll kind of list
some of those things so some of the issues that arose, so
even from a complaint or a survey or an audit or some-
where that’s involved the patient and then kind of outline
what was a result really, kind of what was the outcome
for that? (FG2, P 5, p6, 2 6-33)
4. DISCUSSION
Although the consultation exercise yielded valuable in-
sights into the evolving process of implementing PPI in
NHS Trusts in England from a senior nursing perspective
—which is under-researched—its limitations should be
considered. Five focus groups, representative of nine
SHAs, were initially intended. However, recruitment and
their facilitation organised in collaboration with Trust
gatekeepers, proved very difficult. Issues such as po-
tential participants’ workload or perhaps not-treating the
topic as a priority need to be considered; these may also
help us understanding PPI perceptions of these profes-
sionals. The findings are based on three focus groups
only, and fifteen self-selected participants representing
four SHAs; this cannot preclude bias. Furthermore,
participants were all in strategic senior management po-
sitions; their experiences are not necessarily repre-
sentative of a wider nursing PPI experience. This con-
sultation was conducted in late 2008. However, guide-
lines for PPI implementation have not be en issued yet in
England, and another study exploring senior nurses’ ex-
perience of PPI has not been identified internationally.
Importantly, similar issues may affect implementation of
patient and public involvement not only in England, but
internationally.
With regard to PPI challenges, participants’ exper-
iences were consistent with those identified elsewhere;

M. Boudioni, S. McLaren / Open Journal of Nursing 3 (2013) 472-480 479
limited resources, time, complexities of working across
service boundaries and professional cultures [22,23]. An
interesting new finding was the impact on continually
expanding nursing roles of taking on new PPI and other
responsibilities, which co uld result in delivery problems.
Participants also identified difficulties recruiting repre-
sentative patients, with concerns expressed about hard to
reach groups and the need for recruitment guidelines;
these findings were consistent with those of others [22,
24]. PPI control by committees and professional staff
were seen to be problematic in terms of commissioning
practices. Others have also found that health profes-
sionals determined the areas of participation by service
users [23]. Although many medical staff were supportive
of PPI, some participants had encountered unhelpful at-
titudes; an earlier study [6] noted similar issu es raised by
giving up c ontrol.
Important new findings emerged in relation to PPI
facilitators. Significant facilitators identified here corres-
ponded to some world class commission ing pr iorities [9].
Participants discussed services based on patient expe-
rience, people’s choices, control and more person-
alisation, alongside work with community partners and
engagement with public and patients, all of which were
highlighted within the world class commissioning vision,
associated competencies in England. Similar issues have
also been iden tified in national and internation al policies
elsewhere [2-4]. A strong message was that another PPI
implementation framework was not needed, as some PPI
related benchmarks and competencies were incorporated
in the Essence of Care and Knowledge and Skills Frame-
work in England [30,31]. It appears that nurses felt
overwhelmed by frameworks and regulations. A con-
sensus existed that nurses in practice, because of the
nursing characteristics and nature, performed PPI in its
pragmatic sense, even if they did not recognise or label it
as such. PPI, its learning and achievement has not been
given sufficient recognition, nor has it been robustly
shared and systematised-especially within practice. This
is perhaps one of the most important findings, together
with that of the need for open and transparent feedback
of patient experience evidence to shape services and
expedite action planning at the frontline [21].
5. CONCLUSIONS
This consultation explored “an emerging productive part-
nership”, with regard to senior nurses enabling patient
and public involvement. Notwithstanding its limitations,
rich qualitative data shed light on involvement barriers
and facilitators, as experienced by senior nurses in ma-
nagement positions, an area that is under-researched.
New findings highlighted the importance of two-way
feedback of evidence based on patient experience be-
tween frontline nurses and managers; the utility of exist-
ing policy and service frameworks to enable imple-
mentation of involvement mechanisms; the need for
guidelines to recruit hard to reach groups and the poten-
tial for a negative impact of relevant responsibilities on
expanding nursing roles. Of particular interest, was the
view that nurses performed patient involvement in a
pragmatic sense, by virtu e of t he n at u re o f n ursing.
International and national policies elsewhere [2-4],
and NHS policies in England [5-10,12], place a great
emphasis on patient involvement and empowerment.
However, these findings suggest that although progress
has been made, many challenges still remain in trans-
forming the way that healthcare services in England are
commissioned and provided, if current aspirations on
shared-decision making as “the norm” are to be met [8].
Enhancing awareness about patient involvement could
benefit the development of more effective monitoring
and feedback mechanisms at organisational levels. In
addition, the creation of nursing involvement networks
may be helpful in harnessing collective experiences to
benefit patient-centred services and empowerment of
patients, in England and elsewhere.
6. ACKNOWLEDGEMENTS
We would like to thank all the participants, senior nurses working in
different organisational settings in four Strategic Health Authorities in
England, for giving up their time to take part in this consultation. We
would also like to thank Professor David Sines for his support, the late
Professor Bob Sang for his initial contribution and his comments on the
project, and Dr. Sophie Staniszewska for her comments on the final
report. Ms Helen Caulfield of the RCN Policy Department negotiated
access within NHS organisations to enable focus groups to be con-
ducted.
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