Health Technology Assessment 2001; Vol. 5: No. 23 Methodology

Action research: a systematic review and guidance for assessment

H Waterman D Tillen R Dickson K de Koning

Health Technology Assessment NHS R&D HTA Programme HTA HTA

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The website also provides information about the HTA Programme and lists the membership of the various committees. Action research: a systematic review and guidance for assessment

H Waterman1* D Tillen1 R Dickson2 K de Koning3

1 School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester, UK 2 School of Health Sciences, University of Liverpool, Liverpool, UK 3 Royal Tropical Institute,Amsterdam,The Netherlands

* Corresponding author

Competing interests: none declared

Published July 2001

This report should be referenced as follows:

Waterman H,Tillen D, Dickson R, de Koning K. Action research: a systematic review and guidance for assessment. Health Technol Assess 2001;5(23).

Health Technology Assessment is indexed in Index Medicus/MEDLINE and Excerpta Medica/ EMBASE. Copies of the Executive Summaries are available from the NCCHTA website (see opposite). NHS R&D HTA Programme

he NHS R&D Health Technology Assessment (HTA) Programme was set up in 1993 to ensure T that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and provide care in the NHS. Initially, six HTA panels (pharmaceuticals, acute sector, primary and community care, diagnostics and imaging, population screening, methodology) helped to set the research priorities for the HTA Programme. However, during the past few years there have been a number of changes in and around NHS R&D, such as the establishment of the National Institute for Clinical Excellence (NICE) and the creation of three new research programmes: Service Delivery and Organisation (SDO); New and Emerging Applications of Technology (NEAT); and the Methodology Programme. Although the National Coordinating Centre for Health Technology Assessment (NCCHTA) commissions research on behalf of the Methodology Programme, it is the Methodology Group that now considers and advises the Methodology Programme Director on the best research projects to pursue. The research reported in this monograph was funded as project number 95/19/04. The views expressed in this publication are those of the authors and not necessarily those of the Methodology Programme, HTA Programme or the Department of Health. The editors wish to emphasise that funding and publication of this research by the NHS should not be taken as implicit support for any recommendations made by the authors.

Criteria for inclusion in the HTA monograph series Reports are published in the HTA monograph series if (1) they have resulted from work commissioned for the HTA Programme, and (2) they are of a sufficiently high scientific quality as assessed by the referees and editors. Reviews in Health Technology Assessment are termed ‘systematic’ when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.

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Published by Core Research, Alton, on behalf of the NCCHTA. Printed on acid-free paper in the UK by The Basingstoke Press, Basingstoke. M Health Technology Assessment 2001; Vol. 5: No. 23

Contents

List of abbreviations ...... i Resources ...... 36 Research methods ...... 37 Executive summary ...... iii Project process and management ...... 38 1 The origins of action research Knowledge ...... 40 in healthcare ...... 1 Conclusion ...... 41 Influential writers ...... 1 7Guidance for assessing action research Popular misconceptions and criticisms ...... 2 proposals and projects ...... 43 Conclusions ...... 3 The need for guidance ...... 43 2 The project ...... 5 Notes on the guidance questions...... 44 Aims ...... 5 Guidance: 20 questions for assessing action Objectives...... 5 research proposals and projects...... 48 Methods ...... 5 Validation of the project ...... 10 8Discussion ...... 51 Advisory panel ...... 10 Project methods...... 51 Time-frame...... 10 Definition...... 51 Summary ...... 10 Action research in the UK ...... 52 Analysis of the systematic review and 3 Defining action research ...... 11 consultative process...... 52 A definition of action research...... 11 Distinguishing features of action research.... 11 9 Conclusions...... 57 Philosophical perspectives ...... 14 Implications for policy ...... 59 Judging action research ...... 15 Implications for practice...... 59 Summary ...... 16 Implications for future action research...... 60 Dissemination of the results of this review.... 60 4 Action research in the UK...... 17 Results of the preliminary search and Acknowledgements...... 61 systematic review ...... 17 References ...... 63 Characteristics of identified studies ...... 17 Results of the direct consultative process .... 18 Appendix 1 Electronic search strategy Summary ...... 18 and results ...... 69 5Detailed results of the systematic review Appendix 2 Consultative process ...... 71 and the consultative process ...... 19 Aims of action research...... 19 Appendix 3 Data extraction sheet ...... 75 Reasons for choosing action research ...... 21 Appendix 4 Interview schedule and Issues addressed by action research...... 22 topic guide ...... 81 Outcomes and impacts of action research .... 23 Summary ...... 28 Appendix 5 Advisory panel...... 83 6Pivotal factors: the strengths and Appendix 6 Data extraction tables...... 85 limitations of action research ...... 29 Participation...... 29 Health Technology Assessment reports Key persons ...... 31 published to date...... 159 The action researcher–participant Methodology Group ...... 165 relationship ...... 33 Real-world focus...... 35 HTA Commissioning Board ...... 166

Health Technology Assessment 2001; Vol. 5: No. 23

List of abbreviations

A&E Accident & Emergency [Department]* CARN Collaborative Action Research Network CCU coronary care unit* CDT community drugs team* CHD coronary heart disease CPDA clinical practice development accreditation CRD [NHS] Centre for Reviews and Dissemination DGH district general hospital* ENP emergency nurse practitioner* GP general practitioner GRIP getting research into practice ITU intensive therapy unit* MAU Medical Admissions Unit* OAG oral assessment guide* PCA patient-controlled analgesia* R&D research and development RCN Royal College of Nursing RCT randomised controlled trial RSCN registered sick children’s nurse TNA training needs assessment*

* Used only in tables or appendices

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Health Technology Assessment 2001; Vol. 5: No. 23

Executive summary

Background identification, reflection, research, an action intervention and evaluation were interlinked Action research is employed in many healthcare •indicated that a partnership existed between the settings in the UK but its scope and role in this action researcher and the participants involved context is not clear. It is practised under a variety in the change process. of names and has been applied in many settings since Kurt Lewin coined the phrase in 1947. Its In anticipation of the limitations of the published particular strength lies in the coupling of partici- material, five focus group interviews with partici- pation and research to action and change. pants from included studies and two additional focus groups of action researchers attending an action research conference were carried out. Objectives Data from the studies reviewed were entered into 1. To provide a definition of action research. a statistical software package. For closed questions, 2. To identify action research projects conducted frequencies were calculated to provide descriptive in UK healthcare settings. information; for open questions, content analysis 3. To analyse the identified action research in was undertaken. Data from the focus groups were relation to: integrated with data from the systematic review. • project aims A narrative overview for each of the objectives • reasons for choosing action research was produced. Data synthesis was substantively • issues addressed by action research different in the achievement of the sub-objective • outcomes and impacts on the strengths and limitations of action research. • strengths and limitations. Here the studies and focus group interviews were 4. To develop guidance for the assessment of analysed, drawing on a process similar to meta- action research proposals and reports. ethnography. Data were compared and contrasted, and organised into categories from which themes emerged. Methods There were four interlinked phases: a preliminary Results literature search, a systematic literature review combined with a consultative process, and data The definition synthesis. This interpretative systematic review Reflection on the literature and the primary combined data from written reports of action research findings led to the following definition research with primary data collected from focus being used in this review. group interviews. Action research is a period of inquiry that Fourteen electronic databases were searched. describes, interprets and explains social situations Relevant journals and conference proceedings while executing a change intervention aimed at were handsearched and the project was adver- improvement and involvement. It is problem- tised at research conferences. Over 400 NHS focused, context-specific and future-oriented. research and development (R&D) managers Action research is a group activity with an explicit and 300 action researchers were contacted. critical value basis and is founded on a partnership between action researchers and participants, all Research reports were included if they: of whom are involved in the change process. The participatory process is educative and empowering, • were carried out in a UK healthcare setting involving a dynamic approach in which problem • were published after 1974 identification, planning, action and evaluation • demonstrated or indicated an intention to are interlinked. Knowledge may be advanced follow a cyclic process in which problem through reflection and research, and qualitative iii Executive summary

and quantitative research methods may be were noticeable outcomes throughout. For the employed to collect data. Different types of know- purpose of this review, impacts were defined ledge, including practical and prepositional, may as ‘a lasting effect or influence’, as defined by be produced by action research. Theory may be the action researchers involved. A number of generated and refined, and its general application studies reported impacts such as continuation explored through the cycles of the action of newly established initiatives, adoption of research process. projects into educational curricula and acceptance of new clinical practices. It is hoped that the definition will contribute to debate on the role of action research within the Pivotal factors – strengths and healthcare setting. It is expected that it will be limitations of included studies refined as the understanding and process of Eight pivotal factors related to action research action research evolve. were identified: participation, key persons, action researcher–participant relationship, real-world An overview of healthcare action focus, resources, research methods, project research in the UK process and management, and knowledge. The search yielded 285 possible studies, of which 59 met the inclusion criteria. Most were conducted Guidance for assessment of action between 1988 and 1996. The duration of projects research projects and proposals ranged from 1 to 48 months (median 12 months). These eight factors were used in combination with Nurses formed the largest percentage of active the definition to develop 20 questions that may be participants (70%) and the majority of projects useful in the evaluation of action research proto- took place in hospitals (53%). There were cols and project reports. These questions (and the 21 funded studies (36%). Interview, questionnaire accompanying explanatory notes) should be field- and observation were the three most common tested in order to assess their validity. methods of data collection. Qualitative research methods predominated. Conclusions Aims, reasons and issues addressed The primary aims of the included studies were Action research is a complex research process assessment of current situations, development of that has been used in a wide variety of healthcare changes and evaluation of project outcomes. The settings in the UK. A number of definitions of reasons for choosing action research were partici- action research are currently being applied to pation, facilitation of change and a cyclical process the methodology. The definition provided here related to change. Issues addressed included pro- includes the major components of an action fessional education, assessment of clinical practice research methodology. (areas where there was a conflict in clinical practice or a lack of evidence) and assessment of professional This definition emphasises the importance of roles. The results suggest that action research is ‘involvement’ in the action research process, which frequently selected to understand and resolve is consistent with the emphasis in NHS policy to complex problems, and that the participatory increase the active participation of users of services nature and the process of action research enables in their care. However, few users were involved the development of relevant and appropriate in the studies included in this review. practices, services and organisational structures. The review suggests that action research is being Outcomes and impacts of used and has the potential to play a role in achiev- included studies ing the goals of the NHS. Specifically, the method- Outcomes and impacts varied and were dependent ology has the potential to be useful in areas such on where in the research process they were assessed as developing innovation, improving healthcare, (e.g. during the problem identification, planning developing knowledge and understanding in or evaluation phase). Immediate outcomes from practitioners, and involvement in users and staff. group action produced such things as clarification of issues and identification of need (problem The findings indicate that action research is identification phase), development of innovation suited to developing innovative practices and and preparation for change (planning phase), services over a wide range of healthcare situations. and education, change and ownership (evaluation The review demonstrates how the action research iv phase). Personal and professional developments process can assist in the establishment of an Health Technology Assessment 2001; Vol. 5: No. 23

environment that promotes the generation and •the adjustment of funding and reporting mech- development of creative ideas and implementation anisms to allow for the action research process of changes in practice. •the development of collaborative educational/healthcare institution action Implications for policy research education programmes • Action research should be considered as • field testing of the guidance for assessing complementary to other research approaches action research. with the NHS. • Action research has a potential role within the Implications for future action research NHS R&D programme. Funding of action research would be appropriate •A mechanism for evaluation of the quality of in (but not limited to) the following areas: action research is required. •innovation, for example, in the development Implications for practice and evaluation of new services A movement towards the acceptance within the •improvements in healthcare, for example, NHS of the value of action research could be monitoring the effectiveness of untested assisted by: policies or interventions • development of knowledge and understanding •the inclusion of action researchers on in practitioners and other service providers, appropriate R&D bodies for example, promotion of informed •the provision of appropriate information on decision making action research to those involved in policy •involvement of users and NHS staff, for development and funding decisions example, investigation and improvement of •the dissemination of results of action situations in which there is poor uptake of research projects preventative services.

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Chapter 1 The origins of action research in healthcare

he variety of definitions of action research theoretical structures that would assist in the T has produced confusion in the implement- critique of oppressive power bases in poor ation of the action research process.1–10 In order manager–worker relationships. to understand how these various definitions have arisen, the following brief review identifies writers Hart and Bond10 suggested that Lewin’s work was who have influenced action research. Readers who highly influential in industrial and organisational desire a more comprehensive review of the origins action research (see, for example, Argysis, et al.14 of action research can refer to the work of Hart and Whyte8). Typically, outside action researchers and Bond10 or Greenwood and Levin.11 act as consultants to research (diagnose) the ‘problem’, work with the organisation to resolve it and then use research to evaluate any changes Influential writers that have been made. The diagnostic, democratic, pragmatic and empirical nature of Lewin’s work Kurt Lewin is still apparent in contemporary healthcare The roots of action research lie in the first half of action research. the twentieth century. Kurt Lewin (1890–1947), a social psychologist, is often credited with coining Jacob Moreno the term ‘action research’.11 Lewin was interested Gunz and Jacob15 argued that Lewin was not the in a social science that could ‘help solve social only forefather of action research but that Jacob conflict’.12 He considered that research should Moreno (1892–1974), a social philosopher who, help to address constructively the problems of incidentally, shared students with Lewin, also exploitation and poverty in minority groups. helped to promote a social science that worked Adelman12 noted that Lewin drew on theories with people and did not reduce research subjects of progressive education of the educational into passive roles. Gunz and Jacob reported that philosopher, John Dewey. Lewin was interested Moreno sought to integrate theory and practice in how people could, through self-education, by perceiving researchers as social investigators learn to enable themselves to improve their rather than as observers. In this model, experi- situation. His later work included ‘social experi- menters enter the field of study and participate ments’ in factories aimed at increasing product- with those being researched. This notion of ivity. From this, he made a significant contribution bridging theory and practice through subjects to the concept of action research through his acting as researchers and vice versa remains belief that, in order to solve practical problems, popular in action research today. people are more likely to act upon decisions made democratically in a group than they are Lawrence Stenhouse and John Elliott to act on decisions made without their involve- Educational action research, developed in the ment.12 Lewin was also the first to promulgate latter half of the last century, has also been the action research process as cyclical. He influential in the development of action research described several stages of action research in healthcare. Key proponents were Lawrence including fact-finding, planning, action and Stenhouse and John Elliott.16 Stenhouse is reflection/evaluation, refining the problem. acknowledged for reawakening interest in action A research component may be included in research in the field of education through the any or all of these stages. Humanities Curriculum project in the 1970s.12 The aim of this project was, among other things, Contemporary writers on action research have curriculum reform.16 It initiated interest in the been critical of the sentiments of Lewin’s work. ‘teacher as researcher’ movement. It was at this Carr and Kemmis13 suggested that democracy and time that, with rising dissatisfaction with social group decision making were viewed as techniques science based on traditional scientific/positivist to gain the cooperation of workers rather than philosophy, action research began to emerge as a fundamental principle for social action and, an alternative research methodology. University- according to Adelman,12 Lewin did not develop based education research was considered by 1 The origins of action research in healthcare

these writers to be elitist, and of little relevance been used extensively in developing countries in to teachers. They argued that the strength of attempts to bring about social and political change action research lay in the coupling of partici- in healthcare. patory research to action and change, thus making it relevant to the everyday problems Interestingly, movements and pressures similar to of teachers. those that occur in the promotion of educational action research exist in healthcare action research. John Elliott worked on the Humanities Greenwood1 identified the lack of relevance of Curriculum project and went on to encourage academic research to practitioners and promoted an individual reflective approach to the under- action research as a means of involving practi- standing of educational practice.17 Drawing on tioners in research activities that were aimed Aristotle, Elliott placed particular emphasis on at improving practice. Hart and Bond10 argued realising teacher constructions of knowledge and that a substantial proportion of healthcare action values. Noffke16 considered that action research, research is carried out by nurses and is symbolic as promoted by Stenhouse and Elliott, is part of of their professionalisation, that is, of their in- the professionalisation process of teachers. She creasing confidence and autonomy. Their work, also identified the fact that not all educational although relatively recent, has also contributed action research has challenged dominant to the understanding of the debates in health- conceptualisations of curricula. care and social care action research. Healthcare action research, however, does have a different Wilfred Carr, Stephen Kemmis and context to educational action research with, Robert McTaggert consequently, differing practical issues and In contrast, educationalists based in Australia concerns.21 For example, in healthcare action (Stephen Kemmis and Robert McTaggert) pro- research, the high rate of turnover of participants moted, like Lewin, a collective form of action appears to be a feature that causes problems, research, believing that groups have greater whereas this is not generally the case in potential for effecting change than individuals.2 educational action research. In addition, they clearly sought to work with teachers to understand and challenge repressive and oppressive educational ideologies. It is clear Popular misconceptions from reviewing reference lists that Carr and and criticisms Kemmis’ book, Becoming critical: education, know- ledge and action research,13 has been a reader for This brief overview of the key writings in the area many healthcare action researchers. of action research provides a background to the following discussion of the popular misconceptions Other authors and criticisms of action research. Other authors have also made important contributions to the debate. Gerald Susman and In certain academic circles, action research Roger Evered wrote a paper in 1978 in which has been criticised as being unscientific and not action research was proposed as an alternative to research. These criticisms focus on the role of the positivist organisational science.18 Richard Winter, researcher, the project design and validity, the an educationalist, promoted a reflexive action measurement of outcomes and whether action research that included theoretical perspectives research is a research method. It has been argued of dialectics.19,20 John Heron9 and Peter Reason’s3 that action research is anecdotal and subjective, background was in psychology, and their work was and that it is inherently biased due to a lack of influenced by phenomenology. Their interests researcher independence or separation from the were in communication and the resolution of research process.11 Questions raised about the conflict. They also emphasised participatory objectivity claim of positivist research are suffi- and holistic knowing, critical subjectivity and ciently addressed elsewhere.18,22–24 Objectivity is knowledge in action. Orlando Fals-Borda and strongly associated with the claim of a single reality Mohammad Anisur Rahman based their action or truth put forward within a positivist paradigm. research on the philosophy of José Ortega y Many social scientists have argued that this claim Gasset. They recognised the need for a combi- is inappropriate and hinders the understanding nation of experience and commitment from of the multiple realities that exist. those external to the situation (the researchers) and those intimately involved (the researched) to Researchers following in the positivist tradition 2 achieve shared goals.7 This form of research has attempt to disengage themselves from their study Health Technology Assessment 2001; Vol. 5: No. 23

subjects. Action research requires the researcher expectations until the proposed goals are reached. Or it may end forthwith through impatience and researched to be actively involved in all stages 7 of the research process. The action researcher and/or repression.” is therefore close to those being studied and the roles of the researcher and the researched are Considering the history of action research and often blurred. However, action researchers view its complexity, it is not surprising that differing this intimacy as a means of promoting appropriate definitions exist and that confusion exists regard- change and understanding of practice. ing its application. Even when the process is well defined, it is difficult to predict or evaluate out- Closely related to the issues relating to objectivity comes of action research projects. Preferred is that of validity in action research. From the outcomes are often not known at the commence- perspective of mainstream quantitative science, ment of the process, or may change as priorities action research would appear invalid. However, of participants are identified and developed it is argued that action research needs to be during the research process. Hence, the setting judged according to its own terms; that is, whether of objective outcome measurements can the work is participatory; whether it is aimed at be problematic. change; and whether it involves movement be- tween reflection, action and evaluation.25 Action For these reasons, action research is unlike research features both research and practice mainstream scientific research and is frequently outcomes; for example, project data and action dismissed by those from the traditional scientific may give rise to theoretical insights as well as community. It is not seen as valid research and is healthcare practice developments. Such practice often referred to as a management tool for the developments may, in fact, be generalisable to introduction of change, or as an educational other settings. method for continuing professional development.

The process of action research is aimed at change (e.g. community organisation, improved practice), Conclusions as well as the generation of knowledge. A crucial aspect of action research is the development of Action research has been used in healthcare motivation and ownership of feasible interventions settings in the UK and, subjectively, interest in it in complex real-life situations through the involve- appears to be increasing. Numerous writers have ment of all who are affected by an issue. The described the theory practice gap in healthcare flexibility necessary to develop action, which is and the evidence-based practice movement has owned by all stakeholders, is seen as a strength served to highlight the lack of implementation in action research. However, the identification and impact of research in the NHS. These have and clarification of issues followed by a process focused attention on alternate methodologies of implementation, adaptation and evaluation is such as action research. However, the scope and ongoing. Thus, distinguishing between the various role of this research process in the context of cycles in the process is, at times, difficult. This health technology are not clear. The complexity means that the design of the research projects of the action research process has meant that is evolutionary and, in the words of Fals-Borda researchers, managers and funders have experi- and Rahman:7 enced difficulties in assessing the value and outcomes of action research protocols and “These socio-political tasks cannot be strictly planned, generalised or copied uncritically since project reports. The aim of this project is to they imply open social systems and conjunctural explore and understand these issues, and to processes. There are no fixed deadlines in this consider how action research might be used work, but each project persists in time and proceeds appropriately within the context of a rapidly according to its own cultural vision and political changing NHS.

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Health Technology Assessment 2001; Vol. 5: No. 23

Chapter 2 The project

Aims review and consultative process. The aim of this preliminary review was to be inclusive: to •To examine the role of action research in encapsulate the nature and variety of action UK healthcare settings and to provide guidance research in healthcare and to distinguish action for funding agencies, policy makers, ethics research from other forms of research. Those committees, users and researchers for assessing characteristics identified as being key to action action research proposals and reports. research were the cyclic process (problem identifi- cation, planning, action and change, evaluation) and the research partnership (the participatory Objectives nature of action research). Other aspects, such as theory generation, the nature of the knowledge to The objectives of the review were as follows. be produced and the nature of the collaborative process, were included as components of the 1. To provide a definition of action research framework. As discussed later, the working defin- (see chapter 3). ition was further refined in the light of the syste- 2. To identify published and unpublished matic review and the consultative process, and action research projects conducted in health- led to the achievement of objective 1. care settings in the UK (see chapter 4). 3. To analyse action research in the healthcare Systematic review field (see chapters 5 and 6), by looking at: There is a tendency in the area of health • aims of action research technology assessment to assume that systematic • reasons for choosing action research reviews are synonymous with systematic reviews • issues addressed by action research of effectiveness. This assumption arises because • outcomes and impacts of action research such reviews have primarily been concerned •pivotal factors – strengths and limitations with quantitative research, namely, randomised (see chapter 6). controlled trials (RCTs) that specifically address 4. To develop guidance for the development and issues related to the effectiveness of a defined assessment of action research proposals and medical intervention.26 These reviews draw heavily reports (see chapter 7). on quantitative methodology. Consequently, some research communities have questioned whether it The relationship between the four objectives is possible and even methodologically appropriate and the questions raised by the original HTA to undertake a systematic review of action research. Programme brief and the activities of this study However, as Popay and Williams26 argued, there are are outlined in Table 1. multiple research methods which address differing types of healthcare questions. They went on to argue that, in order to provide a comprehensive Methods understanding of the challenges facing healthcare workers and to inform policy, there is a need to The study consisted of three interlinked phases: develop and undertake reviews of knowledge from other research traditions. •preliminary literature review • systematic review and direct consultative process The systematic review that informed this project • data synthesis. was designed to meet objectives 1–4 (Table 1) and, as such, does not address an effectiveness question. Preliminary literature review In other words, it does not compare formally the Key methodological action research writings effectiveness of action research with other methods were identified. Definitions found in the texts of research and change management. It is better were compared and contrasted, and a working described as a systematic and interpretative review. definition of action research was developed. This The review was conducted using a systematic definition informed and guided the systematic approach to the searching, selection of studies 5 The project

TABLE 1 Relationship between project objectives and questions raised in HTA Programme brief

Questions in HTA Programme brief Objective Method

What distinguishes action research from other types of 1 Preliminary examination of research and development? the literature

What action research has taken place in the healthcare context? 2 Systematic review

What are the potential roles of action research in health 3 Systematic review and direct technology assessment? consultative process What outcomes and impact has this action research had? What are the strengths and limitations of action research?

How can one judge such research? 4 Review synthesis What methodological guidance can be given for future work?

and extraction of data, using the recommendations 5. Requesting information and/or action for conducting reviews published by the NHS research study reports, protocols and/or Centre for Reviews and Dissemination (CRD).27 criteria for judging action research proposals Specifically, it included the development of a review and reports from: protocol, a search strategy, a priori inclusion criteria • research & development (R&D) managers of and a method of data extraction. It will be seen 444 NHS trusts in the UK (appendix 2) that limited quantitative analysis of extracted data • action researchers identified from conference was undertaken in order to calculate frequencies. proceedings (appendix 2) These frequencies provide general information • approximately 200 action researchers known on the number, roles, outcomes and impacts of to the RCN, London action research studies in healthcare settings in • known action research reviewers in the UK. the UK (objectives 2 and 3). Beyond that, the review deviates from those described in the NHS Electronic database searching was carried out in CRD publication. In order to organise and make two phases, with the most recent search being sense of the data on the strengths and limitations carried out in July 1998. Two reviewers agreed of the studies reviewed (objective 3), the approach the search strategy. Search terms are listed in used was similar to that of meta-ethnography, a appendix 1, together with a summary of the qualitative method of qualitative data synthesis.28 results of the search strategy.

Data sources Limitations of the search strategy The search strategy included the following. There was a need to balance the comprehensive- ness of the search against the value of identifying 1. Searching electronic databases all available studies and the time available. The (01/1975–07/1998): MEDLINE, CINAHL, limitations of this search strategy included EMBASE, BIDS (Social Science Citation the following. Index, Science Citation Index), PsycInfo, ERIC, conference proceedings, Dissertation • Funding lists from funding bodies/researchers Abstracts, HMIC (Health Management Infor- were not searched. mation Consortium), Aslib Index to Theses, • The search of conference proceedings Current Research in Britain, National Research was limited (1992–98) and biased towards Register, British Nursing Index, POPLINE, nursing conferences, with only one qualitative Institute of Education (see appendix 1). research conference and one mixed nursing/ 2. Handsearching of reference lists and journals, collaborative action research network including: Journal of Advanced Nursing, Journal of conference included. Clinical Nursing and Educational Action Research. • The CD–ROM version of the National 3. Searching the proceedings of two recent Research Register has only been available qualitative research conferences held in the UK. from November 1998. Only the prototype 4. Advertising the systematic review at two major was searched. research conferences and through the Royal •‘Action research’ did not exist as a delimiter in 6 College of Nursing (RCN). MEDLINE or the National Research Register. Health Technology Assessment 2001; Vol. 5: No. 23

• Action research studies were referred to in Data extraction journal publications but references were in- The development of the data extraction sheet, complete; hence, copies of papers could not consisting of closed and open questions, was be retrieved. informed by a template designed by Meyer and • It was not possible to target the key people Spilsbury (J Meyer and K Spilsbury, City University, at all NHS trusts who may have had knowledge St. Bartholomew’s School of Nursing, London: of action research activities. Letters were personal communication, 2000). The form was addressed to ‘The Research and Development developed, pilot-tested and amended (appendix 3). Manager’. Thus, action research carried out in One reviewer extracted data from all included the healthcare setting, of which a trust R&D studies and three additional reviewers cross- manager was unaware, may have been missed. checked a selection of studies (ten studies each). •Projects that were not identifiable as being Discrepancies in interpret-ations were discussed action research from their titles or abstracts and extracted data changed as appropriate. were likely to have been overlooked by the search strategy. Unlike RCTs and systematic reviews, there is no accepted or standard format for reporting action Inclusion criteria research.29,30 This made data extraction a difficult Identified studies were selected for inclusion in and time-consuming process. Thus there was the review if: limited time available for contacting authors of included action research reports to clarify or • they were undertaken within the healthcare expand specific aspects. setting (primary, secondary or tertiary) in the UK It is acknowledged that the reviewers’ interpret- •they were dated after 1974 (studies prior to ations during data extraction may be at variance this time were unlikely to be relevant to the with those of the authors. This is a potential current NHS) problem in all systematic reviews. It is particularly •they involved or had the stated intention of important when examining reports of action involving a cyclic process in which problem research because of the sheer volume and identification, reflection, research, and action complexity of information in included- intervention and evaluation were interlinked studies projects. •they were founded on a partnership between the action researcher and participants, all of whom Data entry were involved to some degree in the research Data extracted from closed questions were and change processes. entered into the statistical software package, SPSS. Responses to open questions were registered Study selection, retrieval and inclusion as present or absent in SPSS and, if present, the The process of selection, retrieval and inclusion relevant statements were extracted and entered occurred in stages. into the qualitative software package, NUD*IST. The two datasets were crosschecked when 1. Two reviewers independently reviewed the appropriate to ensure that relevant data abstracts of studies identified by electronic entries matched. searching, in order to select studies for retrieval. Any disagreements were discussed and Assessment of the validity of included studies consensus reached. It is accepted protocol when conducting a syste- 2. All retrieved publications and papers received matic review of effectiveness to assess the quality from researchers and NHS trusts were pre- of the included studies. At the time of this study, screened by one reviewer for inclusion in the the reviewers identified an ‘unvalidated’ tool to review according to the predetermined assess the appropriateness of action research.25,31 inclusion criteria. A second reviewer However, it was not possible to identify a validated independently assessed a random selection tool designed to assess the quality of studies re- (114) of retrieved papers. porting action research in healthcare. An attempt 3. A second round of study selection occurred as was made to systematically appraise the quality of studies were processed for data extraction. Some the included studies, using a modified version of reports that had originally appeared to be action the critical appraisal of qualitative research tool research did not, in fact, meet the inclusion being developed by Professor Jennie Popay and criteria and were excluded following discussion her colleagues at the University of Salford (per- between the two reviewers. sonal communication, 2000). However, this tool 7 The project

was neither designed nor has it been validated limitations of action research. The second is to for use with action research, and the results of consider what studies are relevant and of interest. this assessment were uninterpretable – the main It was decided to include all the studies because problem being that it did not consider all the key they provided an overview of perceived advantages characteristics of action research. Hence, for the and drawbacks that can be encountered in action purpose of this review, no attempt has been made research. The range of studies illustrates the to report the quality of the included studies. various ways in which issues were played out and they added depth and richness. The third phase, However, although a systematic appraisal of the according to Noblit and Hare,28 is to read the quality of each included study was not carried out, reports of studies, although they acknowledged each study was examined in detail in the context that this happens over and over again and is not a of the data extraction process. In this process a discrete phase. They suggested that texts be read pre-established data extraction sheet was used for information on the topic under review. In our that included aspects identified in the definition case, relevant information was extracted on to of action research. This enabled critical commen- a computerised database. The sources of these taries to be made about each of these aspects extracts were kept, in order to refer back to the within the included studies, in relation to the original paper if necessary. In phase four the objectives of the review. findings from the studies are compared and contrasted. Phase five is the process of translating Reference is made to the action researchers’ own the information from different studies into a assessments of the success or failure of their study. coherent interpretation. This has similarities to It is important to note that this refers to whether our endeavours to categorise the information. the action researchers were able to meet their In phase six, categories are collapsed into eight objectives, and is not necessarily a reflection pivotal factors that served to describe and explain of the quality of the action research project. the strengths and limitations of action research in healthcare. The researchers are in agreement Data analysis with Noblit and Hare28 that the phases overlap Closed questions and may run concurrently. Thus, although the Frequencies were calculated to provide descriptive general focus remains the same throughout, information about studies. the resulting interpretation and supporting information develop simultaneously. Open questions Content analysis of identified statements The direct consultative process (responses) to open questions for objectives 2 A direct consultative process was undertaken to and the first two components of objective 3 add quality and depth to the information provided resulted in emergent categories. As the data by the systematic review. It was designed to gain extraction proceeded, the number of emergent information unavailable through conventional categories decreased and statements were allo- published research reports. cated to existing categories. In order to ensure that categorisation was performed uniformly, Focus groups were considered to be the most data were reanalysed at intervals. The final appropriate method of obtaining the views of categories were exported to SPSS to provide action researchers, participants and users on the frequencies. These categories also provided themes that were emerging from the systematic detailed information on which to base the review. Focus groups are particularly useful for narrative components of this review. gaining people’s opinions on common experi- ences, in this case the action research process. A qualitative analysis was undertaken of the Group interviews may trigger debates or critical statements relating to open questions on the discussions of issues that may not have occurred strengths and limitations of action research (the in single face-to-face interviews.33 Sarantakos33 final component of objective 3.). The analysis or discussed how focus group interviews work, on translation of data needed a qualitative approach, the assumption that, in a group, people become because this particular objective sought to describe motivated and stimulated to examine their experi- and understand the issues involved.32 For this, the ences more critically. This has to be balanced method parallels that of Noblit and Hare,28 in against a major drawback of the method, which which six phases were identified. The first phase is its lack of ability to provide individual in-depth of the process is to identify an area of intellectual data. For the purposes of this review, group 8 interest that is, in this case, the strengths and interviews were considered as providing an Health Technology Assessment 2001; Vol. 5: No. 23

opportunity to consult a wide range of people in on the basis of relevance and the type and avail- the time available. General advice, such as that ability of the study’s participants for interview. Two given in Kruger,34 was used in the preparation of centres were unable to arrange focus group inter- the interviews. For each focus group interview, a views. The final site selection was agreed in con- moderator was identified whose role was to wel- sultation with two of the grant-holders who were come interviewees and to put them at ease. The knowledgeable in the field of action research. moderator explained the purpose of the interview Access was negotiated through the key person at and how it would be conducted, and sought each each study centre who had invited the original participant’s consent. She also ensured that the study participants to take part in focus group or topics covered were relevant. individual interviews and had organised the inter- view dates. It was stressed that, whenever possible, Sampling for the consultative process participants should represent the complete range Two focus group interviews were conducted in of participant groups involved in the study. A 1998 at an RCN/Collaborative Action Research drawback of pre-specifying the number of inter- Network (CARN) conference in Manchester. The views to take place is that it limits the flexibility conference was selected because it was billed as and responsiveness of the project to explore multidisciplinary and the delegate list included further the issues raised by participants. In our many healthcare action researchers. It provided an case, however, it was considered that there was opportunity to explore the developing themes with no need to sample more centres because data both novice and experienced action researchers. saturation was already being achieved, that is, Participants were invited to take part in the focus by the last interview no new information was group interviews prior to the conference. The being generated. moderators of these two focus groups were Korrie de Koning and Heather Waterman. Topic guide A framework for the consultative process was Healthcare settings in which action research had produced and incorporated in an interview been conducted were identified and selected for schedule and topic guide (appendix 4). This further focus group interviews to be carried out framework, the questions itemised in the HTA by Dominique Tillen. Four study centres were documentation, and the results of preliminary identified from reviewed articles and selected data analysis provided the basis for the for in-depth investigation. Criteria for selection topic guide. were determined and applied in four consecutive steps (Table 2 ). Analysis of data from the direct consultative process Seven of 31 centres met the criteria. It was possible Analysis drew on qualitative techniques described to contact a key person at six of these, and one by May.35 Interviews were transcribed by a secretary action research study per centre was selected and then checked for accuracy. The framework for

TABLE 2 Identification and selection of four study centres

Consecutive steps/criteria for selection Results

Step 1 Select funded or PhD action research studies in order to identify centres 31 centres identified at which they were carried out

Step 2 Select identified centres that have undertaken different action research 7/31 centres identified studies in at least two different settings • NHS trusts/regions, hospitals, community-hospital interface, community and 6 centres = 2 settings educational institutions 1 centre = 3 settings

Step 3 Confirm that sample of centres represents most participant groups All participant groups •Nurses, medical staff, managers, paramedical staff (social workers, physiotherapists, represented and occupational therapists), ancillary staff, service users, educators, students and voluntary workers

Step 4 Confirm that sample of centres demonstrates a range of action research studies Range of action research •A range of methods, settings, sizes, change innovation and participant groups demonstrated was considered satisfactory 9 The project

the initial analysis of the focus group and interview providing guidance and feedback on the protocol information was based on the issues identified in and final report, identifying action research pro- the topic guide (appendix 4). For the first two jects, and providing information on published components of objective 3, qualitative data have and unpublished studies. However, the resultant been used both to illustrate and to add depth to report should be considered as a reflection of the the quantitative data. With regard to the final opinions of the reviewers, and not necessarily those component of objective 3, the qualitative data of the advisory panel or its individual members. were compared, combined with the data extracted from the reviewed studies, and contributed to the genesis and exploration of the pivotal factors. Time-frame

Limitations of the direct consultative process The project was conducted over 17 months, from • The sample from which the selection was made February 1998 until June 1999. The definition of does not include all action research centres action research was developed in the first 2 months. in UK. Protocol development and the conducting of the •Information used for making the selection systematic review extended over 12 months, from may be missing and, thus, centres that would March 1998. The consultative process was carried otherwise have been eligible for inclusion may out during the middle 6 months of the project. The have been passed over. preliminary results of the research were presented • The selection of interviewees by the key person at two conferences in April and June of 1999, in at each location may have introduced selection order to obtain feedback on the conclusions bias in the sample. reached by the reviewers.

Data synthesis As discussed above, data from the systematic review Summary and direct consultative process were integrated. A narrative overview for each of the objectives The aims and objectives of this project were with the presentation of tabulated information achieved through a mixed methodology that and frequencies, if appropriate, was produced. aimed to combine what might be considered The resulting data synthesis informed the guidance ‘hard’ data from quantitative research with the for the assessment of action research projects, depth and understanding of qualitative research. presented later in chapter 7. In chapters 3–7, the results of the project are presented, as follows. Validation of the project • Chapter 3 contains a definition of action Validation of the project’s process occurred research, and a definition and discussion of its through: distinguishing features (objective 1), • An overview and summary of action research in •involvement of an advisory panel of researchers the UK health setting is presented in chapter 4 with experience in action research (objective 2). • regular communication between co-applicants • The findings on the existing roles of action •use of a consultative process with key action research and the outcomes and impacts of such researchers to elaborate on findings of studies follow in chapter 5 (objective 3). the review • These lead on to the presentation of results on •presentation of preliminary results at two the strengths and limitations of action research, research conferences. which are presented in chapter 6 in the form of eight pivotal factors identified during the review (objective 3). Advisory panel • Finally, a synthesis of the key findings of the review is used to provide guidance in chapter 7; An advisory panel consisting of researchers and this takes the form of 20 questions that could be members of interested parties advised the project used to begin an assessment of action research team (appendix 5). The role of the panel included proposals and reports (objective 4).

10 Health Technology Assessment 2001; Vol. 5: No. 23

Chapter 3 Defining action research

A definition of action research Extensive investigation and reflection on the literature2,4,5,9,10,36,38,39 and lengthy discussions resulted in the definition of action research used As previously indicated, there are a selection of in this review. descriptions and definitions of action research offered in the literature.1–6 Holter and Schwartz- Barcott36 pointed out that the core characteristics Action research is a period of inquiry, which and differing approaches and uses of action describes, interprets and explains social situations research have not been systematically identified. while executing a change intervention aimed at As a result, an embracing definition of action improvement and involvement. It is problem- research remains elusive and existing definitions focused, context-specific and future-oriented. tend to focus on the description of characteristics.5 Action research is a group activity with an explicit critical value basis and is founded on a partnership between action researchers and participants, all 10 Hart and Bond presented a typology of action of whom are involved in the change process. The research that identified seven distinguishing char- participatory process is educative and empowering, acteristics: it has an educative base; it deals with involving a dynamic approach in which problem individuals as members in groups; it is problem identification, planning, action and evaluation are focused; it involves a change intervention; it aims interlinked. Knowledge may be advanced through at improvement and involvement; it involves reflection and research, and qualitative and cyclic processes; it is founded on collaboration. quantitative research methods may be employed These characteristics were related to four action to collect data. Different types of knowledge research types: experimental, organisational, may be produced by action research, including professionalising, and empowering. Hart and practical and propositional. Theory may be gen- 37 Bond also argued that the four types of action erated and refined, and its general application research are indicative of the evolving nature of explored through the cycles of the action action research. The strength of Hart and Bond’s research process. typology is that it has been developed to be “...able to retain a distinct identity (of action The definition does not specify a particular research) while spanning the spectrum of philosophical perspective. This is deliberate, research approaches...” Thus, while not offering in order to be able to encompass the variety a definition of action research, the typology does of approaches in healthcare action research. make explicit the identified characteristics of A general discussion follows of the distinguishing action research, it attempts to clarify action features of action research and the variations that research types, and avoids the problems associated exist within the definition. Consideration is also with narrow definitions. An attempt was made to given to the philosophical frameworks that inform use these four action research types to categorise action research, and how they relate to the scope the reviewed studies but it was found that they of the studies reviewed. did not accurately reflect the findings in the included studies. To be fair to Hart and Bond, they did argue that their types were ideal and not prescriptive of action research. The action Distinguishing features of research reviewed did not fall into distinct types. action research There are many different ways of potentially classifying action research according to, for Like Hart and Bond,37 a number of other example, level of participation, research methods, authors3,5,10,13,18,36,40,41 have identified key character- and topic. Ultimately, a multidimensional matrix istics of action research. However, when these were would be required to explain the variations scrutinised by the review team, it was noted that but that would become unwieldy and too com- two criteria were fundamental to action research plicated. Finally, a definition was considered and these have been included in the definition. to be most helpful. These were: 11 Defining action research

• the cyclic process of action research, which in the study by McKenna and colleagues.46,47 involves some kind of action intervention Other variations were in whether the focus was on •the research partnership, in which the practice issues, theory generation or evaluation of degree of involvement or participation of the changes. For example, Gibson and colleagues48 researched may range from cooperation, when considered the practice of oral care, whereas the research participants work with outsiders to Waterman and colleagues49 chose to theorise determine priorities but responsibility remains on barriers to changing nursing practice in an with the outsiders to direct the process, to ophthalmic outpatient department, and Hanlon collective action.42 and colleagues50 presented an evaluation of a radical reorganisation of acute medical care. These two criteria are inextricably linked; it would be impossible to have one without the other. As Not all projects have an intervention. For example, the definition indicates, there are other important in a project in which action research is used to aspects to action research, some of which overlap explore the acceptability and feasibility of an with other types of research, management and innovation, it might be decided that implement- educational practices. ation is neither feasible nor acceptable. In our opinion, in the example just given, the work still The cyclic process constitutes action research even though the In theory, action research is presented as a cycle intervention is not accepted. This is because the of problem identification or situation analysis participants will have learned something new in (including reflection), planning, action (imple- the process; intervention is used loosely to refer to mentation of change and monitoring) and evalu- any changes in understanding, beliefs, values and ation, which may lead to identification of new behaviour. Moreover, they will have moved through problems, planning, action and evaluation, and the cycle and, having evaluated the innovation, so on. In practice, action research may be made they may have found it unsatisfactory. Projects up of small-scale interventions, often as part of that appear to have no intention of taking any a larger project, that are reflected on, planned, form of action do not fulfil the basic criteria of implemented, reflected on and adapted, and the link between action and research, and would not necessarily formally evaluated. An example not be considered action research according to of this is Lee’s work in training and developing our definition. Projects in which an attempt is registered nurses to become clinical supervisors.43 made to take action but the action is thwarted for whatever reason, for instance, through lack The depiction of the action research process as of support as in the case of Jones,51 would be cyclical is necessary to aid understanding but, as considered to be action research because there with all models, this is the ideal and the ideal is are opportunities for evaluation of the processes not always attained. The manner of reporting of that occurred. These issues are dealt with further action research means that at times it is difficult in the discussion chapter of this report. to discern the cycles within a given action research report. The movement between the phases is, in Action research provides a framework for the reality, iterative and difficult to present clearly in introduction and evolution of strategic action that written reports. For example, it is necessary to recognises the effect of and uses local contextual have some conception of the problem and factors in its advancement.52 In professional possible action in order to reflect on and settings, the process of action research may research it effectively. However, the study by overcome the separation of theory and research Burrows and Baillie44 is an example in which from practice.53 The movement between reflection, they claim completion of at least two cycles to research, action and theory that may occur in investigate and bring about changes in the each phase of action research has the potential to education of student nurses. produce experientially and professionally relevant knowledge. Action research has a potential to The research component may be the process of provide a process in which understanding and change and monitoring of outcomes; for example, development of practical knowledge can take Huby45 employed qualitative research methods in place (some examples of the variations that exist the development and study of health service users’ are given in chapter 5). Action research can assist experience of HIV/AIDS care in Lothian, Scot- in putting knowledge/research into practice land. Alternatively, research may feature as formal through reflection and the implementation of projects embedded in the process: for example, a change, and can also lead to the development of 12 controlled trial was part of the process of change innovative methods of managing the change pro- Health Technology Assessment 2001; Vol. 5: No. 23

cess (see chapter 5). Thus, it allows practitioners organisations, have not been able to address to exercise their responsibilities towards the uncertainty, complexity, instability, uniqueness development of accountable practice.53 and value conflict.1,56 In contrast, changes in direction are to be expected in action research Changes in practice or services contribute to as participants’ understanding of a situation and are affected by the development of clinical develops and differing avenues of inquiry are knowledge. These changes and developments realised.57 The technical/mechanistic approaches are captured and evaluated through reflection to problem-solving found in other R&D strategies and/or qualitative and quantitative research, thus tend to play down contextual factors, such as potentially leading to concrete or substantive relationships, organisational structures, anxiety, theories. The cycles of action research also allow and professional culture and identity. These participants to explore practical and theoretical issues are analysed and addressed by participants understandings from a variety of perspectives, for in action research in order to inform and to example, in different settings or with different take appropriate action. The consideration of people, that could serve to increase the general relationships and vested interests in particular application of the outcomes of the process. How- practices highlights the critical attitude of some ever, as will be reported later, in only a minority action researchers towards oppressive ideologies of action research projects included in the review and systems.2,13 Through the philosophy and was an attempt made to theorise beyond the local process of action research, McTaggert and setting. Meyer,54 for example, theorised to explain colleagues58 argued that there is a recognition her experiences of developing lay participation in that the generation of knowledge, moral care. The presence or absence of generalisable considerations and the drive to improve people’s theoretical abstractions may be due to the import- circumstances are inextricably interrelated. Some ance attached to this, compared with the import- action researchers therefore work from a critical ance of individual practitioner understandings. value basis and explore these as they move In addition, some action researchers attempted through the action research process. An example to produce findings that could be generalised of this is a study by Bellman,59 in which she sought statistically: for example, Clarke55 surveyed a to investigate and advance nursing care through sample of nurses about practice development. reflection on a model of nursing. However, not The sample was representative of the total all action researchers report a critique of their population of nurses in the Northern and underlying beliefs and values explicitly. Yorkshire Health Authority. Action research requires participants to reflect, Research partnership research and analyse collectively their own Action research, unlike traditional research, actions, values and knowledge, with a view to includes those who are being studied, whether researching and evaluating them. Action research, they are practitioners or clients, as ‘co-researchers’. consequently, has an educative function, as those Without stating the obvious, the cycles of action who are involved refine and develop their under- research described above illustrate that partici- standing of not only the topic under scrutiny but pation in action research is crucial to development also of research and the management of change. of practical knowledge and implementation of Action research can also have a liberating and change in practice. However, participation is often enabling (empowering) effect among participants thought of as more than just a technique to en- because it provides them with a collective means courage change; it is conceived as fundamental to of addressing current inadequacies or inequalities. an overarching aim to promote more democratic The degree of education and empowerment research practices and to (de)politicise research, appears to be related to the level of participation that is, to make research inclusive of everyone, afforded in an action research project and the not just within the domain of an elite group of problem under study. researchers.7,9,11 Action research thus takes an egalitarian approach. The degree of participation varies in practice within and between studies. In chapter 4, six Participation in action research turns the modes of participation are listed: co-option, com- conventional research wisdom of neutral and pliance, consultation, cooperation, co-learning, independent researchers on its head, for good and collective action.42 Accepting that at times reason. Traditional research studies, which rely it was difficult to tell which mode was in operation, on objectivity and control of variables when participation appears to depend on the aim of dealing with human beings within complex the action research, the phase of the project, the 13 Defining action research

experience of action researchers, the philosophical to the types of knowledge generated, is dependent approach, personal factors, and the financial and on the combination and emphases of the human resources available. Indeed, it is possible employed philosophies. to have several modes of participation running simultaneously, depending on the group of • Critical This philosophical framework of participants involved. For example, in Nicoll and action research is informed by critical theory, Butler’s study,60 teachers and students were closely particularly by the writing of Habermas.22,61,62 involved in changes to the nursing curriculum This approach arose from a desire to demo- relating to the study of biology, whereas others cratise research in order to present a challenge participated only when asked to consult on pro- to the institutionalisation of research, which posals. Overall, therefore, it would be unwise to is viewed as being exclusive and exploitative. suggest that there is a threshold level of partici- An aim is to encourage those who are normally pation that would guarantee success. On the other excluded from the process of informing it, hand, since participation is key to action research, thus making research participatory. Linked it seemed sensible to exclude projects in which to this is the desire for social improvement. participants did not appear to progress beyond Advocates of this approach seek to criticise compliance at any stage. dominant conceptualisations of society that, in their opinion, may serve to disadvantage Summary certain sections of society. They take the view An attempt has been made to present an overview that practice including research is socially, of the key features of action research and to show historically and discursively constituted. The the variations that exist within this definition. It notion of dialectics influences their stance. is argued that the variations are ‘variations on a Thus, the necessary interdependence of theme’. An inclusive definition such as ours runs subjective and objective perspectives, indi- the risk of being too broad. It could potentially vidual and social perspectives, and practice allow a wide range of research, change or edu- and theory are embraced (see Kemmis & cational mechanisms to be classed as action McTaggert63 for full explanation). Drawing research – possibly inappropriately. It is argued on hermeneutical ideas, practice is viewed that this is less likely to be the case with the as a reflexive exercise, underpinned by mean- clearly articulated distinguishing features ings, values and intentions that are continually of action research. being informed and reformed by both the practitioners and the organisations in which they take place.24 This approach enlarges on Philosophical perspectives the Aristotelian notion of praxis – of acting on the conditions of one’s situation in order to As intimated previously, there are philosophical change them.21 In this context, Kemmis and notions that underpin action research in health- McTaggert63 argued that to study practice care. The most influential appear to be critical means to change it but, also, that practice is theory, dialectics, hermeneutics, praxis and changed in order to study it. In this approach, phenomenology. These have been combined in value is attached to both qualitative and quan- a variety of ways, to provide philosophical frame- titative research methods; they are seen as works for action research by key writers in the complementary. An eclectic stance is also field. Those that appear to have informed health- taken on the development and testing of care action research are discussed later. For the theory, insomuch as local accounts of practice promotion of understanding (and for the want and/or general theoretical abstractions and of better terms), these have been called critical, statistically generalisations may be made. participative and qualitative. Each framework will be discussed in turn, together with how it might Critics of this approach argue that it is influence certain practices in action research. idealistic. By this they mean that its analysis However, the differentiation is somewhat artificial of power, with its desire to create a more just for there are probably more similarities between healthcare system, is naive and optimistic. the different frameworks than differences. Further- Others suggest that it is a vehicle by which more, the work of action researchers included individuals can import ‘radical’ social ideas in the review did not draw exclusively on any into social settings.63 one framework to understand or to justify their approach to action research. The process and • Participative In another philosophical 14 outcome of action research, and the priority given approach to action research, phenomenology, Health Technology Assessment 2001; Vol. 5: No. 23

participation and ecological considerations are Generally, this perspective emphasises emphasised. Reason3 urged action researchers involvement, qualitative research methods and to be aware of how Western thinking encourages the generation of local understandings and a narrow and materialistic understanding of evaluations of practice that have clear benefits the world that alienates people from their own for those involved. The production of statistic- understandings and from the natural world. ally or theoretically generalisable results is not There is a sense of wanting to create a ‘better the main focus of attention, however; it is and freer world’ that ‘liberates the human acknowledged that what is learned from one mind, body and spirit’.64 Primacy is given to setting might usefully inform another.18 the search for experiential, spiritual and practical knowledge by groups of inquirers. Criticisms of this approach to action research That being said, it is pluralistic in its accept- focus mainly on its failure to acknowledge ance of other kinds of knowledge. Group and the influence of organisational structures and individual reflection is promoted as a means dominant ideologies on people’s understand- of helping practitioners to engage deeply with ing and abilities to change their situations. experience and practice.3 Formal research In other words, it does little to challenge methods (generally qualitative) may be incorp- managerial philosophies. orated and theories generated but this is not the key aim. The problem of oversimplification that occurs when attempting to understand the differences Criticisms of this approach centre on its between perspectives is acknowledged. As stated introspective nature that, ironically, does little previously, the differences are largely on emphasis. to address the alienating systems of which it is However, the philosophical perspectives partly critical. Boundaries between reflection and help to explain the variations in the application qualitative research are often ambiguous; hence, of action research. Somekh65 proposed that the criticisms or misunderstandings arise about various applications arise because of the different whether it is research and about the rigour cultures and values that people have, even within of the research methods. the same discipline. Somekh65 goes on to draw attention to the fact that action research, like all • Qualitative In this philosophical perspective research, is a product of its time and history, and there is a critique of most organisational that the backgrounds and experiences of action science that is informed by positivism. Susman researchers will shape the type and focus of the and Evered18 argued that, above all, the find- action research process. ings from positivist science are not helpful in solving practical problems experienced No attempt is made here to say which is best – it by members of organisations. Drawing on will depend on the circumstances of the individuals phenomenology, priority is given to the sub- concerned and the aim of the action research. jective meaning of the behaviour of those For example, if a research aim was to improve the involved with change and research. The care of bereaved parents through consideration notion of the hermeneutical circle24 is in- of professional and lay beliefs, a participative fluential in this approach, that is, knowledge approach might be undertaken. Alternatively, is only possible through pre-positions. In other if a research aim was to make community-based words, without prior understanding, new know- healthcare services more responsive to the needs ledge is impossible to gain, and that under- of elderly people, critical perspectives might standing is constantly reconfigured as one be helpful. moves from the particular to the general and back again, or from one person to another and back, and so on. Therefore, in this reflexive Judging action research approach, it is thought necessary to understand the reasoning behind people’s (including the Conceptually, it would be inappropriate to rely on action researchers’) actions; this includes an standard research quality criteria to judge action examination of their intent, experiences, research. This is because action research goes values and ethics. Through discourse and beyond the traditional boundaries of description reflection with members of the organisation, and theory generation about the ‘here and now’ it is argued that a new understanding and to consider and realise, potentially, ‘what ought to resolution of the problem under be’. Any guidance on how to assess action research investigation will occur. needs to take into account the process of action 15 Defining action research

research, its participative qualities and the manage- As the methodology of action research suggests, ment of change, and how all of these relate to it is not possible to rely solely on quantitative reflection and research. The quality of research methods of measurement. Instead, qualitative in action research cannot be viewed in isolation. data from multiple perspectives in the form of Consideration needs to be given to the philo- reflective notes, diaries, observations, interviews sophical background and purpose of the project, and documentary evidence may be preferred. and how the processes of change and other con- This provides an opportunity to examine a textual factors influence the type and extent of range of data that can be used to inform the research. and evaluate action.

In mainstream research, practice developments are secondary to the research. As Rapaport and Summary Rapaport66 described, there is a ‘smash and grab’ tendency, in which researchers gather evidence The key characteristics of action research have been and quickly leave the research setting without identified and discussed, including a cyclic process having had any practical effect. This scenario is of assessment, action and evaluation, as well as a reversed in action research, in which the emphasis research partnership that encourages participation. is on practice or behaviour, with research being A definition has been presented. Variations in the a tool to bring about and support change. Thus practice and philosophy of action research that fall outcomes of action research should not be within the definition have been identified, and judged purely by their research outcomes these will serve as a focus for further discussions or theory development. and clarification of the action research process.

16 Health Technology Assessment 2001; Vol. 5: No. 23

Chapter 4 Action research in the UK

Results of the preliminary search of people participating in the studies were difficult to calculate; information was provided in 33 studies and systematic review and ranged from 1 to 60 individuals. A total of 368 published studies were identified. Electronic searching identified 259 studies while An attempt was made to assess the studies to handsearching identified a further 109. The determine the mode of participation according search of conference proceedings identified to the six categories defined by Hart and adapted 104 researchers who had reported using action by Cornwall,42 and listed below. research. Of 444 NHS trusts contacted, 104 (23%) responded to the request for information. Of • Co-option – token representatives are chosen these, 40 said they undertook action research but have no real input or power. while 64 had no information; that is, their records • Compliance – tasks are assigned, with incentives; did not indicate whether or not studies were outsiders decide agenda and direct the process. action research. • Consultation – local opinions asked; outsiders analyse and decide on a course of action. At initial assessment, 285 studies appeared to have • Cooperation – local people work together with the potential to meet the inclusion criteria. These outsiders to determine priorities; responsibility were retrieved for further examination. Applica- remains with outsiders for directing the process. tion of inclusion criteria to these studies resulted • Co-learning – local people and outsiders share in 59 studies (72 reports) being included in the their knowledge, to create new understanding, review. Data extraction tables for each study are and work together to form action plans, with presented in appendix 6. Included studies came outsider facilitation. from published articles (44), unpublished reports • Collective action – local people set their own (11), theses (3) and abstracts of the research (1). agenda and mobilise to carry it out, in the absence of outside initiators and facilitators.

Characteristics of identified As previously suggested, information was not studies often available on which to base a sound judge- ment on the mode of participation. The data Of the 59 studies, 57 (97%) were carried out after extraction tables (appendix 6) contain our inter- 1988; 18 (30%) had been undertaken for academic pretation of the style of participation during qualifications (PhD, 7; Masters, 8; diploma or different phases and are therefore limited. It undergraduate, 3). would be an oversimplification to present frequencies for each phase for what is, in Information regarding the duration of the study effect, quite a complicated process. was provided in 41 studies (69%); this ranged from 1 to 48 months with a median of 12 months. Study The basis of decisions for membership of action settings were reported in 43 studies (73%), while research groups was also difficult to discern from the setting could be inferred from the remainder. the information presented. Some relevant infor- A total of 32 studies (56%) took place in hospital mation was provided in 37 studies (63%). How- settings, nine (15%) in educational institutions, ever, the overlap between terms and vagueness eight (14%) in the community, five (8%) involved of descriptions makes it impossible to present both hospital and community, four (7%) were in further meaningful information. general practices, and the remaining study was carried out within a health authority. Most studies used more than one method of data collection. The primary methods used were Study participants were most likely to be nurses interviews, questionnaires, observation and focus (41 studies, 70%). Other groups listed as groups. Qualitative research methods were used participants included medical staff, educators, in 41 studies (70%), while in nine studies (15%) students, other staff and managers. The numbers a combination of quantitative and qualitative 17 Action research in the UK

methods was used. In only 33 studies (56%) were All focus group interviews were taped, transcribed the methods of data analysis reported. and entered into NUD*IST, and categorised as appropriate. As discussed in chapter 3, relevant A total of 21 studies (36%) were reported to data from these interviews is not reported separ- have received funding and in 16 (76%) of these, ately but has been integrated, as appropriate, the source of funding was reported. Four studies into the results of the systematic review. (19%) received funding from more than one source. The NHS (Department of Health, regional health authorities, trusts or R&D depart- Summary ments) was the primary reported funding source, while in three studies educational institutions and A total of 59 studies met the inclusion criteria. charitable organisations were listed as other A large proportion of studies that were labelled sources of funding. Three studies (14%) specified as action research did not fit the inclusion criteria. the amount of funding received; this ranged The vast majority of studies were carried out be- from £4000 to £46,000. None of the studies tween 1988 and 1996. Research methodologies reported an economic evaluation of the within the action research process varied with both action research process. qualitative and quantitative methods being used, qualitative research being the most predominant. Nurses in healthcare institutions were the most Results of the direct consultative active healthcare action researchers and partici- process pants. The majority of projects were conducted without the benefit of funding. The costs of carry- Seven focus group interviews were conducted ing out action research were not explored. These between September and November 1998 (Table 3 ). findings are elaborated upon in later chapters.

TABLE 3 Overall results of the direct consultative process

Location Interview type Setting Number of Type of participants participants

Conference 2 focus groups Action research 6 Action researchers from different projects conference, 8 Manchester

Centre 1 1 focus group NHS trust 12 Senior nursing staff leading nursing action groups

Centre 2 1 focus group Hospital 4 Physiotherapist, senior nurse, hospital manager and university researcher

Centre 3 2 focus groups Hospital– 2 GP and project co-ordinator community 2 Project researcher and practice manager interface

Centre 4 1 focus group Community 4 Community project workers

18 Health Technology Assessment 2001; Vol. 5: No. 23

Chapter 5 Detailed results of the systematic review and the consultative process

resentation of data in this and the following TABLE 4 Aims of action research in the included studies P sections presented a challenge. The project gave rise to a large amount of textual information Aim Number (%) that needed to be condensed, and a number of of studies, from the sections contribute to more than one of the a total of 52, in project’s objectives. Each of the following sections which included contains quantitative and qualitative data. The To i m prove the existing situation 33 (64) discussion of this data in relation to the role of To develop and implement innovation 31 (60) action research in healthcare appears in chapter 8. or intervention To e valuate project outcomes 24 (46) The data are presented under the following subheadings: To assess the existing situation: to 16 (31) identify needs for developing an appropriate intervention •aims of action research • reasons for choosing action research To contribute to knowledge/ 14 (27) develop theory • issues addressed by action research • outcomes and impacts of action research. To d e v e lop roles 8 (15)

Primary-care services included: Aims of action research • general practice services relevant to health Aims and/or objectives were provided in 52 of needs of users69 the 59 included studies (88%). In 16 (31%), aims •targeting people infected with HIV45 and objectives were provided; 30 (58%) provided •establishment of a Children’s Resource aims but did not specify objectives, and six (11%) Centre for children with special needs70 provided objectives only. In seven (12%) neither •a liaison health service for people with the aims nor the objectives of the study were pro- learning disabilities71 vided. Lack of clarity over the difference between •a nurse practitioner service for patients with aims and objectives meant that, for the purposes dementia and their carers.72 of the review, they have been analysed together. Studies also reported multiple aims and objectives. Hospital-based patient services included: Categories of aims and objectives are provided in Table 4. • splint aftercare73 • mental healthcare in Accident & Emergency Improvement was the most frequently stated aim (A&E)74 or objective and centred on clinical and tech- • pain management75 nological skills, education, the service provided, •self-medication for elderly patients.76 perceptions and attitudes, management processes and the quality of life of patients. Improvement The following quote from a focus group interview in service delivery within the community, primary demonstrates how multiple aims were seen to care or hospital services was a common focus. positively influence each other:

Community services included: “We used two drivers for that. There are two things happening here that you are trying to achieve: one is •a health promotion service to change the risk delivering on the bit of research and, in tandem with of coronary heart disease (CHD)67 that, using the work to change the culture of the •a community-based service to reduce the spread place to care for a particular group of people.” of HIV.68 [Focus group 4] 19 Detailed results of the systematic review and the consultative process

The development and implementation of an •the usefulness and acceptability of portfolio intervention/innovation included considering learning to trainers and general practitioner organisational approaches, educational (GP) registrars81 methods or programmes, specific tools and •interactive drama for peer health promotion technological developments, clinical care in schools of nursing82 standards, guidelines or protocols, and • GP fundholding92 changes in clinical roles. •a model of nursing care59 •the impact of changes to acute medical care in Innovative organisational approaches included: a district general hospital on staff and patients50 •the effect on quality of the King’s Fund • an approach to clinical leadership77 organisational audit.80 •primary nursing72 • getting research into practice (GRIP)78 Existing situations were the foci of other • multi-agency procedures for referral, care evaluations, including examination of the role, management, training, audit and records70 skills and attitudes of nursing auxiliaries,84 the •organisation and management of mid- coordination of services for people affected by wifery teams79 HIV45 and research utilisation by nurses.78 •a process evaluation model80 • practice care developments in healthcare Making an assessment of the situation to identify organisations.55 the kind of intervention required was an aim or objective in 16 studies (31%). Four studies Innovative educational methods or programmes (8%) indicated that assessment information were aimed at post-registration and student would be used as a baseline against which to education in a number of studies.44,60,81–86 measure change.45,69,78,80

Innovative tools and technological developments The aim in 14 studies (27%) was to develop included: knowledge. In most of these the aim was to produce knowledge at a practical level but in two • audit tools87 the aim was to verify or collate existing knowledge. •a tool for analysis of the change88 In only two studies was theory generation specified •a hospital computerised system89 as an aim and while one specified the type of •a multi-agency record system.70 theory, the other did not and eventually failed to meet this objective. The development and implementation of clinical care standards, guidelines, or protocols focused A smaller number of studies were concerned with on patient control of clinical care.76,90 Develop- nurses’ understanding of their own roles, the roles ment of clinical roles were either specified in of colleagues and the relation of their roles to the advance or acknowledged as emergent in two provision of healthcare and education. Role adapt- studies.69,91 An example of the objectives of one ations included adapting nursing roles concurrent project to develop an action plan was outlined to the development of a user-led service69 and to the at a focus group interview: specific needs of patients with dementia and their carers,72 and extending the role of experienced regis- “The two meaty objectives we’ve got are to review tered sick children’s nurses (RSCNs) to a specialist the work and recommendations of the care of the service in a paediatric casualty department.51 dying and the bereavement and loss group, and develop an action plan to address those issues across the trust.” The example offered below from one focus [Focus group 3] group interview illustrates how action research was used to review, identify and develop Project evaluation concerned innovations community nursing roles: developed during the project and pre-existing innovations in the areas of education, “...we’re looking to put a study together that would organisational change and clinical practice. ultimately have two ends. One is to integrate the nurse Evaluation of a pre-existing innovation team and the other is to identify what roles were included: required and by whom they should be performed. There are two parts, one to build the team and the •the effect of an educational process model other to look at what the future nursing need is...” 20 on participants’ learning outcomes85 [Focus group 5] Health Technology Assessment 2001; Vol. 5: No. 23

As might be expected, the specific aims of action The strengths and limitations of participation are research were closely tied to the reasons stated for discussed in more detail in chapter 6. choosing action research. Action research was perceived as a way of effecting change in 33 studies (69%) – as stated by a Reasons for choosing member of one of the focus groups: action research “I think, from my point of view, the reason why I like In 48 studies (81%), the reason(s) for choosing an action research is its immediacy of effect.” action research approach was specified. These are [Focus group 1] listed in Table 5. Another member of the same focus group stated: TABLE 5 Reasons given in included studies for choosing an “...I very much see the world of action research as action research approach being something that can take practice forward in a systematic way, while acknowledging the chaos that Action research was Number (%) can be inherent in action research. However, that chosen because it: of studies, from you are actually impacting on practice ... It involves a total of 48, in people and you can actually make a difference and I which included think that appeals to me as an individual. I think if I Encourages participation 36 (75) am going to work with practitioners and patients, I want to make a difference...” Results in change (of some sort) 33 (69) [Focus group 1] Has a cyclic process, involving feedback 30 (63) Contributes to understanding, 28 (58) Action research was viewed as being flexible and knowledge and theory responsive, and therefore suited dynamic, develop- Solves practical/concrete/ 21 (44) mental and sensitive situations, particularly when material problems more rapid responses or changes were required. Educates 14 (29) Action research was seen as providing opportunities to overcome barriers to change by developing an Acknowledges complex contexts 12 (25) understanding of constraints. Sustainability of Embraces a variety of research 11 (23) change was attributed to the action research cycle, methods enabling benefits and internalisation of skills and Evaluates change 8 (17) knowledge. A variety of projects indicated that the Empowers and supports participants 7 (15) change did not end with the end of the project but that participants were going to take forward the work begun during the project. Participation was the most frequently listed reason. Participation was described as ‘collabora- Action research was selected in 30 studies (63%) tive’. However, as previously discussed, definitions because of its process. Feedback and continuity varied and study reports frequently failed to clearly were the features of the process that were con- describe participant activities. The quote below sidered important, although studies did not always illustrates how a previous, more traditional form specify the ultimate recipient(s) of the feedback. of research failed to get cooperation from people The importance centred on increasing partici- and, consequently, had little effect on the identi- pation, the speed of implementation of findings, fied community problem. The action researcher enabling concurrent evaluation and modification concerned argued that there was a need to use an and increasing sustainability of any occurring approach that emphasised the participation of a change. Discussion and feedback in groups was range of people and organisations: identified as important at one focus group inter- view because it helped people to resolve problems: “...there had been quite a bit of research that had no outcome and cost a lot of money, so a lot of “Yes, because the solution becomes clearer and the people were feeling frustrated. Certainly, as we were discussion pulls it on. If you just put it [the project] speaking to different groups, there were a lot of on a piece of paper and send it back, you just leave issues. People do not get together in a town like it and expect it to happen. If you are in a group and this... We had to get communities involved to discuss it, you get motivated and enthusiastic, and address myths, to get people together...” you may want to see it through.”

[Focus group 7] [Focus group 7] 21 Detailed results of the systematic review and the consultative process

Another frequently quoted reason for choosing particularly suited to complex dynamic situations, action research was its contribution to under- reducing the theory–practice gap and, as a tool standing, knowledge and theory (28 studies, itself, could have a sustainable educational effect 58%). Knowledge generated by action research on users. The fact that action research acknow- was reported as occurring during the action ledges the complexity of healthcare practice and research process and at the endpoint of the change was identified in 12 studies (25%). research. The types of knowledge provided by action research were usually generated through Action research was also chosen because of the qualitative research, and include: ‘useful’ know- perceived flexibility it offered in relation to the ledge, descriptive knowledge, models, evidence research methods that could be used. Few studies and theory. Thus, the knowledge gained ranged explicitly linked the use of quantitative methods from personal knowledge (attitudes, assumptions, with action research. experience and perceived needs) to scientific knowledge and theory. It also included infor- In eight studies (17%) action research was favoured mation about an existing situation and structural because it evaluated and/or monitored change. and cultural constraints contributing to the Only in one study was the nature of evaluation issues to be addressed. However, most frequently, specified, that is, as formative, and in three the way experiential knowledge was being sought. The in which evaluation would take place was specified, following statement was made at a focus group that is, systematically, involving monitoring. interview and highlights the importance of gathering different viewpoints on a problem: Other reasons for the selection of action research included its use of support and empowerment. “Insights from different perspectives for me – having Support and empowerment as outcomes of action evidence from different perspectives that’s generated research were seen as being enabled by its partici- through systematic collection of data whether it’s pative and educational characteristics, and influ- quantitative or qualitative. Whereas change manage- ment could be changes happening but not necessarily enced by participants and their relationships with informed by data. In this project, we were really trying the structures and within the organisation or to find out what the patients thought of the services.” institution. The reasons for choosing action research were directly linked to the problem/ [Focus group 6] issues to be addressed.

Action research was chosen in 21 studies (44%) because of its focus on problem solving. The major- Issues addressed by action ity of studies described the ‘problem’ as a practical research one and these studies focused on clinical practice or practitioners. Action research was therefore The issues addressed were reported in 47 studies perceived as a way of promoting improvement and (80%) and are summarised in Table 6. In a further was seen to have a role in addressing problems in a specific setting that had either local or national relevance. Improvements were anticipated in TABLE 6 Issues addressed by action research in the clinical practice, education and services. included studies

One of the reasons for action research being Issue Number (%) chosen because it: of studies, from selected was to address the challenge of bridging a total of 47, in the research and practice gap. Action and research which included were perceived as occurring concurrently or being integrated. In one study, it was assumed that both Professional education, skills training 14 (30) the action researcher and practitioner could Inappropriate or conflicting practices 13 (27) contribute equally to closure of the gap and, Lack of evidence 12 (26) in two studies, the dominance of research was indicated by the statement that research would Professional roles 10 (21) inform or be integrated into practice. Health service provision 8 (17) Communication and/or involvement 7 (15) Reflection was the main educational tool of action Targets, standards, guidelines 6 (13) research influencing both process and outcomes. Implementation of research in practice 3 (6) It was employed in 14 studies (29%) and variously 22 interpreted and applied. It was considered to be Power 1 (2) Health Technology Assessment 2001; Vol. 5: No. 23

twelve (20%) studies, the issues addressed were patient groups and the underperformance of not clearly outlined. managers and clinical care practitioners, as well as organisational processes. The use of action Professional education, inappropriate or con- research allowed members of the healthcare teams flicting practices and lack of evidence were the to examine and address these issues through an most common issues addressed. Issues related organised process. A lack of communication and to deficits in, and potential for, professional involvement among practitioners or between development and, more specifically, the usefulness practitioner and service users or managers was of educational strategies and their delivery. For addressed in seven studies (15%). Two of these example, issues relating to appropriate educational involved practitioners and service users, for approaches were of concern in four studies; these example, GPs and practice nurses, and included professional profiles,81,93 clinical super- patients with diabetes. vision43 and core nursing skills training for student midwives.94 Clarification of targets or standards not met was a focus for six studies (13%). These included Inappropriate or conflicting interventions included situations in which managers were unable to clinical care, policy and educational interventions. implement changes necessary to meet targets,98 Inappropriate interventions, for example, included care planning and delivery outcomes,75,99,100 and the use of seclusion for the forensic psychiatric clinician teams or educators who had not fulfilled patient95 and processes designed to protect their expected potential.79,101 sexually abused children.96 The wide range of issues addressed by action In studies in which a lack of evidence to support research also led to a large variety of outcomes existing approaches and innovations was exam- and impacts from projects. ined, the issues to be addressed arose in the areas of organisational change, education, clinical prac- tice and the development of roles and models of Outcomes and impacts of care. A lack of evidence associated with organis- action research ational change and development was addressed, for example, by four studies. These were the An examination of the reported outcomes and commissioning of district general hospitals,97 impacts of the included studies provides another the creation of GP fundholding practices,92 perspective on the existing roles of action research. a policy to reduce hospital admissions50 and For the purpose of this report, ‘outcomes’ were the provision of professional education in defined as either research outcomes or immediate healthcare organisations.55 results of events; they included personal, pro- fessional and educational outcomes. These are Studies looking at the roles of healthcare pro- viewed as being equally important as ‘impacts’, viders, particularly nurses, concerned the clarifi- which were defined as ‘lasting effects’. cation, identification and development of new and existing roles, as well as overcoming barriers to Categorised outcomes and impacts are presented their uptake. The issue addressed in the following in Table 7. It is important to note that process quotation from a focus group interview illustrates outcomes are presented from three of the phases the desire to introduce a different way of organ- of the action research studies. There were no ising community nursing services: outcomes reported in the action phase of the included studies. For the purposes of simplifying “The [GP] practice put forward a module of primary the many data, only the two most frequently nursing care teams, as opposed to practice nursing reported outcome categories from each section and community nurses who had gone in the business are presented in the text (identified as C1–C8). band back in 1992. I think that matched quite closely, by chance, the model which ... Health Authority had Readers wanting more detail are directed to been pushing round its various departments, so we appendix 6, in which outcomes and impacts of had a view of where we wanted to go...” each included study are included in the data extraction tables. [Focus group 5] Outcomes Eight studies (17%) dealt with complex and Problem identification phase sensitive issues, including a lack of service Outcomes from the problem identification phase provision between institutions and to particular that related to clarification of issues (C1) to be 23 Detailed results of the systematic review and the consultative process

TABLE 7 Categories of outcomes and impacts in included action research studies

Phase of action research Number (%) of Categories Number (%) studies, from a of studies in total of 59, in which included which included

Outcomes Problem 47 (80) Clarify issues to be addressed (C1)* 27 (57) identification Identify need (C2)* 25 (53) Baseline information 17 (36) Motivate action 11 (32)

Planning 38 (64) Develop innovation (C3)* 31 (82) Preparation for change (C4)* 18 (47) Identify existing innovation 8 (21) Action plans 5 (13) Emerging information 5 (13)

Evaluation 52 (88) Education (C5)* 35 (67) Change (C6)* 31 (60) Participation 23 (44) Educational approaches 15 (29) Service provision 14 (27) Role 12 (23) Contribution to theory 6 (12)

Impacts 32 (54) Same location Educational approaches (C7)* 9 (28) Clinical care (C8)* 7 (22) Management 4 (13) Service provision 4 (13) Role 2 (6) Users 2 (3)

Other location Education 1 (3) Clinical care 1 (3) Organisational approaches 1 (3) Research 1 (3)

* C1–C8, categories addressed in the text

addressed included: service provision and Through the problem identification phase, con- clinical practice; education; role and participation; flicting or alternative perspectives on the issue under information technology and management issues; investigation were identified by the studies. In one, alternative perceptions to problems; and barriers managers wanted to ease the transition of senior to change. For example, an early audit of nursing nurses from the traditional senior nursing role to a care plans revealed how a new hospital’s com- new role that included standard setting and budget puterised system was inflexible and too time- management.100 Managers perceived senior nurses consuming, thus allowing for revisions to be as blocking change by a simple unwillingness to made before its full implementation.89 Another change. However, interviews and workshops revealed study revealed how middle managers had become that senior nursing staff were willing to change, and so overburdened that audit was viewed as another that the root cause of the problem was a lack of “paper-based project”, with the result that there ownership and understanding of the management- was a limited effort to make organisational proposed changes, structural constraints and dif- changes designed to promote quality.80 One fering agendas for change. Another study revealed study highlighted the management concerns of that a lack of integration of welfare rights into the health visitors – no standardised form of record- services for HIV-infected individuals was of far keeping and no tools available for caseload greater concern to service users than the service 24 profiling and analysis.88 providers had previously assumed.45 Health Technology Assessment 2001; Vol. 5: No. 23

The most frequently identified needs (C2) were ... As a result, one of the people on the steering related to education. They included staff edu- committee then went on to do some research and cation49,72,78,98,102 and the educational needs of produced a document on it and how effective it was.” students.44,94 Using focus groups, one study high- [Focus group 3] lighted students’ needs to practise skills away from the clinical setting.44 It also highlighted the nega- Preparations for change activities (C4) included tive attitudes held by lecturers on changes to seeking permission to undertake or complete the teaching practice. project, selecting the sample for research, project management (gaining premises, establishing Comments from a focus group interview high- steering groups, terms of reference, contracts, lighted how an action research project led to personnel and roles), gaining or providing funding, consultation with people in a community to educational preparation of participants, overcoming identify community needs: barriers and creating a willingness to change.

“I did some street work with X on the project and Evaluation phase initially it was difficult to get people to talk to us and Outcomes were identified from the evaluation get them to open up; I guess the subject of drugs phase in 52 studies (88%). Seven did not perform makes people cautious. Using the PRA [participatory rural appraisal] exercises helped to widen it, so [by] an evaluation of the change. Three of these studies asking direct questions about drugs or what they see were still in progress when data were collected for 91,100,104 as the problem or whatever, we were opening it up this report, two stopped prior to implement- and then focusing it back down again, and were able ation because of a lack of funding or resources,51,88 to use it with [our] methods ... I don’t think you in another too much resistance to change was would be able to do that with a questionnaire.” encountered105 and, in another, agreed changes 106 [Focus group 7] were not implemented.

Planning phase Positive educational outcomes (C5) for individuals Outcomes of the planning phase of studies were classified as personal and professional included development of an innovation and development. Personal development was reported preparation for change. The most frequent in 15 studies (29%) and, while one study report innovations (C3) developed during the planning stated only that personal development had taken phase were educational. These were primarily place, others provided more details. Personal aimed at participating staff to facilitate change development mainly included: or initiate development of an educational pro- gramme. In a number of studies, pilot educational • an increase in confidence;43,44,51,59,77,78,82,84,86,90,94,96,98 programmes were developed as the main aim, with for example, Burrows’ project44,90 led to the expectation of further refinement during the improved confidence in staff in the course of the studies.44,74,78,81,103 Few educational management of acute pain innovations were developed for or by service users. • an increase in awareness;59,80,96,107 for example, In one of the few studies that involved student Marrow107 reported that clinical supervision nurses, a health education/promotion programme had led to increased self-awareness in the for 14–18 year-olds was developed.82 nurses concerned •the ability to recognise one’s own strengths, Tools and strategies were also developed during weaknesses and limitations86,94,98 the planning phase. These included: clinical care •increased maturity.94 tools, audit tools, standards of care, written and computerised documentation, educational tools The following quotation from one of the focus and research tools for use in the study. For group interviews sums up these points well: example, an integrated care pathway assessment tool for coronary events69 and a tool for patient “I think the exciting thing about this whole business self-medication76 were devised in two studies. This of research is that it stimulates people to be self- quotation from a focus group interview provides critical, to ask questions, to analyse what they are an example of a strategy developed for career doing, to check out better ways of doing things. It progression for nurses in an NHS trust: just stimulates this whole process of enquiry – asking questions, helping people – so they themselves take things forward. I think this is a healthy productive “I’m on the clinical leadership focus group and as way to operate...” part of that we looked at career development, and we have developed a career program by action learning [Focus group 4] 25 Detailed results of the systematic review and the consultative process

Personal development was mainly reported among •developing innovations – in documentation students and staff but also included managers and on care,99 nurse education83 and primary service users. healthcare delivery69 • providing services – for example, a leg ulcer Professional development was reported in clinic69 and consulting services for patients103 20 studies (38%), which included increases in •saving time – through the sharing of ideas98 knowledge and skills. An increase in knowledge and the rapid uptake of new ideas.44 was reported among practitioners in the areas of: That some change occurred (C6) could be • clinical practice73,74,90 inferred from most studies but ‘change’ was • management92,98 listed specifically in only 31 studies (60%). This •education provision.82,103 quotation from a focus group interview describes one innovative outcome that provided a structure Skills development was reported in: for nursing research in an NHS trust:

• research; for example, research skills of “What’s impressed me so far is the fact that there’s a practitioners, or students and action researcher structure in place for anybody within the trust who’s looking to start their own research project, which in were reported to have improved through their 78,90,96 itself can be quite a daunting prospect. There are participation in the project people there with whom they can link up who can •teaching; for example, self-education through put them in touch with [other] people who’ve done 107 59 reflection, patient education and student similar research ... There are courses on research education82,101,108 awareness and research skills, advice from people •clinical practice; for example, of student an how to approach research ethics committees, and nurses or midwives44,94 and qualified nurses51,99 all the kinds of things [that] you tackle when you •communication; for example, in health embark on a research project – which has been education,82 counselling103 and written and quite useful.” 59 verbal communication skills [Focus group 3] •management; for example, through making a case for resources, decision making, problem The occurrence of a ‘change’ was not dependent solving, prioritising98 and auditing87 on the successful implementation of an innovation. • non-specific professional development was There are cases when an innovation had been reported in two studies.48,109 implemented and no change was reported in some aspects of the project.47,110 Alternatively, when an Empowerment occurred through personal innovation was not implemented or adopted, mini- development.43,59,82,86,96,98,109 However, it also came mal changes were reported.80,101 For some studies, about through gaining the support of manage- it was reported that no change had occurred.51,105,111 ment73 and reversal within the action researcher– This may indicate a need to consider more carefully participant relationship, as demonstrated in the how to define and assess change. study by Bond and Walton:96 Positive ‘change’ was reported in a number “...it was a very strange thing for us [mothers] to be of areas: teaching them [social workers]. That, actually, was 96 what it was in the end.” • clinical practice44,48,73,90,103 • provision of services50,80,91,92,110 Educational input was also reported as having an • provision of education60,101 effect on structure and processes including: •attitudes and perceptions of staff.44,45,82,108,112

•increased participation – two studies attributed In addition to providing outcomes about the educational input directly to increased partici- change, studies offered insights into the changes pation of study participants;73,98 this also included that occurred. Rapid change occurred in two such things as networking, working together and studies.89,98 However, not all changes were sustain- sharing ideas;82,96 it was identified that, at times, able.92 Some changes were reported as occurring this could result in conflict, as in “increased within the time-frame of a project and some after financial awareness may lead to conflict within its cessation. Conversely, in one study, changes individual doctor–patient relationships”92 occurring after the official completion of the •roles – the clarification of roles,109 uptake of project were not clearly attributable to the 26 roles77 and development of new roles72,73 action research.74 Health Technology Assessment 2001; Vol. 5: No. 23

While events and outcomes of change were often •alterations to the teaching of biology being described and sometimes interpreted, they were made in a nursing school.60 less often explained. Interestingly, studies in which fewer changes were reported provided more Following one study, participants organised the detailed explanations of how and why change first national conference on mental health issues did or did not occur.49,111,112 and emergency nursing.74

Impacts Clinical care initiatives (C8) included activities For the purpose of this review, ‘impact’ has such as the identification and use of a system of been defined as ‘a lasting effect or influence’. annual audit to monitor the implementation of Thus studies in which a continued effect was patient-controlled analgesia90 and mouth care.48 reported were categorised as having an impact. New approaches to nursing care were taken up This approach is supported by Jackson and in research wards47,109 and, in another study, Rolfe,91 who argued that: despite initial failure to implement Lay participation in care: a challenge for multidisciplinary teamwork,112 “The real evaluation of the success of this project is the additional funding to continue the initiative was fact that, at the end of the funded period, funding was taken up jointly by the University of Portsmouth and reported. The continued use of patient-centred the Portsmouth Healthcare Trust, despite severe consulting, developed through action research, restrictions within both organisations.”91 was reported and an associated teaching pro- gramme was planned to proceed to an RCT.103 Initiatives that persisted at the same location were It was reported at a focus group interview that found in 32 studies (54%) and, in a small number the project had had an impact on the perception (four studies, 13%), an effect beyond their location of nursing at trust level: was claimed. “It’s also put nursing on the agenda of the board. The Educational impacts (C7) at the same location strategy is well recognised by most board members and got their full support. That’s quite an achieve- were reported in nine studies (28%). However, a ment, for nursing to be recognised corporately. It’s number of educational initiatives were reported as not the same elsewhere.” continuing through having achieved additional funding, university validation, support through [Focus group 3] existing systems or incorporation into the under- graduate curriculum, or uptake by practitioners. The quotation below from another focus group These initiatives included: interview illustrates the continuing impact of action research on staff approaches to issues •the value of action learning sets to support and how they work together: midwifery managers being recognised and the project receiving additional DoH funding “We have changed the way we manage three services, for 1 year98 and [have] looked at a couple of other services since the end of the project. There is more of a feeling that • clinical practice development accreditation it’s team nursing. We bring special skills to that team. (CPDA) being validated at a university for There is an approach that is consistent, hopefully. 5 years with one successful CPDA event being We certainly talk more and we certainly have more accomplished and plans being drawn up to regular meetings in the nursing team. Those are operate internationally55 quite constructive – at the moment we’re looking • research education (GRIP) of nurses being at the ’flu campaign. We’re looking at that more continued through open learning supported as a team approach than we did in the past.” 78 by education staff employed by an NHS trust [Focus group 6] •a clinical supervision culture being promoted in a unit, with participants experimenting The reported impacts of action research with peer group supervision77 demonstrate its potential for continuing effects •the value of medical/surgical/mental on staff and users and on services. Continuing health placements for student midwives changes were reported in educational approaches, being established94 service provision, establishment of roles, manage- • formal, taught clinical-skills sessions being ment and user-led initiatives. Viewing these changes incorporated into the nursing curriculum44 through a positivist perspective limits our ability to • interactive drama for health education attribute these outcomes and impacts to the action becoming recognised as part of the students’ research process. However, there is no question that curricular activities (2 years later)82 changes occurred in these environs and, given the 27 Detailed results of the systematic review and the consultative process

complex and dynamic nature of the action research roles. The outcomes of action research were process, it is likely that it contributed to them. dependent upon the stage of the project and the issue to be addressed. The findings of the review highlight the difficulties of attributing outcomes Summary and impacts to the action research process. Typical outcomes include: clarification of issues and identi- Healthcare action research projects aimed to fication of problem to be addressed, development improve existing situations and develop and of innovations and preparation for change, and implement innovations or interventions. The personal and professional development. Impacts main reasons for selecting action research were over and beyond the stipulated period of enquiry its participatory nature, facilitation of change and included the dissemination of findings into edu- cyclical process. Action research reports addressed cation curricula and funding to support clinical issues such as: professional education, inappro- innovations. The strengths and limitations of priate or conflicting practice, areas of practice action research identified from the included where there was no evidence, and professional studies are discussed further in the next chapter.

28 Health Technology Assessment 2001; Vol. 5: No. 23

Chapter 6 Pivotal factors: the strengths and limitations of action research

he systematic review and consultative process • action researcher–participant relationship T identified the aims, use and outcomes of • real-world focus action research. In this chapter data from a variety • resources of perspectives are examined in an attempt to • research methods identify the strengths and limitations of action • project process and management research. This was accomplished through the • knowledge. analysis of data from the included action research reports and the consultative process. Data were Even though there appeared at times to be an compared and contrasted, and organised into cate- overlap between factors, it was considered that gories from which themes emerges. These have there were enough differences to warrant their been grouped into eight categories that are called separation. The combined reporting of findings here pivotal factors. In the following analysis the and discussion used in this section of the report perceived positive and negative aspects of these is common in qualitative research and, given the factors are summarised. It could be argued that nature of the analysis, was considered appropriate. the presentation of what appear to be opposing These pivotal factors are used later in the identi- aspects of the same pivotal factor helps to provide fication of factors that may be considered in assess- possible avenues for reconceptualising under- ing action research protocols and project reports. standing of the process of action research in health- care and offers ideas for its further development. This is discussed in the light of contemporary Participation thinking on action research. The pivotal factors identified from the action research process are: Participation was identified as a key component of 41 studies (70%). The positive and negative •participation aspects of participation, as a component of the • key persons action research process, are summarised in Table 8.

TABLE 8 Pivotal factor: participation

Perceived positive aspects Perceived negative aspects

•Promotes understanding of the context of study •Disrupts existing boundaries of decision making • Allows for problem identification by participants and strategic planning •Develops appropriate, relevant and feasible innovations and • Initiates shifts in existing relationships strategies for change, leading to sustainable change • Requires energy to maintain • Makes use of available resources of knowledge and experience •Provides opportunity for domination of projects •Provides educational opportunities through sharing of experience, by more powerful participants knowledge and ideas • Encourages feedback on performance of • Generates interest in the project participants which may be viewed as a threat • Increases or develops willingness to participate and to change •Takes time •Overcomes barriers to change •Creates resistance to change •Promotes ownership of change •Creates negative feelings if changes are not implemented • Allows for rapid uptake of change • Establishes rapport •Provides support •Saves time 29 Pivotal factors: the strengths and limitations of action research

Participation was reported as being important in participation as well as access before the study had every phase of the action research process. Dis- formally started. Conflict among participants was cussion on participation included who participated reported in several studies. Conflict was seen by in a project, their level of participation and the some as originating in different perspectives of a varied activities of the participants. problem, which arose from different professional and philosophical backgrounds and dominance Participation of staff and, in a few instances, by more powerful staff. Participation or lack of it, users was reported as having benefits at all stages through the imposition of projects on unwilling of the action research process. Participation, it participants, also led to resistance to proposed was claimed, generated interest in the project change. In these cases, change was not imple- and the establishment of rapport between action mented or the rate of change was so slow that it researchers and participants, which led to motiv- was unsustainable, as the next quotation from a ation and willingness to change. Ownership of focus group interview demonstrates: change was seen as an important outcome of participation. Participation was considered to “We have had such a lot of difficulty from some areas have an educational component because experi- and a lot of resistance, mostly from the therapies, presumably because they feel threatened. I felt, ence, knowledge and ideas were shared, and because it was trust-driven, there could have been participants felt supported by the action research more pressure from a higher level, executive level group. Participation by various people meant maybe, to get the cooperation that we needed, that groups had access to useful experiences whereas that has been another factor that has and knowledge that were employed as resources slowed things down with the project.” to the project. In some instances these were [Focus group 4] resources that would not normally have been available to participants. Participation led to a more comprehensive and contextualised under- There were examples in which participants found standing of problems, as well as the identification it difficult to cope with a heightened awareness of problems and the development of appropriate, of problems and this led to conflict in existing relevant and feasible innovations and strategies. relationships. Feedback of research to participants Participation was viewed as helpful in overcoming was also difficult for some. Conflict arose in one barriers to change and in reducing possible study when feedback on participant performance negative effects of change. There are examples was provided by action researchers and was viewed in which participation led to a rapid uptake as incorrect by the participants.105 This is not a of innovations, in that staff viewed the change problem with action research per se, as such positively. The following quotation from one problems occur in other forms of research. of the focus group interviews illustrates this point: It is noteworthy that some participants brought attention to their difficulty in accepting greater “If you are in a group and discuss it, you get responsibility for the research process. It is unclear motivated and enthusiastic, and you may want to take whether anxieties from lack of preparation or from part in seeing it through. They [the group] feel part other sources led to this problem. As indicated in ownership in it, getting involved in it.” chapter 3, action researchers aim to be non-elitist [Focus group 7] and democratic but, in practice, this is not always easy to achieve. Participation was reported to lead to shifts in existing relationships that, at times, both action Although some innovations may be ‘owned’ by researchers and participants found difficult to participants in the action research group, this manage. This was particularly true of those does not guarantee ownership by all those who relationships between different professions, senior may be affected by the change. As indicated pre- and junior staff, and practitioners and managers. viously, it is impossible in some circumstances to Management of such changes often required include all those who will be affected. Participation diplomacy and tact. These changes frequently in action research groups means that usual focused on people who did not ordinarily take channels of communication and decision-making part in decision-making processes. may be bypassed and, as a result, may cause disruptions to normal patterns of working. Participation was also viewed as a negative influence on the research process. In one study, Practicalities of participation also meant that in- 30 it was regarded as time-consuming to secure stances occurred in which people were unavailable. Health Technology Assessment 2001; Vol. 5: No. 23

This, in turn, could reduce effectiveness or delay hierarchical structures. In such an environment projects. Practical reasons for non-participation the potentially empowering aspects of action included lack of time or payment. Movement of research are often more difficult to achieve. staff due to pre-set rostering arrangements also This is illustrated by examples in which there are meant it was difficult to maintain participation, changes in boundaries of decision making and and continuation of work could be affected. In strategic planning, and in which these changes some studies, key people were overlooked as might be viewed as negative. participants and this served to slow or prevent the process of change, while in others it took energy There were indications that, although participation to maintain interest in participation among all was accepted as important, sufficient consideration those concerned. was not given to the potential problems that might arise in relation to the active participation of Participation was evaluated qualitatively through diverse groups of individuals with, at times, con- interviews, diaries and field notes in all but one flicting goals and objectives. This, in our view, is study; the authors of this report attempted to not a limitation of action research. It does, how- quantify changes in participation and reported ever, indicate that managing participation within difficulties in demonstrating such a change.70 This an action research project is both important and lack of reported measurement of participation complex. It requires an understanding of how might simply mean that action researchers did not people and organisations interact, as well as the identify a need to quantify participation in their skills to use these interactions to meet the goals project, that such a quantification would not add of the project. Participation is discussed further value to the outcomes or that it was too difficult in chapters 8 and 9. a concept to measure.

Participation comes across as being organic,113 Key persons in that it takes time to nurture and flourish, and the course of participation is not smooth. Key persons included those traditionally regarded Opposing viewpoints on the value of participation as having formal positions of influence within do not serve to denigrate it but help us to question organisations, for example, managers, medical it critically so that the process may be improved staff and senior nursing staff. In addition, there on constructively. Participants continually have are those seen as having less formal positions in to balance private and personal needs with the clinical setting (for example, junior nursing professional desires to participate in and medical staff, and students). Only two studies action research. reported service users as key persons.45,96

The consistency of issues across studies indicates Managers, senior nurses, and the action that management of group and individual partici- researcher (particularly if an insider) were pation is an important factor in any action reported most frequently as key people who research project. It indicates that monitoring as positively influenced projects. Such people were well as sensitive and appropriate management of important in sanctioning the project, providing personal and professional relationships is required. support, establishing networks and providing An understanding of the context in which research resources to implement and sustain change is being undertaken is crucial to the success of (see Table 9 ), as the following quotation action research. These activities require both from a focus group interview shows: time and skill. “It’s good to have [X] and I more on a ground There appears to be a tension in reported advan- level doing the basic teaching which goes along with the research. But we couldn’t get anywhere tages, in that participation tends to be set in the if we didn’t have the back-up from higher up the context of facilitating appropriate change rather organisation, and that to me is one of the most than as an important principle in democratising important things.” research.13,114 Heron9 argued that action research had an important role to play in empowering [Focus group 4] participants through its participatory approach. Empowerment seems incidental in relation to There was recognition that there were staff with facilitation of change in some of the studies knowledge and skills relevant to the project, who included in this review. Most studies took place could initiate or undertake change in practice. in a nursing setting with a tradition of strong Such staff were instrumental in overturning the 31 Pivotal factors: the strengths and limitations of action research

TABLE 9 Pivotal factor: key persons

Perceived positive aspects Perceived negative aspects

• Request study •Impose the project • Obtain permission to conduct study • Oppose the project • Authorise access to staff • Do not participate, e.g. do not impart • Link different agendas e.g. managerial and professional agendas information, do not complete diaries or viewpoints • Do not participate, resulting in changes with •Initiate or undertake the practice that is the focus of change low significance •Provide skills relevant to the proposed change • Dominate project •Provide resources: funding, materials, time, staff •Refuse to allow shifts in power • Sustain change: alteration of organisation structure and policy to accommodate innovations, provision of resources, funding, personnel

traditional view of the action researcher as Key persons who held influential positions were ‘expert’.74,95 This is also related to the next pivotal able to support a study; however, hesitancy or an factor (the relationship between researcher and inability to delegate responsibilities to participants researched). A quotation from a focus group could negatively affect the progress of a project. interview supports this: From another perspective, some participants became too dependent on key persons, making “... [X] was that to begin with. She had influence at it difficult to sustain change once the key board level but also influence within the nursing persons withdrew. arena. That was really important to focus our energies and our minds to looking at changes in nursing The findings indicate that, in order for action practice...” research to proceed, it requires key people who, [Focus group 3] indicated by their name, are in a position to sup-- port or thwart a study. Key persons, as with others, Key people who did not respond or support the cannot be presumed to approach action research projects in this review included medical or nursing without any prior agendas and to work in manner staff in positions of authority. Their influence was aimed at achieving a rational discourse and solu- regarded as having limited or blocked the imple- tion.22 These findings highlight the importance of mentation of innovations, or limited the ability of consultation and assessment of the key participants participants to collect data. The underlying reason in an action research remit. It must, however, be often listed for these negative effects was either pointed out that the dynamic nature of action lack of inclusion of key people at the outset of research means that new ‘key persons’ may be the project or their inability to participate due to identified as the project evolves. This draws atten- other commitments. With reference to the non- tion to the fact that it may not be possible, during implementation of patient-controlled analgesia, the planning phase of a given action research it was reported in one study: project, to identify all future participants. This also means that action researchers and participants “I had assumed that anaesthetists had collaborated.”90 must continually assess the evolution of the project In another study it was suggested that the lack of aims and the possible need to add (or in some involvement of medical staff resulted in changes cases withdraw) participants from the project. of low significance: Identification and consultation with key people is “...without medical staff involvement, the quality important to the success of other types of research, group tend to work on the areas marginal to the as shown by research testimonials on gaining access central problems facing the healthcare organisation ... to ‘subjects’.115–117 The results suggest, however, We now recommend that medical staff are involved 80 at the outset of such projects.” that because action research is intent on resolving social and practical problems, more commitment On the other hand, over-involvement could lead to and participation is required by key persons. The domination of the project direction, drowning out political nature of action research, which arises 32 the views of other participants.69,104,112 from the inevitable challenges to the status quo, Health Technology Assessment 2001; Vol. 5: No. 23

means that key persons have to make investments The action researcher– in the project on a scale generally greater than participant relationship that required for conventional research. Different models of the action researcher– Elliot118 raised an important point when he participant relationship were represented in the argued that organisational structures are internal included studies. One of the most distinguishing and not external to human experience, as pro- features was whether the action researcher was an posed by some critical theorists. Drawing on work ‘insider’ or an ‘outsider’. An ‘insider’ is classed as by Giddens, Elliot also suggested that people’s a person who has a formal role in the study setting behaviour and beliefs are not only shaped by the and is usually in paid employment, whereas an institutions that they work within but that their ‘outsider’ has no formal role in the setting other actions and values also contribute to the form and than as part of the action research project. The effect of these institutions. He went on to suggest most important advantages and disadvantages of that action researchers cognisant of this will take both situations, in relation to the success of a it into consideration and develop a network of project, are presented in Table 10. collaborators, with varying roles, within the organisations in which they are working. Difficulties arose from being so familiar with a situation, as an ‘insider’, that the development The limited involvement of users as key persons of a fresh perspective was difficult. At times, this in the included studies is somewhat surprising. meant limiting access to confidential and sensitive Action research, by its nature, suggests that its information. Conversely, some ‘outsiders’, un- application within the healthcare context would familiar with the institution or the context, found be to empower groups such as clients or patients.9 it difficult and time-consuming to become inte- This could support the premise that the principles grated. This integration included such things as or underlying philosophy of action research were the establishment of the project and the develop- either misunderstood or considered to be inap- ment of credibility with the staff. Of course, both propriate in the healthcare context. It could also situations were found to have their positive sides: be interpreted to mean that empowerment within the ‘insider’ was familiar with the situation and the included projects focused on the research had an established role in the team, while the participants who, in this case, were primarily ‘outsider’ brought a fresh perspective to the nurses. Alternatively, lack of involvement of users identified problem. might have been caused by lack of knowledge about how to facilitate users in action research or Self-assessments were made of whether projects by insufficient funds to involve them properly. had been successful in achieving the aims and

TABLE 10 Pivotal factor: action researcher–participant relationship

Perceived positive aspects Perceived negative aspects

Insider action researcher • Familiarity clouded understanding •Improved understanding of issues and context • Conflicting commitments may have caused delays • Enhanced credibility with participants • Participants disclosed information reluctantly • Challenged barriers to change •Had limited access to sensitive/confidential information • Increased commitment to the study •Perceived as owning the data •Sustained change • Could generate feelings of vulnerability of participants if researcher regarded as having outside approval • Experienced threats from certain alliances • Dependence of researcher or participants

Outsider action researcher •Brought fresh perspective to issues • Had difficulty in understanding context • Led to empowerment of participants •Found it time-consuming to understand context and establish credibility • Lacked concern for the outcomes over the long term • Appeared to have more to gain (e.g. higher degree) 33 Pivotal factors: the strengths and limitations of action research

objectives. A comparison, between those who had action research project, due to the exposure of been successful and those who had not, showed both the action researcher and the participants that, in the latter case, there was a larger pro- within the process. portion of outsider action researchers (63% compared to 30%). Recently a ‘double act’, Action researchers and participants had varying consisting of a partnership between insider (as levels of commitment to the relationship. This was change facilitator) and outsider (as researcher) indicated by the amount of time they dedicated to has been recommended.109 The success of the the project. The inability of certain staff to provide project, however, may have been influenced necessary support when required caused difficulty more by the position of the insider. in moving a project forward. This was particularly important if the project was a primary focus for Regardless of whether the action researcher is the researcher. This was also an issue in relation an insider or an outsider, the development of a to who gained from the successful completion of positive working relationship between the action a project. Some action researchers gained in terms researcher and participants in all aspects of the of a higher degree or a research publication, while project is critical. As a group they will be required the participants had to live with the change to assess the identified problem, identify possible (which, it was to be hoped, was a positive one). alternate solutions (plan), implement (take action) and evaluate new practices. Factors relating to The relationship between the action researcher both the action researcher and the participants and participants was complex and evolving. This affect the success of the development of an meant, at times, a shift of dependence. In some effective action research team. projects, this took the form of participants taking on more responsibility for the project. One factor identified as important in the develop- ment of this relationship is the personality of There is no ideal way of dealing with the action the action researcher, as represented by researcher–participant relationship, apart from these examples: acting ethically. This can include developing an awareness of relationships that may disadvantage “without the strength of character, the project would participants. The ability to maintain successful never have reached completion ... personal, inter- relationships is not easy and requires close super- personal, intellectual and educational qualities of the vision by an experienced action researcher.112 project ANP [advanced nurse practitioner, the co- researcher and facilitator] are of utmost importance, It is necessary to monitor and examine the per- 72 and will greatly influence the success of the project.” ceived relationship from all perspectives and thus to question the tensions that are experienced “I think personality is very important. It obviously throughout a project. This critical analysis might helps people like [X] and me, who are trying to get provide ideas for positive action to enhance these people to do a lot out of their own goodwill; [so] we have got to be persuasive and enthusiastic the relationship. in leading it, and if we show any doubt it would die down. ...you can’t get people on your side to try The insider–outsider debate is common to something ... if they don’t like you. They won’t qualitative research, in which similar issues about bother. At the end of the day, people have to get on access and ethics are debated.119,120 Because the with you, to cooperate with you. We have had to get aim of action research is to go beyond description along with a lot of people to get as much as we can. and to introduce change, the issues to be nego- You can’t really bulldoze people, that doesn’t work tiated between action researcher and participants in a project like this.” are numerous and complex. Consequently, there [Focus group 4] is more likelihood of difficulties being encount- ered. This suggests that action researchers need A few participants were reluctant to reveal be cognisant of the possibilities of problems and information into the public domain of the project. make efforts to anticipate and address them. The problems addressed by projects included Zeni121 offers a guide to ethical issues and edu- sensitive areas of patient-care delivery and the role cational action research. Much of her advice would and activities of healthcare professionals. Ethical be applicable to action researchers in healthcare issues arise in the context of any relationship. but further consideration would need to be given In action research, the desired closeness and to the ethical tensions that may arise from being involvement of action researcher and participants both an action researcher and a healthcare pro- may lead to issues relating to confidentiality. This fessional, that is, balancing the needs of both 34 is an issue in any research and is critical in an without disadvantaging or compromising patients. Health Technology Assessment 2001; Vol. 5: No. 23

Real-world focus Although projects were described as working in the real world, there were project limitations, as An acknowledgement of the context in which described in this quotation: the research takes place (a real-world focus) was a key aspect of included action research studies “The only common criterion for the selection was and brought with it both positive and negative qualified nurses [who] worked on Fridays; in these 84 aspects (Table 11 ). ways the criteria do not reflect the real world.”

This real-world focus is seen as the ability of action Executing change in the real world requires an research to identify concrete (and often complex) ability to accommodate the present as well as the problems, to seek and implement relevant, appro- wider arena of influence. However, this is not priate changes and to evaluate the effects of these always possible and some disruption was reported changes. This requires an understanding and as necessary, as shown in this quotation: acknowledgement of the complex contexts in which healthcare is delivered. “We negotiated some very short-term bed closures so that staff could be released [for 109 Initial assessment and description of the ‘real a 2-day workshop].” world’ take place in the initial stages of most pro- jects. This is a time when the situation under study One of the challenges of conducting research in is assessed through reflection and research prior the real world identified in some reports was the to planning changes. Much of the information amount of time and perseverance needed to see gathered at this stage has a strong experiential projects through to completion, as reflected in basis. However, less than half (36%) of the in- this quotation from a focus group interview: cluded studies provided data (either qualitative or quantitative) on context and conditions “I think we have all felt this from time to time; with this prior to attempts to implement change. It was sort of approach you need a lot of sticking power, a lot of tenacity to see it through, and myself and [X] and acknowledged that this initial assessment is time- [Y], we have been with this germ of an idea now for consuming and can constitute a major time com- about 3 years, through thick and thin, through organis- 55,72 mitment. It was also found that even though ational changes, mergers of trusts, resistance from assessing conditions prior to change and the colleagues, sabotage, yes; whereas, had it been more likelihood of change was regarded as important, of a discreet package of things, a different approach, it was not always an accurate predictor of success then you could have probably managed it in a tighter in implementing change. This may be due to the way, with less fatigue, less external interference...” lack of precision of the identified indicator(s) or [Focus group 4] the transient nature of the context. Of two studies that used indicators to assess conditions prior to Hence, action researchers and participants may change, one did not implement change75 and the have to deal with feelings of frustration over the other was discontinued prior to completion.106 time it takes to move a project forward and the Projects highlight difficulties in understanding the possibility that, in the end, they may not be able real-world context and the difficulties of drawing to accomplish their initial goals and objectives. conclusions relating to changes that may have These problems are not unique to action research. been made. However, they may be greater than those that might be expected in other types of research

TABLE 11 Pivotal factor: real-world focus

Perceived positive aspects Perceived negative aspects

•Reflects ‘real world’ situation •Creates conflict and tension as complex issues •Clarifies context and issues are addressed • Increases relevance of research • Disrupts existing relationships •Addresses mismatches, e.g. between operational •Fails to meet expectations and strategic issues •Draws attention to issues that may have low strategic •Promotes service-led research or financial significance • Exposes action researchers to realities of practice • Requires time out/away from the clinical area for education, reflection, analysis 35 Pivotal factors: the strengths and limitations of action research

projects. The situation is compounded because Resources action researchers and participants must address issues related not only to the management of the Resources critical to action research projects project but also to their attempts to implement were time, staff, money and material, with time change. These changes often lead to the disruption being listed as the most important and the and then redefinition of pre-existing procedures most lacking. Most studies focused on ‘lack’ and lines of communication. of resources:

“A lack of resources can be a strong barrier to Reports showed that the real-world focus high- implementing change.”88 lights mismatches between operational or strategic priorities, as identified by managers and research In relation to time, two studies reported that priorities. Research led by service staff had a strong projects moved ahead quickly, which could experiential basis. However, when issues identified mean that time was saved by using an action by staff for research were of lower strategic or research approach: financial importance to the trust concerned, there was limited support from key persons. “...it must be emphasised that these results demonstrate the benefits after only two or 98 An advantage of the real-world focus was that three meetings.” researchers were exposed to the realities of “...at the third meeting innovations were practice. It was indicated that this increased their perceived”.59 understanding of clinical practice (real-world) situations and, in some instances, provided However, most studies reported that action research motivation for action. took a significant amount of time. This included time to negotiate access, to understand the context, Action research is perceived as being suited to to establish group processes and relationships, to promoting change. Winter19 discussed how action accommodate existing working practices, and to research encourages a questioning approach that undertake analysis. Time was needed particularly seeks alternative viewpoints on a particular issue, in difficult or controversial situations84,95 and when which are illuminative and inevitably generate the time required spanned months: suggestions and opportunities for change. This perception was supported by the findings of the “I spent the first few month familiarising myself with review, insofar as studies indicated this as a reason the sites selected for the project.”123 for choosing this approach. However, a number of researchers were not able to implement a change Time was reported as a limiting factor in 31 studies even after periods as long as 24–36 months.84,95 (52%). For six projects it was acknowledged that Elliot122 discussed real-world factors, in an action the aims of the projects were not compatible with research environment, that are conducive to the time available: enabling effective change. He identified manage- ment structures that give rise to collegial relation- “To have fully implemented the project in one ships and peer accountability as being more academic year was ambitious.”51 receptive to change. These are, in fact, similar to the situations created during action research. Limitations of time affected both participants Kemmis and McTaggert2 argued that action and action researchers, as seen from the following researchers need to act strategically and realist- two quotations: ically. They went on to point out that action research should be conducted in environments “...time constraints ... one of the biggest disadvan- in which there is a chance that the project will tages is balancing research activities alongside a 94 be successful, otherwise valuable time and full-time job.” resources may be wasted. “I was holding back some of the group by not having implemented some of the planned action for which The real-world focus of action research has I had assumed responsibility ... it took from one advantages and disadvantages in relation to the meeting to the next to transcribe tapes and carry 79 implementation of projects. How these factors out the first analysis of the data.” affect specific projects is dependent on how they are assessed and managed by the researchers and Reports suggested that action researchers often participants, and whether there are mechanisms underestimated the time required to carry out 36 within the organisation to encourage the changes. the project: Health Technology Assessment 2001; Vol. 5: No. 23

“The ... period of the study may be critical ... 1 year is work. This, in turn, influences decisions regarding 109 not long enough.” future funding of other projects. “Two action plans were perhaps too ambitious in attempting to achieve change in a short period [9 months] ... Significant changes can take a Research methods minimum of 2–3 years ... more realistic objectives could have been set bearing in mind the time limit Research methods refer here to the data collection of the project fell short of the ideal.”101 methods used within the research component of action research projects, as opposed to project One report indicated that the additional time management and the implementation of change. required for action research studies was necessary In some projects, study reports refer to all of these in order to implement change: in relation to the research methods. It is important to add that, since action researchers change prac- “An exploratory study resulting in recommendations tice in order to study it (see chapter 3), this is not would have been quicker and easier ... but would not have changed attitudes or resulted in the recom- unwarranted. However, this tendency towards a mendations being implemented.”44 lack of distinction between these various com- ponents appears to be linked to a lack of infor- Reports indicated that participatory approaches mation about how the research was carried out. do appear to take time and are not cheap in that sense but do generate other outcomes not Descriptions of the research component(s) within expected in conventional approaches. On the the action research reports were frequently limited other hand, there was a perception that there was and incomplete. General statements regarding a more rapid uptake of innovations as a result of research methodologies were provided but details staff involvement in the research and development of research protocols were infrequent. For instance, of a project. Commitment by participants to the reference might be made to the use of qualitative project was sustained in situations in which there methodologies, with a statement that focus groups was an awareness of demands of clinical/service were used to collect the data. However, details time and time was provided for research activities. regarding the research tended to be limited and it was not possible to assess the quality of the research Additional resources are also necessary to carry carried out within the majority of action research out a project. Staffing issues were mentioned projects. It is not possible to identify if this lack of previously and could be considered in a financial detail is a function of limited space in the project context or in a human resource context. Some report/journal article or simply incomplete managers agreed to replacements or additional research planning and implementation. A flexible staff, which reduced participant workload and word limit could be considered by journal editors enabled them to take part in the action research. in order to facilitate more detailed reporting This, however, was not always promised and, at of action research. times, although promised, was not provided. As previously noted, qualitative research methods Funding for the included action research projects were used most frequently within the included was limited. Information in the included studies studies. Qualitative methods were shown to have does not provide enough information to know a dual function in action research studies: that the reason(s) for this. It is not known whether of data collection and of facilitating the partici- it was related to: a belief that the research would pative processes. This was especially true when not require funding; a lack of knowledge about the research component increased participation, how to request funding; a rejection of funding thereby encouraging participation in action (that is, to remain free of the agenda of funding components of the project. The review found agencies), or a lack of awarding of funds to carry 11 studies (23%) in which motivation to action out the research. It is also unclear from the studies was reported as a result of the qualitative research whether remarks related to lack of equipment in the process of problem identification. relate to funding per se or to a lack of commitment of the involved institution to meet the needs of Problems were reported with the use of qualitative a research project. It appears that a ‘Catch 22’ methods. However, the context of the comments situation may exist. Poor funding means fewer suggests that these may be a reflection of the available resources, which in turn means that experience of the action researcher rather than a projects may not be able to fulfil their potential, limitation of the method. Data collection methods leading to poor evaluations of the quality of the could be perceived as a threat to participants: 37 Pivotal factors: the strengths and limitations of action research

“...staff reluctance to participate in open discussion.”84 This type of reporting of findings suggests that action researchers may be either inexperienced in The need for prospective data collection and the process of action research, or that they did not analysis is time-consuming, as is the transcription fully understand how to use qualitative research and analysis of the large quantities of data pro- methods to monitor and demonstrate changes, or vided during a qualitative research project. There that they simply did not report research method is an indication that action researchers may not information in journal publications. have been able or prepared to deal with this aspect of the research: Differing opinions were reported in the included studies as to whether their research findings could “In the event, the tapes of the group sessions were be generalised, thus reflecting the philosophical not transcribed and analysed, as too many data were generated for the scope of this project.”93 perspectives found in action research. Some argued that findings were context-specific. Occasionally, relevant essential data could be missed: Others argued that issues identified during the action research process were similar to other “Our researcher attended many meetings between settings and could, therefore, have relevance in the practice administrators and consultants ... There were inevitably many key meetings which were private other situations. General application in some of and about which we have no information or these instances did not refer to the representative- incomplete information.”92 ness of findings in the quantitative or probabilistic sense but more to the logical sense of applying/ The problem of accessing appropriate information transferring the findings to other, similar is not unique to action research; it is an issue for situations19,26 (see chapter 3). all qualitative researchers. As previously discussed, the focus of action The use of qualitative methods in multi- research is practice. Elliott,122 an influential writer disciplinary groups was reported as problematic in educational action research, argued that “the in that not all participants were familiar with the fundamental aim of action research is to improve key components.112,123 Providing sufficient time practice rather than to produce knowledge”. This to promote the understanding of the research view may explain why research is perceived by process is a way of preventing many of these some to be a small part of the action research potential problems. This inexperience or lack of process. These action researchers are missing training or understanding of qualitative research the point that a fundamental aspect of improving methods should not be viewed as an inherent practice lies in its evaluation – practice, reflection disadvantage of action research. and research go hand-in-hand.

Data from the problem identification phase of an action research project, whether derived Project process and management from qualitative or quantitative methodologies, were reported in 36% of studies. There was a pre- In the included studies, action research was dominance of omission of rationales for samples, frequently chosen because of its process. Studies a lack of measurement of change when it might described the incorporation of fact-finding, plan- have been helpful, for example, educational ning, action, reflection and evaluation as part of effects, and unsubstantiated claims for significant continuous cycle or spiral. Responsiveness and flexi- changes. For instance, in two studies59,79 significant bility; feedback mechanisms and evaluation were changes were claimed but neither qualitative three sub-themes that were recurrent (Table 12 ). nor quantitative evidence to support these claims was provided: As in many models, the apparent simplicity of action research belies its complexity. Included project “All six midwives agreed that the most significant reports described the difficulty of comprehending achievement of the project was the provision of the process in play and that not until a project is adequate staffing levels in the maternity unit, well established or completed is there a clearer particularly on the late shift. This had improved by picture of how all the components fit together. lessening anxiety, exhaustion and stress and has 79 improved safe care for mothers and babies.” The responsive and flexible nature of action “...The standard of care severely declined for some research was identified as the main strength of of the patients initially prepared in the ward for PCA the reviewed projects. Studies demonstrated 38 [patient-controlled analgesia].”59 how action research enabled: Health Technology Assessment 2001; Vol. 5: No. 23

TABLE 12 Pivotal factor: project process and management

Perceived positive aspects Perceived negative aspects

Responsiveness and flexibility • Leaves the project without established goals and • Receptive to new ideas objectives • Fits with qualitative approach • Lacks clarity – difficult to gain funding, interest, support •Promotes participant-led projects • Encourages hijacking of project by strong participants • Encourages emerging information to contribute to • Conceals poor project management as responsiveness strategic plan • Leads to numerous action plans that spawn complex • Allows for more rapid changes in research projects and implementation

Feedback mechanisms • Enables contemporaneous monitoring •Overshadows evaluation • Enhances participation •Threatens participants, leading to tension and •Provides valuable guidance to the project potentially reducing participation • Enables more effective planning, developing •Takes time and implementing • Increases relevance of the study

Evaluation • Encourages agreement of end-point •Discourages establishment of an end-point • Allows for evaluation in any phase of the project

•investigation of issues as they emerged; for Another aspect of flexibility and responsiveness example, the responses to a questionnaire was related to reports that studies lacked direction, concerning mouth care raised issues of cost which could potentially lead to management and, subsequently, pharmacists carried out problems. A lack of direction imposed a limitation a cost analysis48 on at least one action research study before it •a shift in the focus of a project in accordance started. This occurred because, without clear with clarification of the problem and identified objectives, it was difficult to secure interest and needs; for example, a study shifted focus to funding for the project.43 There is always a danger welfare rights45 that the adaptable qualities of action research may •a switch to more appropriate research methods; be taken to mean that there is no need for project for example, one study shifted from the use of planning and management. It is acknowledged diaries to interviews45 that it may not be possible to predict, at the start • accommodation of the real world; for example, of a project, the methods that will be used to meetings were arranged to fit in with the evaluate any changes. However, it is reasonable demands of practitioners78 to expect to see clearly stated aims and objectives • rapid response68 for the first phase of a project, even if they are •contemporaneous monitoring through feed- about fact-finding. These objectives may be back, providing valuable guidance, and main- refined or even changed during the project; taining and developing the innovation123 however, the reasons for any such changes • more formal evaluation when requested by should be explained as part of the action participants99 or at the end of a phase, for research project documentation. example, the information-gathering phase.91 As would be expected in any approach to The overall effect, as summed up in one research, a lack of direction at the beginning study, was: affects the remainder of the study. The identi- fication of the issue to be addressed can be a “Rather than being driven exclusively by any one 100 model, the programme was shaped in response to major undertaking, using up valuable time. the wants and needs emerging from both the pilot As discussed previously, a failure to consult more work with practices, and subsequently during the influential people and groups could lead to objec- training programme itself.”103 tives or innovations of low strategic significance.80 39 Pivotal factors: the strengths and limitations of action research

However, something of low strategic significance not unique to the method. They are, however, might have great local significance. increased by the nature of the process. Research- ers attempting to conduct any clinical research Lack of direction was shown to lead to: project face challenges related to carrying out the project as laid out in their research protocol. •the formulation of objectives or ideas Action research, by its nature and through its which could be biased in favour of more inclusion of participants as co-researchers and powerful groups or persons, including change agents, must deal with an ever-shifting the action researcher112 environment, in which the needs of the action • an inability to address all identified problems84 researcher, the participants and the patients need •the generation, sometimes, of extensive ideas.69 to be considered. This complexity means that in order to successfully manage the process, action Rapid feedback can assist in moving the project researchers require expertise not only in all along; however, care needs to be taken that it does aspects of research design and implementation not result in inappropriate actions. On the other but also in human resource management. hand, feedback can be time-consuming and appear to delay progress of the project. A need, during the project, to move action phases forward can Knowledge affect where the emphasis is placed in a project. For example: Action research was chosen because of its ability to produce knowledge and contribute to theory “Enthusiasm for the success of action plans led to (Table 13 ). much emphasis being placed on action, resulting in little time being spent on planning and managing the change.”101 The knowledge derived from the problem- identification phases of action research has Evaluation of outcomes is often difficult and can been demonstrated as crucial in highlighting be made more difficult if appropriate outcomes gaps in services and inappropriate policy, are not identified during a project. However, the addressing untested approaches, clarifying nature of action research can make this even more issues, developing appropriate innovations and difficult, as the responsiveness and flexibility of the preventing the implementation of inappropriate process mean that the focus of study may evolve or ones. For example, one study prevented the change during the project. In addition, there is the installation of a computerised system in a hospital difficulty of when to carry out the evaluation, as that would have been unworkable for nurses; shown by these two quotes: a more appropriate system was developed with their participation.89 “...once started, there is no natural end [to action 112 research].” The knowledge discovered as a result of action “...The nature of action research is continuous and, research studies also focuses on the development in theory, a never-ending process makes a formal of innovations and preparation for change 101 summary of conclusion inappropriate.” intervention. This is reflected in the ranking of ‘improvement’ (64%) and ‘developing and However, 90% of studies did provide results implementing change’ (60%) as the most of an evaluation as an end-point, which was, in frequently reported aims of action research. some cases, reported as being negotiated with participants. A number of projects that claimed While events and outcomes of change were often success reported that, although the action described, the basis of the change or the theory research had formally finished, work was that might explain the change was infrequently ongoing. For example: addressed. Interestingly, studies reporting few changes were explicit in providing explanations – “As I withdrew from the study, the problem was still 49,111,112 59 of how and why change had not occurred. being addressed.” It is of interest that while in 54% of studies a The low prevalence of aims and objectives relating lasting effect (impact) was reported, in only two to theory may indicate that, although there may be were the results of a re-evaluation reported.44,48 an awareness of the value of theory development, it is not a primary concern of action research The challenges faced by action researchers studies as they are currently undertaken. This is 40 in the ongoing process of action research are indicated by the following quotation: Health Technology Assessment 2001; Vol. 5: No. 23

TABLE 13 Pivotal factor: knowledge

Perceived positive aspects Perceived negative aspects

The knowledge from action research: • Theory development currently not a primary •Highlights gaps in services concern of action researchers • Identifies inappropriate policy • Participation does not always foster theory •Addresses untested approaches development •Clarifies issues •Develops appropriate innovations •Develops practical knowledge •Prevents the implementation of inappropriate interventions • Describes events and outcomes of change

“The working party recognise that their use of action action research is given less emphasis; that is, its research did not result in the development of theory capacity to generate different types of knowledge, ... it did enable them to work more effectively with a ranging from the propositional to the practical that 48 large multi-disciplinary team”. may be applied in a variety of healthcare settings.

It is possible that participation in and of itself Conversely, and as discussed in chapter 3, lack may not foster the development of or contribution of general theoretical abstractions could be a to theory: result of the philosophical persuasion of the action researcher. Elliott122 argued that traditional “I had assumed that the nurses would have made theory alienates practitioners because they con- strong links with the model ... co-researcher responses sider that it is idealised and unachievable and, demonstrate varying levels of theoretical attainment and many experience difficulty relating practice therefore, implicitly critical of their practice. The to theory.”59 advantage of action research is that practitioners develop and explore their own hypotheses, which A strength exhibited by the reviewed action serve to enhance their own and other practi- research studies was their ability to produce know- tioners’ understanding of their work. ledge primarily in the initial phases of assessment. A limited number of projects were able to link this knowledge and use it in development.81,85,89,109 Conclusion

The outcomes of action research as discussed The strengths, limitations and complexity of action previously indicate that practical knowledge is research need to be widely communicated so that developed in the majority of studies and even they can be considered, and appropriate strategies when specific study objectives are not achieved. identified prior to the commencement of any Winter124 argued that action research can over- action research project. Potential areas of tension come the ‘impasse’ between the disciplines of should be anticipated, and be addressed in action theory and practice, because it requires a move- research proposals and explored as part of the ment or “an exploring back and forth between action research process. The eight pivotal factors theory and practice”. Results from the studies identified in this systematic review could be used included in this review indicate that this has not as focal points to gain an understanding of the yet been refined in healthcare action research. It challenges that need to be acknowledged by those would be useful to explore whether this occurs in proposing to conduct an action research project. other disciplines such as education and, if it does, Awareness of these factors throughout the process how this might apply to health. It is apparent from of action research should assist in the achievement the included studies that an important quality of of action research project objectives.

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Health Technology Assessment 2001; Vol. 5: No. 23

Chapter 7 Guidance for assessing action research proposals and projects

he fourth objective of this project was to consideration of the process of action research, T develop guidance for the assessment of action particularly the participatory processes that require research proposals and completed projects. The an examination of both theory and practice. The combined research strategy used by this project iterative nature of the action research process has provided the reviewers with the opportunity to implications for the way in which objectives and address the first three objectives of the project, indicators for success of a project are formulated. while a combination of the results from these Not all outcomes can be determined in advance, provide the data to inform the fourth. This and objectives and indicators need to be adapted chapter includes a discussion of the need for and further developed during a project. The such guidance, the guidance itself and a short participatory process with various stakeholders discussion of each of the 20 questions included and interests requires skilled facilitation. Thus, in the guidance. the reporting of action research requires infor- mation that is not standard to other formats of research report. The need for guidance The review findings also support the assertion It is possible that some action researchers will by Popay and colleagues127 that there are general regard the use of guidance for evaluating action aspects in the evaluation of research that could be research as the antithesis of the anti-elitist and considered whatever the research method. These democratic principles of the process. There is include discussions related to background, design, a risk that by setting standards too high novice sample, data collection methods and analysis. action researchers may be inhibited. Conversely, Readers will note that guidance in the sections guidelines may provide new researchers with a relating to these aspects of research are general- structure within which to develop their work. ised. This is deliberate. Qualitative or quantitative ‘Purists’, who consider the process of action research methodologies may be employed research to be inherently good, might also struggle during the action research process. Readers are with the concept of appraising action research. referred to Popay and colleagues,127 Moher and The reduction of action research into a checklist colleagues128 and CRD27 for particular advice is inevitably dissatisfying. This is reflected in the on assessing the validity of specific research inability of such a list to capture the interactions methodologies that may be employed within between the different components of action the action research process. research. The growing interest in evidence-based healthcare, however, means that unless guidance For this project, the guidance has been generated is offered, action research may be assessed from a synthesis of the results of objectives 1–3 according to criteria designed for use with other (see chapter 2). This guidance will, it is con- research methodologies and, consequently, be sidered, allow action research protocols or misunderstood or even dismissed. The questions projects to be assessed on the basis of criteria provided in the guidance are designed to relevant to the process of action research. help reviewers integrate information in a systematic manner. It is common when evaluating quantitative research to assign a score to research studies.128 Guidance is needed to stimulate a more However, the authors would argue that this is appropriate system for reporting the results of inappropriate in the case of action research an action research process. A few writers have studies. As the review demonstrates, there is made recommendations about how action extensive variation of emphasis on aspects within research might be evaluated.5,25,57,125,126 They the action research projects. Hence, it is not appear to agree that the assessment of action possible to establish any valid weighting of the research proposals and reports should include components of the action research process 43 Guidance for assessing action research proposals and projects

that would allow for the logical assignment of It would appear appropriate for a full report and numerical scores. This problem is related not only proposal of an action research project to attend to action research but is shared with quantitative to all the suggested areas. This, however, would research assessment scoring systems.129 The authors not necessarily be the case (indeed, it would be also hesitate to suggest minimum quality indicators impossible) for a journal article, in which one for action research for the same reasons, apart aspect of the work might be discussed, with the from offering the guidance. reader referred back to the main report for more details. The guidance will have audiences from at least two potentially different backgrounds, namely The 20 guidance questions and the points for action researchers (primarily qualitatively based) discussion are listed below. At the end of the and members of research funding committees chapter, the questions are listed again, together (primarily quantitatively based). These groups are with additional questions that could be used in likely to have different discussions and an attempt an assessment process. The 20 questions are has been made to take both into account. presented in the past tense, as would be used in the assessment of a completed action research The guidance is a draft and has not been tested project, while assessment of protocols would in practice. It is expected that it will need modifi- be phrased in the present tense. The guidance cation following field testing and as understanding is in a format similar to that currently in use of action research evolves. The set of questions are within the NHS. Discriminating components seen as a tool for critical reflection and it is hoped of action research are indicated by that they will be employed to enhance the assess- an asterisk (*). ment, implementation and interpretation of action research. 1. Is there a clear statement of the aims and objectives of each stage of the research? As previously discussed, the issue to be addressed Notes on the guidance questions and the aims and objectives were not expressed explicitly in between 10% and 20% of the in- As indicated, the guidance questions for cluded studies. This may be accounted for by assessing action research proposals and reports the difficulty in defining the exact purpose and were developed from literary sources identified outcome of an action research project at the in this report, action researchers and findings of outset. However, sub-objectives that might have the review. There was no evidence to support a been defined as the project developed were hierarchy of action research, in that no single rarely reported. For the sake of clarity, it seems application of action research appeared to be reasonable for action researchers and participants more successful than any other. to articulate their aims and objectives in reports. In proposals, it would be impossible to specify A problem with identifying determinants for aims and objectives beyond the first phase guidance on the assessment of action research (see question 3). proposals and reports is that it can easily develop into a technical exercise, and the philosophical 2.Was the action research relevant to persuasions that lie behind action research, such practitioners and/or users? as social improvement, can quickly become The reviewed projects identified and sought to neglected. It is important for action researchers resolve local tensions, ambiguities, problems and to stipulate their philosophical approach and to ‘gaps’ within healthcare organisations, services indicate how it has influenced the development and practices. The evidence suggests that action of their action research project. The questions research was versatile. The studies that were are not meant to be prescriptive but rather as a reviewed took place at all levels of healthcare, means of understanding and developing further for example, from GP’s surgeries and in-patient the action research process. services to local authorities. A range of issues was tackled, including the technical, the educational It is accepted that to research and reflect on every and the interpersonal. The studies sought new aspect of the process is impossible. However, there understandings that, in general, had relevance is a need to justify those areas that are chosen for beyond the immediate situation. Such character- research and reflection. These and other issues istics of action research suggest that it would be can be informed by the 20 questions and the appropriate to discuss its relevance to local and 44 pivotal factors. wider contexts in reports and proposals. Health Technology Assessment 2001; Vol. 5: No. 23

3. *Were the phases of the project process. Thus, discussion of these factors should be clearly outlined? expected in action research reports and proposals. The review of the literature showed that there are a number of misconceptions in relation to 6. *Was the relationship between researchers the primary components of action research. A and participants adequately considered? large number of publications that were identified The studies included in this review indicate the by the initial search were later excluded because importance of the relationship between action they did not demonstrate (or intend) a process of researchers and participants, and also the diffi- problem identification, action, evaluation and re- culties faced by action researchers in attempting assessment, or have a participatory component. to establish participative relationships. Some of This process is considered a distinguishing the included studies did not provide details of attribute of action research and thus would be the mode of participation, that is, the participants’ expected to feature in reports and proposals. role in the decision-making process and involve- ment in the research, or their level of partici- It is difficult to specify, in advance, specific pation. The included studies indicated a need activities or cycles, because the outcomes of each for action researchers not only to be aware of the phase inform the next. It would denigrate a key potential benefits of participating in the project characteristic and strength of action research if this but also to recognise that participation takes time important factor were ignored. The first phase of and that it cannot be forced. Action researchers action research, which includes an initial analysis should be expected to discuss how participation of the situation under study, sets the scene for has served or will serve to enable practitioners subsequent phases and, hence, it is essential that and users to address local conflicts/problems this is planned and undertaken as thoroughly as in reports and proposals. possible. It is necessary to describe and justify how the first phase of a project might be executed, and In only a few studies was the effect of action to estimate what the outcomes of that phase might researchers’ and participants’ perspectives on the be and how those outcomes might influence future collection and analysis of data discussed critically. phases. Intermediate reports could be submitted to Reflexive commentaries help action researchers to funding agencies as a condition of funding. These analyse their values and beliefs, and how they and reports could outline the aims, objectives and others have influenced the project. This critical methods of subsequent phases of the project. attitude leads to a more informed understanding of the limitations of their approach and, at the 4. *Were the participants and stakeholders same time, may improve the scope of their work. clearly described and justified? Thus, it appears reasonable to advise action As the review demonstrates, appropriate selection researchers to be reflexive in their accounts and inclusion of participants and stakeholders is and to suggest that action researchers indicate vital to the success of an action research project. in proposals the reflexive qualities of their work. It is appropriate for action researchers to explain how individuals (or groups) were selected and 7. Was the project managed appropriately? why their participation in the project was con- Management of action research projects is sidered important. They should also explain complex and requires a variety of skills. Key how adjustments to project aims and objectives persons contributing to the success of included necessitated the inclusion of additional partici- projects tended to be senior nurses or managers. pants. It would be helpful if action researchers They were influential in bringing together the described how conflicts were addressed, for objectives of the action research group and the example, how skilled facilitators assisted groups trust or health organisation in which the research in dealing with such conflicts. was conducted. The outcomes and impact of action research is likely to be greater, that is, the 5. *Was consideration given to the local context effects are likely to have greater strategic signifi- while implementing change? cance if those in powerful positions are involved. Challenges described in included studies indicated Awareness and discussion of the importance and a lack of thoroughness in the understanding of the role of key persons appear to be essential local beliefs, values and structures or failure to components of reports and proposals of any identify the knock-on effects of a proposed project. action research projects. These factors are crucial to the success of any project and it would appear to be a critical con- The review indicates that one of the strengths sideration prior to and during any action research of action research is its real-world focus. Action 45 Guidance for assessing action research proposals and projects

research provides a framework for researchers to may be that there was a lack of anticipation, on investigate current issues and implement change. the part of the action researchers, in relation to However, within this real-world focus lie many the resources required for the project (especially challenges. Reports should include discussions time). It is expected that the application of the on how projects were managed, so that readers guidelines developed in this review will encourage can understand the outcomes. This review suggests action researchers to develop appropriate time that a more rigorous approach to action research schedules and budgets for future work, and the may be required. Action researchers need to con- same criteria will guide funding agencies in pro- vince funding agencies, ethics committees and viding appropriate funds and support. This section other agencies that they have a comprehensive of any research project report should also include understanding of both change processes and an acknowledgement of any conflicts of interests research: for example, that they have experience related to support or funding of a project. of (or access to) not only action research but also management of research projects and groups. 10. Was the length and timetable of the They should demonstrate that they have secured project realistic? appropriate support that will be maintained Action research often aims to affect the culture throughout the study, so that comprehensive of study participants; the review suggests that this planning is carried out before and during the takes time and that funding agencies ought to be action research process. This includes appropriate prepared to fund studies for 3 years or more when timetabling of activities, together with the ability necessary. Action research proposals should to be responsive and to justify changes within contain an approximate timetable and milestones the action research process. to demonstrate that the timescale is realistic.

8. Were ethical issues encountered and how 11. Were data collected in a way that addressed were they dealt with? the research issue? As the review indicates, action researchers often As discussed previously, the extent and type work with vulnerable groups of people who might of research/evaluation varied between studies. be at risk from unintended and unknown con- There were examples that demonstrated the sequences of the action research process. It is potential of action research. Indeed, some studies important to consider these in project design, to used multiple research strategies to collect data. discuss such issues in action research reports, and However, not all projects addressed important to be aware of how reports might negatively affect methodological issues: for example, whether the participants. For example, some participants play research method(s) is/are appropriate to the a significant role in the action research process question(s) being addressed. It is easy with the and, thus, it may not be possible (or desirable) benefit of hindsight to suggest how research to maintain anonymity. However, action research might have been carried out. However, notwith- proposals should show how ethical issues will be standing the aims, and the often qualitative and identified and monitored during the project. evolutionary nature of action research, there were clear indications from the included studies In addition, in some studies professional ethics are that research was secondary to action and, con- constantly under review during the action research sequently, opportunities were missed for in-depth process; discussion of this would reasonably be and comprehensive data collection. Whatever the expected in the project report and proposal. This research methods selected, action research reports is pertinent to studies which to seek to develop should provide explanations that demonstrate professional roles, in which there will be an that they were appropriate to the issue(s) under examination of the values and assumptions investigation. It may also be appropriate before the which underpin practice. first phase begins to indicate how research might be employed to address the aims and objectives 9. Was the study adequately funded/supported? by specifying potential research questions, with The results of the review indicate that action a proviso that, as the project develops, these researchers consistently felt under-resourced. The might be revised. The amount of detail available term ‘resource’ is used in its broadest sense and depends, of course, on the extent and depth of includes time, funds, staff and materials. It is not preparatory work that has been completed. possible to tell from this review if this shortfall is due to a lack of application by action researchers The lasting effects of action research were to funding and support agencies or to a lack of discussed in just over half of the projects reviewed. 46 approval from these groups. Another explanation They were wide-ranging but, at times, difficult to Health Technology Assessment 2001; Vol. 5: No. 23

assess. This was because it was often difficult to to balance the creativity that arises out of not determine whether effects were directly attribut- predicting all the processes and outcomes of a able to the project. Greater emphasis on the project against the need to be thoughtful, syste- research aspect of action research should make it matic and productive in one’s actions. Action easier to discern impacts, although the nature of researchers should explain how they have adapted the research means that this dilemma will never their activities and research to the circumstances be totally solved. of the research setting.

12. Were steps taken to promote the rigour of A number of action researchers managed to the findings? structure their work so that it could easily be There was recognition and demonstration of the communicated, while others, unfortunately, made value of feeding-back information to participants, it difficult for the reader to make sense or ‘unpick’ and discussion of the mechanics and purpose of their projects. As part of the review, a data extrac- this feedback in some of the studies reviewed. tion table (see appendix 6) was generated which This contributed to an understanding of the action helped the reviewers to summarise and compare researcher–participant relationship. Triangulation methods, findings and outcomes of different phases of methods was also frequently employed. This of an action research project. Such a table may be featured as within-method or between-method employed as a structure to assist in the reporting triangulation, which means that either several of action research findings. qualitative or quantitative methods were used, for example, unstructured interviews and participant 15. Are there clear statements of the findings observation, or both qualitative and quantitative and outcomes for each phase of the study? methods. It is reasonable to expect a discussion In general, several outcomes are identifiable of the value of triangulation according to the at the end of each phase of an action research circumstances of each project. No matter what project. The notion of outcome is interpreted research method has been used in a project, it is broadly in action research and relates to outcomes useful for action researchers to outline clearly what from reflection, action and research. These should steps were taken to ensure the quality of the data. be presented clearly and critically appraised. For In action research proposals, researchers need to example, an assessment of a situation is made indicate that their approach will be rigorous, while during the first phase of action research and is an subsequent reports should include a justification of important outcome of the project. The outcomes the methods of data collection, data checking and from the evaluation phase might include personal changes in data collection during the research. and professional developments, as well as the findings from research conducted during the 13. Were data analyses sufficiently rigorous? action research process. In proposals, it would As with data collection, the review found that, in appear to be undesirable for specific outcomes general, more information regarding data analyses to be pre-determined; however, an indication is necessary in order to understand the process and could be given of the type of outcomes that outcomes of a project. In the case of qualitative might be expected. research, this might mean derivation of categories and themes, and how they informed practice or 16. Do the researchers link the data that the next phase of a project. Quotations from are presented to their own commentary participants are often used as evidence in qualita- and interpretation? tive research, and information could be presented As the review shows, self- or collective reflection to explain how these were selected for inclusion in is often cited as an important element of action the report. Similarly, for quantitative research this research. Reflection is a thread that runs through- means an explanation of the management of data, out a project and contributes to theoretical under- the application of statistical principles and the standing and practice development, yet it is fre- interpretation of results. For the reasons already quently not clearly described or discussed. Reports given, it is not always possible to predict methods of should contain explanations of how reflection was data analyses in an action research proposal; how- employed in the project, particularly in relation ever, applicants would be expected to refer to how to practice or service developments and to the they might expect to handle specific types of data. research data gathered during the project. It would also appear reasonable for proposals to 14. Was the study design flexible and responsive? indicate how reflection might be employed as a Flexibility was cited as a reason for choosing action critical endeavour and be used to monitor and research. The findings suggest that there is a need inform the action research process and outcomes. 47 Guidance for assessing action research proposals and projects

17. Is the connection to an existing body of 20. Have the authors articulated the criteria knowledge made clear? on which their own work is to be read/judged? In just over a quarter of studies it was claimed As the review indicates, action research does not that theory would be generated or a contribution fall easily into the categories usually used for re- would be made to theory. However, the theory to porting research that are expected by researchers be generated was not well defined. Action research or academic audiences. Some studies recom- reporters often overlook the generation of theory. mended that action researchers stipulate how their Their publications tend to focus on the action report should be read, in order to counter possibly aspect of action research, to the detriment of the inappropriate assessment of action research research and theoretical component, that is, on projects. The existing variations in action research the action rather than the reason for it. Further- suggest that it is reasonable for the researcher’s more, when theory was considered, the focus position or standpoint on action research to be tended to be on the process of change, and presented, so that their report or proposal is re- theoretical insights into the topic under study garded appropriately. This has particular relevance were often missing. Interpretation and explanation to the research and reflective modes adopted and of events and findings need greater emphasis if whether action researchers choose to generalise action research is to realise its potential in the beyond their immediate setting. context of healthcare. To this end, action research- ers should consider the theoretical implications of their work from the start, as these may offer a Guidance: 20 questions for useful focus. Furthermore, consideration of find- assessing action research ings from different theoretical perspectives may proposals and projects be a vehicle for critical discussion and action. It is acknowledged that some proponents of action The 20 questions are phrased in the past tense as research consider the development of theoretical would be used in the assessment of a completed generalisations as secondary to the development action research project. For the assessment of an of practical knowledge. action research proposal, the 20 questions would need to be phrased in the present tense. The 18. Is the extent to which aims and objectives discriminating components of action research were achieved at each stage discussed? are indicated by an asterisk (*). Reports were primarily presented in a narrative format that did not explicitly indicate the extent 1. Is there a clear statement of the aims and to which aims or objectives were met. This process objectives of each stage of the research? was, of course, hampered in those projects that did •Did the authors of the project clearly define not have clearly defined aims and objectives. It the aims and objectives of the project? would contribute to methodological debates if •Were the aims and objectives appropriate? reports could include data and discussion on successes and/or failures. For project proposals these may only include aims and objectives of the first phase of the project and 19. Are the findings transferable? a description of when, and on what basis, future The review findings suggest that although the objectives will be generated. action research was locally relevant and driven, many of the outcomes would be of value to other 2. Was the action research relevant to health service professionals/services. Some of practitioners and/or users? the findings also had theoretical potential •Did it address local issues? beyond the setting in which the project took • Does it contribute something new to place. It would be helpful for reports to contain understanding of the issues? detailed discussions and descriptions of the •Was it relevant to the experience of those context of the action research to allow readers participating? to assess whether the changes and findings • Is further research suggested? could be usefully transferred to their • Is it stated how the action research will own settings. influence policy and practice in general?

Multisite action research projects may be 3. *Were the phases of the project particularly well placed to provide an overview of clearly outlined? issues that might be applicable to areas beyond •Was a logical process in evidence (or intended)? 48 those studied. including: Health Technology Assessment 2001; Vol. 5: No. 23

– problem identification •Was consideration given to underlying – planning professional values? How were these explored – action (change or intervention that and realised in practice? was implemented) •Were confidentiality and informed consent – evaluation. addressed? •Did these influence the process and progress of the project? 9. Was the study adequately funded/supported? •Were the assessments of cost and resources 4. *Were the participants and stakeholders realistic? clearly described and justified? •Were there any conflicts of interest? •Did the project focus on service users and/or health professionals? 10. Was the length and timetable of the • Is it stated who was selected and by whom for project realistic? each phase of the project? • Is a timetable given for the project and, if • Is it discussed how participants were selected appropriate, an indication of where the section for each phase of the project? being reported fits into the overall timetable?

5. *Was consideration given to the local context 11. Were data collected in a way that addressed while implementing change? the research issue? • Is it clear which context was selected, and why, •Were appropriate research methodologies used for each phase of the project? to answer research questions? •Is there a critical examination of values, beliefs • Is it clear how data were collected, and why, and power relationships? for each phase of the project? • Is there a discussion of who would be affected •Were data collection and record-keeping by the change and in what way? systematic? •Was the context appropriate for this type of study? • If methods were modified during data collection is an explanation provided? 6. *Was the relationship between researchers and participants adequately considered? 12. Were steps taken to promote the rigour of •Is the level and extent of participation clearly the findings? defined for each stage? •Were differing perspectives on issues sought? • Are the types of relationships that evolved over • Did the researchers undertake method and the course of the project acknowledged? theoretical triangulation? • Did the researchers and participants critically •Were the key findings of the project fed back to examine their own roles, potential biases and participants at key stages? influences, that is, were they reflexive? • How was their feedback used? • Do the researchers offer a reflexive account? 7. Was the project managed appropriately? •Were the key persons approached and involved 13. Were data analyses sufficiently rigorous? where appropriate? •Were procedures for analysis described? •Did those involved appear to have the requisite •Were the analyses systematic? What steps skills for carrying out the various tasks required were made to guard against selectivity? to implement change and/or research? • Do the researchers explain how the data •Was there a feasible implementation plan that presented were selected from the was consistent with the skills, resources and original sample? time available? • Are arguments, themes, concepts and categories •Was this adjusted in response to local events and derived from the data? participants? •Are points of tension, contrast or contra- •Is there a clear discussion of the actions taken diction identified? (the change or the intervention) and the • Are competing arguments presented? methods used to evaluate them? 14. Was the study design flexible and responsive? 8. Were ethical issues encountered and how •Were findings used to generate plans and ideas were they dealt with? for change? •Was consideration given to participants, •Was the approach adapted to circumstances and researchers and those affected by the action issues of real-life settings: that is, are justifi- research process? cations offered for changes in plan? 49 Guidance for assessing action research proposals and projects

15. Are there clear statements of the findings 17. Is the connection with an existing body of and outcomes of each phase of the study? knowledge made clear? • Are the findings and outcomes presented • Is there a range of sources of ideas, categories logically for each phase of the study? and interpretations? • Are they explicit and easy to understand? • Are theoretical and ideological insights offered? • Are they presented systematically and critically – can the reader judge the range of evidence/ 18. Is there discussion of the extent to research being used? which aims and objectives were achieved • Are there discussions of personal and practical at each stage? developments? • Have action research objectives been met? • Are the reasons for successes and 16. Do the researchers link the data that failures analysed? are presented to their own commentary and interpretation? 19. Are the findings of the study transferable? •Are justifications for methods of reflection • Could the findings be transferred to provided? other settings? • Is there a discussion of how participants were • Is the context of the study clearly described? engaged in reflection? • Is there a clear distinction made between the 20. Have the authors articulated the data and their interpretation? criteria upon which their own work is • Have researchers critically examined their own to be read/judged? and others’ roles in the interpretation of data? • Have the authors justified the perspective • Is sufficient evidence presented to satisfy the from which the proposal or report should reader about the evidence and the conclusions? be interpreted?

50 Health Technology Assessment 2001; Vol. 5: No. 23

Chapter 8 Discussion

he issues related to the methods used in research, action and evaluation. Hence, studies T this project are discussed here, followed by that lacked this were excluded. a discussion of various aspects of the results, with the aim of exploring the potential roles of action Data extraction and synthesis of data from the research in healthcare in the UK. included studies and the consultative process posed a substantial challenge. In terms of the systematic review, frequencies for selected variables have Project methods been calculated. For objective 3, the strengths and limitations of action research, the review has more A combination of methods was used in this project: in common with meta-ethnography as described by a preliminary and systematic review of the literature Noblit and Hare,28 who discussed how, in attempting and a consultative process. These methods identi- to arrive at a holistic interpretation of qualitative fied action research projects carried out in health- studies, reviewers need to decide how individual care settings in the UK and obtained the opinions study results are related; this is done through a of action researchers regarding the action research process of comparing and contrasting findings. process. The authors consider that the methods Here, the articles were read and data extracted complement each other and that the systematic that pertained to the strengths and limitations of nature of the first phase of the project was strength- action research. These were then grouped. The ened by the qualitative nature of the second. process was not straightforward and the data were grouped and regrouped until there was The criteria for the systematic review limited in- satisfaction with the eight pivotal factors. clusion to studies carried out in healthcare settings in the UK that had demonstrated a partnership As previously discussed, the concept of conducting between action researchers and participants, which a systematic review of action research has been involved them in a process of problem identifica- contentious. In the light of the objectives of this tion, planning, action and evaluation. These criteria review and experiences in this project, it is proposed meant that studies in which only the participatory that this review of action research would allow for assessment phase of the work was reported, and an assessment of the variety of action research being whose authors did not express their intention to carried out in healthcare settings in the UK. This take further action, were excluded. It is possible review did not fall into the classic category of a that by excluding these reports some information systematic review of effectiveness. In fact, the review has been missed related to the commencement could be criticised because it has not identified or of action research projects. included all the available action research projects carried out in the UK in the defined period. More Some writers have argued that undertaking studies have been identified and forwarded to the research with clinicians or users is action authors during the writing phase of this report. research, because the action researcher is work- Although these studies have not been included in ing in collaboration with others to investigate a the review, the authors are confident that the time mutual topic of interest. Bearing in mind, how- taken to assess and extract data from them would ever, that action research is carried out in order not have changed the conclusions of this review. to understand and resolve a practical problem, In fact, it is our opinion that they would have an expressed intention to undertake further work simply confirmed the information and analysis after the initial problem identification would be of data obtained from the initial studies that expected in action research studies. The key point met the inclusion criteria. is that action has to be seen as part of a process that leads to change, the development of know- ledge, enhanced practice or social justice. The Definition definition that was developed, and which guided this review, stipulates that the action research The definition of action research attempts to process needs to be dynamic and have interlinked be inclusive of the existing descriptions and 51 Discussion

interpretations. It includes the essential change should be integral to the culture of the components and the philosophical underpinnings healthcare organisation and that appropriate of action research as identified through exam- mechanisms to facilitate change, based on best ination of the writings of key current and evidence, should be a part of the overall manage- historical action researchers. ment strategy. Proponents of this view argue that both the research and change are compromised when they are brought together in the form of Action research in the UK action research.

Of the included studies, 31% were undertaken as The results of this review suggest a different first or higher degree projects. Most were carried perspective. There are indications that there are out by health professionals working in the NHS possibilities for the understanding and develop- or in educational institutions (as opposed to the ment of innovative practices, services and organis- community). Nurses were the primary participants ational structures through the iterative movement in the included studies. These factors need to be between research and change, as is the case in considered when establishing a dissemination action research. If the fundamental goal is to strategy for this report. It was an unexpected develop practice underpinned by research, it does finding that users were infrequently described not make sense to separate the two. As a recent as co-researchers or full participants, although review of evidence related to the implementation some studies did assess and evaluate their work of change in clinical practice states: by consulting or surveying patients and clients. “...any attempt to bring about change should first involve a ‘diagnostic analysis’ to identify factors likely 132 to influence the proposed change.” Analysis of the systematic review and consultative process and “...multi-faceted interventions targeting different The perceived challenges in implementing action barriers to change are more likely to be effective 132 research were identified in chapter 6. However, than single interventions.” overall, the results of the systematic review and consultative process suggest that action research It is possible for action research to be one of the can contribute to the achievement of aims and facets of such interventions. objectives of the Department of Health R&D programme.130 Specifically, this is in relation to The studies included in this review of action innovation, improvements in healthcare practices, research addressed a wide variety of clinical, edu- development of knowledge and understanding cational and service care issues, and demonstrated in practitioners, and involvement of users and the wide range of issues amenable to the action NHS staff. The results of the small proportion research process. The issues addressed were of projects undertaken by those outside the topical and consistent with current NHS policies nursing profession suggested that an action (for example, clinical governance, evidence-based research approach can be helpful for all practice).133 This could be interpreted as an health professionals. indicator that action research is operating at the leading edge of healthcare practice. Innovation Using the term broadly, innovation featured highly A frequently cited criticism of action research is its on the agendas of the included action research emphasis on local problems, as defined by practi- studies. This suggests that action research may be tioners, and therefore an inability to generalise the chosen not only as an approach to research but findings. The results of the review demonstrate, also as an approach to change management and however, that study topics have both local and practice development.131 The ability to address global perspective and implications. Assessing complex issues while moving between problem whether the results of action research projects identification, planning, action and evaluation have had or could have an impact outside their is the appeal of action research for many immediate clinical area was beyond the scope healthcare researchers.18 of this review.

There is a view that, within healthcare delivery, A feature of action research that leads to inno- research and change should be separated. This vation is its acknowledgement of the complex 52 view suggests that the importance and process of nature of social situations and its ability to be Health Technology Assessment 2001; Vol. 5: No. 23

responsive and flexible, and provide feedback. attribute effectiveness to a research project. On However, this complexity demands that action the one hand, action researchers would argue that researchers possess a variety of skills. These include such an expectation is unrealistic, and that the knowledge of multiple research methodologies, ethos of action research does not allow for such as well as skills related to project and group evaluations and conclusions; on the other, it could management. Examples from problems arising be argued that the inclusion of more specific aims in the included studies suggest that action and objectives, identification of indicators of researchers do not always possess these skills. change, and well-planned and executed research as part of the process of change, would enable The findings indicate that the cyclical nature of clearer attribution of effects. There is no easy action research is seen to be important. Utilising solution to this dilemma. Action research has such a process means that participants have input played a role in innovation in healthcare; however, at various stages throughout a project. This input the review suggests that for a variety of reasons its allows action researchers and participants to potential has not yet been fully realised. evaluate and make adjustments as the project progresses. This fits with Roger’s theory of Improvements in healthcare practices ‘diffusion of innovation’, in which ‘trialability’ This review demonstrates that action research (for example, things can be tried and then has a potential role to play in the improvement changed) and ‘observability’ (results can be of healthcare practices, services and organisation. seen) are important components in the Quantitative research methodologies demand use successful implementation of change.134,135 of measurable variables and the implementation of planned procedures allowing limited opportunities Prior to any change or improvement, action for development and innovation. This approach is research promotes the collective gathering of useful for the investigation of clinical problems information and a thorough investigation and and the measurement of the effectiveness of an analyses of the issue under study. The included intervention. However, it is limited in the extent studies showed this as a strength of action to which the perceived reality and complexity of research. Through collaborative assessment, healthcare practice can be represented. Qualitative reflection and research, constraints and oppor- research methodologies based on a naturalistic tunities are ‘uncovered’ and examined within research paradigm120 are more appropriate to the context of the proposed change. In addition, describe the complexity of organisations, social consideration can be given to personal and relationships and human behaviour. They are professional relationships, beliefs and values. increasingly being used in the field of health.32 Problems which may appear, for example, simply However, a qualitative research process, although technical may be as much a function of individual providing opportunities for participants to express or organisational philosophies or policies, and their ideas, feelings and suggestions, is still extrac- be symbolic of the exercise of authority of a tive and does not involve the practitioners and person or group. Within an action research beneficiaries of services in the decision-making process, conflicting beliefs, values and the process. The result is that the opportunity to nature of relations, which might form barriers enhance ownership and active cooperation in the to implementation, are identified. The partici- development of best practice is missed. What has patory process helps to reflect on these issues become apparent is that these methodologies and promotes conscious decisions making individually have limitations in their ability to relating to how barriers can be overcome actually improve healthcare practice.13 However, (see, for example, Crowley74). action research provides an opportunity to use these methodologies individually or in combi- The potential impact of action research was nation, to address complex practice issues. found to be another advantage. Impact, for the purpose of this review, was defined as ‘having a Discussions related to the implementation lasting effect or influence’. Impacts were reported of research findings suggest that quantitative as change in practice or continuation of a given and qualitative research have often been under- project over and above those reported as out- taken in a practice development vacuum, with comes. Here, then, arises one of the difficulties no immediate intention to enhance healthcare encountered by action researchers. How do you practices. Recent government policies130 seek to assess outcomes in projects that may not have clear address this by encouraging the dissemination end-points? This poses a problem for empirical and use of research, under the umbrella of researchers who would prefer to be able to evidence-based practice. Systematic reviews of 53 Discussion

research are key to the evidence-based practice of education and support appear in the discussions movement136 and provide healthcare workers with of the roles and outcomes of action research. access to evidence of effectiveness. The current direction from the Department of Health137 The generation of knowledge or theory was describes a linear progression that moves from reported to be important in about half of the review of evidence of effectiveness, to the formu- included studies. The knowledge gained was both lation of frameworks and on to the implement- theoretical and practical. Few projects showed ation and measurement of practice against these evidence of a contribution to the development frameworks. However, it could be argued that of theory, except in the production of knowledge this approach is disempowering and potentially from the assessment phase of the action research disabling, because it requires passivity on the process. However, there was consistent emphasis part of healthcare professionals. It requires them and priority given to the increased personal and to wait for direction and then to act according to professional knowledge of participants, as might be directives from national bodies. As shown, through expected from certain philosophical perspectives its participatory process, action research can that underpin action research. Conversely, the provide an opportunity for participants to take lack of theoretical developments may be due responsibility for their own learning, research to lack of educational preparation of the and practice developments, and to view them researchers in theory generation. as integral and interdependent components in the achievement of quality care. In other words, The review reveals that action research may action research is a potentially useful additional produce findings and develop knowledge that approach to improving healthcare practice has relevance beyond the immediate situation. that embraces professionals’ and users’ direct However, as in other research, the difficulty participation, and the integration of education, remains of finding mechanisms by which to apply research and practice development. these appropriately in other research settings. Even though there are similarities between clin- There is a limit to how effective the results of ical care settings, the premise of action research systematic reviews138 and national frameworks requires that individual assessment (problem can be in determining activities at local levels. identification) be made in each action research The findings from this review indicate that action situation prior to the implementation of changes. research can assist in determining local priorities The included studies highlight the advantages and in designing plans for the use of resources, of changes that are internally developed as facilities, and involvement of local groups. Action opposed to being externally imposed, and research can address important and unique local encourage the use of action research to idiosyncrasies in ways that the national frameworks facilitate this development. and audit cycles may be unable to achieve. The findings demonstrate that action research could An analysis of personal and professional ethics is be used as a valuable component alongside other encompassed in action research and is of increasing methods in a strategy for improving the quality importance to the NHS. Ethical issues were de- of healthcare delivery within the NHS. scribed in the included studies; however, they were not explicitly reported as a reason for selecting Development of knowledge action research. Whether action research generates and understanding more ethical problems than it solves is open to All research aims to generate knowledge, and debate. There is concern about projects that may action research is no different. However, the purport to be action research but are conducted epistemological focus of action research is the without consideration of these ethical issues.122 production of knowledge that is of direct rele- vance to people and informs both their work and Involvement of users and NHS staff lives. What differentiates action research is the As previously noted, the low level of user involve- underlying philosophy of education, empower- ment in the included action research studies was ment, support and ‘emancipation’ of research surprising. When users were involved their role participants.130 These were not frequently-cited was primarily consultative. Insufficient resources, reasons for choosing action research. It was not lack of knowledge about how to facilitate their possible to tell if these were not listed because participation and lack of confidence may be pos- they did not apply or because they may have sible explanations. In the few projects that have formed secondary or unconscious reasons for included users, for example, Bond and Walton,96 54 selection of the approach. Certainly, the themes favourable outcomes are reported in the services Health Technology Assessment 2001; Vol. 5: No. 23

provided. Action research has potential in An additional factor pointed out by Somekh65 is promoting user involvement in healthcare. that there is a need to balance practitioner partici- Reasons for the lack of reported studies need pation in the research process with non-research to be investigated. responsibilities. Examples from the review indi- cated that this was often problematic, with clinical Participation of people directly concerned with priorities interfering with planned research activ- the situation is the most frequently reported ities. Discussion about the lack of time to under- reason for choosing action research. There is take both activities was a common theme in the a consensus that participation is a fundamental reports. This issue is common to other types of aspect of action research although, as was research but perhaps is more prominent in action demonstrated in the section on the strengths research because of the emphasis on participation. and limitations of action research, there are variations in what is meant by participation. An Even though action research was chosen because important function of participation mentioned of its recognition of the context of the research in various reports was a sense of ownership of and change, not all researchers explored critically the research and a commitment to change in the effect of the action researchers and partici- the light of the findings. However, the literature pants on the study. A few reflexive accounts exist also indicated that action research is related to (for example, Waterman et al.49) that formally working with oppressed groups and is used to recognised the hermeneutic characteristic of address unequal relationships.7,11 The included action research. The value (and difficulties) studies did not identify this as a focus. It could be of reflexive action research have been outlined argued that the participants in the studies were elsewhere.18,19 A key function of taking a reflexive primarily from groups within the health services stance is to contribute to the critical examination (for example, nursing and other professions allied of events, outcomes and conclusions. to medicine), who work at the lower end of the healthcare hierarchy. This view is strengthened by Action research plays a part in the democratisation the fact that change was the next most common of research by involving those who may be affected reason for choosing action research. Nurses and by the research in making decisions.9 It allows others in the professions allied to medicine are participants (for example, staff and service-users) frequently excluded from the decision-making who are being studied to influence the research process. Their selection of action research may agenda, and to participate in research activities be influenced by their need to increase their that have previously been viewed as being in the participation in this process and lead to domain of distant and powerful researchers.9 greater empowerment. However, this process is complex and fraught with difficulty. There was evidence from the A number of the wider issues addressed in the included studies that more equal relationships included studies reflect managerial issues. Hart139 between action researchers and participants and drew attention to the fact that action research and a pragmatic approach to contextual issues may its processes may be subverted to suit the goals of serve to produce answers to and knowledge managers. She also explored how reflection, used of difficult practical problems. For example, as a component of action research, may emphasise participation in the clarification of problems and individual rather than group or organisational the development of interventions is reported to responsibilities for problems. This can serve to generate enthusiastic and active involvement in deflect resolution of problems from an organis- implementation. On the other hand, the time- ational to a more personal level. This shift in consuming nature of participation for all stake- focus is more likely to suit the working agendas holders, and the subsequent enhanced awareness of managers than health professionals or service of differences in perspectives between various users. Kemmis and McTaggert2 argued that action groups, can lead to conflict and resistance researchers needed to act strategically. It would to interventions. appear from the included studies that action researchers do this through a combination of The review has shown that a variety of issues their own interests and those of managers. This related to NHS staff involvement and to the role combination appears to be used in order to gain of healthcare workers can be addressed through support and funding for their studies. However, action research. The development of roles, particu- care needs to be taken to ensure that the interests larly nursing roles, was the focus of a number of of all participants are considered throughout the studies, for example, Rolfe and Phillips,72 Jones51 action research process. and Manley.102 They analysed the development of 55 Discussion

advanced nursing roles in which practitioners people’s circumstances.141 Nurses, in addition, seek greater autonomy. Hart139 offered a useful work in teams so that participation in group analysis of the increasing interest in action decision making is common. The process of research by nurses. She identified several reasons, action research has many similarities with the including the fact that action research is viewed nursing process and is thus familiar to nurses. as a method to reduce the ‘theory–practice gap’; The dissimilarities between action research and that is, it enables practitioners to undertake the medical model may explain why doctors have research and improve their practice. She not taken up action research more widely. aligned these reasons to the increasing focus on accountability, the desire for research-based Since the review found that nurses formed the practice and the related issue of increased pro- largest group of healthcare professionals who had fessionalism. Hart139 also suggested that the other taken part in action research projects, it could be reason for action research being favoured by assumed, therefore, that, compared with other nurses is that there is a dissatisfaction with the health professionals, nurses have developed limitations of traditional methods of research, expertise in action research. Meyer and Bateup,142 especially their lack of relevance to the complex for example, argued that nurse action researchers issues in nursing practice. She referred to the may have a great deal to teach other health pro- qualities of action research (participation, social fessionals with regard to action research, and that context and problem focus) that make it an their expertise formed a useful resource for those attractive research approach. It is our opinion attempting to implement changes in practice. that the affinity of nurses for action research also lies in their history and philosophical Overall, the results of the review indicate that, persuasions. The history of nursing suggests with appropriate support, action researchers that it is a practical and hands-on ‘profession’;140 have a clear role to play in the Department of action research allows nurses to remain true to Health’s R&D programme. It is considered that this component of nursing while, at the same action research can contribute to innovation, time, allowing for investigation. The philosophical improvements in healthcare, developing know- underpinnings of nursing that emphasise holism ledge and understanding in practitioners, and and caring have parallels with those aspects of involvement of users and NHS staff. It is concluded action research that focus on the complexity of that action research is best conceived of being people’s situations and the desire to enhance complementary to other research methodologies.

56 Health Technology Assessment 2001; Vol. 5: No. 23

Chapter 9 Conclusions

he objectives of this review were to provide a in healthcare, developing knowledge and under- T definition and conceptual framework related standing in practitioners and other service to action research, to identify and analyse action providers, and involvement of users and NHS research carried out in UK healthcare settings, and staff have been identified as key areas in which to provide guidance on the assessment of action action research has a role to play in the NHS research protocols and project reports. Here, the R&D programme. Action research appears to results of the various stages of the review process have the potential to assist practitioners, managers are brought together and direction is provided and policy makers in their efforts to provide for the integration of the findings into the NHS high-quality healthcare. As such, it should be R&D agenda. considered as being complementary to other research approaches and should, therefore, be The review was guided by specific aims. These integrated into the NHS R&D programme. included the presentation of a definition of action research, identification and examination of action The results of the review show how action research carried out within healthcare in the UK, researchers attempt to be democratic and non- and the development of guidance for the assess- elitist by involving research participants. It has ment of action research. A mixed methods been noted that participation in research by those approach to achieve these aims was used. not normally involved is contrary to ‘positivistic’ notions – that researchers ought to be indepen- Action research is a complex process and an dent and distant from those they study, for fear attempt has been made in our definition to en- of contaminating the research findings. It is also compass this complexity. Specific philosophical at odds with the existing conventional research influences were outlined, and it has been confirmed relationships, which are in favour with those who that action research is interpreted and put into are the researchers rather than the researched. practice in a variety of ways. As a result, research- and practice-based outcomes varied extensively. It The review demonstrates that not only can action was found difficult to place an organising matrix research produce evidence (or knowledge) that upon the studies in order to show the scope of the is similar to that produced through traditional action research projects. For instance, they could be quantitative or qualitative research methodologies organised according to the degree of participation, (that is descriptive, theoretical or evaluative), but the type of research method employed, the change it also produces types of evidence and knowledge or intervention, the influence of reflective practices, that can inform healthcare practices, services or whether theoretical abstractions were produced. and organisations. To give examples and show the range and outcomes of each category would be an almost impossible The findings indicate that action research task. Readers have therefore been provided with can play a role in changing healthcare practice, data from each included study to allow them to because it crosses the ‘boundaries’ of research examine this variety and variability. and action (or development). The reviewed studies went beyond an analysis of the status quo Action research has been perceived as ‘unscientific’ to directly consider questions of ‘what might be’ by some researchers and funders and, therefore, as and ‘what can be’. The ongoing links between not being of value in the context of research and reflection and research were shown to contribute development. The discussion on the pivotal factors to the usefulness of action research as a research highlights the tensions that may arise in action process. As the included studies indicated, the research. However, the results of this review, and link does not simply come from evaluating those of a Canadian review that examined the role whether a change has occurred or if it is effective; of action research in health promotion,25 indicate the iterative process also allows for this evaluation that, with adequate support, action research has the to be fed back into the care setting and to be used potential to address many of the current challenges to inform current and future practice. In this within the modern NHS. Innovation, improvements approach to research and development, the 57 Conclusions

production of research is not viewed as separate action research process. When local people or from developments in practice. This is in contrast others are involved in the research, funding to linear progression from research findings to arrangements could include expenses for their the dissemination and use of findings traditionally participation, such as childcare and travel. symbolised in the evidence-based practice move- ment. Attempts are being made to identify the In relation to the funding process, there is a most effective means of ensuring the integration need for peer reviewers on funding-decision of research findings into practice. It appears bodies who are familiar with the action research sensible, therefore, to suggest that approaches process. This, in part, relates back to the accept- such as action research, which view this process ance and understanding of the action research from a different perspective to conventional process that has been mentioned above. In conceptualisations, should be facilitated. addition, it relates to development of a cadre of experienced action researchers. The end Major concerns identified in the review relate result, however, requires that funding bodies to the funding and resources required in action include in their membership peer reviewers with research projects. The first is which funding agency the necessary background and experience to is most appropriate, the second is the level of appropriately appraise action research proposals. funding, and the third is the decision-making The guidance questions provided as a part of and funding management. this report will assist in this process.

The included studies highlight that action research Funding management is also a critical issue. The is a method of inquiry that can generate knowledge process of action research means that the normal and understanding that, potentially, could have a structures in place for the monitoring of financial direct, positive effect on the NHS. It is argued, management of research projects are not suitable. therefore, that healthcare action research should The iterative process of the research means that be funded by the NHS R&D programme. However, research and action strategies may not be estab- the characteristics of action research, which include lished until much later in the process. Hence, these practice development, evaluation and education, projects will require interim financial reviews. Such also suggest that it would be appropriate to fund a system has been integrated in the Sustainable projects from other funding programmes as well, Health Action Research Programme (or SHARP) such as the ‘New Deal’ scheme. project in Wales.143 The evaluation of the effective- ness of this system should be used to inform In relation to the level of funding, the review research monitoring policies in other areas. found that the resourcing of action research projects was problematic. Limited resources (for There was a discrepancy between the components example, equipment, staff, time) were allocated of the definition established for this review and to the included projects. It is not possible to deter- what was being reported as action research. The mine if this was a function of a failure on the part primary discrepancy is that researchers have been of the action researchers to seek resources or a describing action research as research with health- denial of resources. Resources include not only care users and/or health professionals but with no equipment but, more crucially, action researchers’ intent to proceed through the action research and participants’ time. Included projects also process of problem identification, planning, indicated that there was consistent under- action, evaluation and so on. estimation of the time required to complete cycles of the action research process. Data extraction from studies in the review included the identification of aims of the As with other research approaches, the evidence research, reasons for choosing action research, indicates that action research projects require issues addressed by the research, and roles, out- sufficient funding, extended over an appropriate comes and impacts of action research. Action period in order to successfully complete the project. researchers were inconsistent in defining their Funding should include the replacement of staff aims and objectives. It is unclear if this was who participate in the research process, so that they caused by the changing of aims and objectives are not expected to continue their normal duties during the action research process, a lack of in addition to their research responsibilities. There research experience, or a lack of understanding are a number of ways in which this may be accom- of the need to clarify aims and objectives as each plished including, but not limited to, the funding phase of a project evolved. There are grounds, 58 of sabbaticals for staff who want to participate in the therefore, for arguing that, for a variety of reasons, Health Technology Assessment 2001; Vol. 5: No. 23

researchers either think they are doing action Implications for policy research when they probably are not (as per the definition provided in this review), or are under- The implications of this review indicate that: taking action research without sufficient pre- paration. This suggests that there is need for • action research be considered as complementary further education of healthcare professionals to other research approaches within the NHS and researchers about action research. This • action research has a potential role within the educational activity could take place within NHS R&D programme current research methodology programmes •a mechanism for evaluation of the quality of and/or be conducted independently. action research is required.

The diversity of activities involved in action research (varied research methods, group process manage- Implications for practice ment, project management) has implications for the range of skills required by action researchers. A movement to the acceptance of the value It is unlikely that a single action researcher will of action research within the NHS could be possess all the skills necessary to facilitate the par- assisted through: ticipatory process, negotiate conflict, design and conduct qualitative and/or quantitative research, •the inclusion of action researchers on and assess the safety and appropriateness of inter- appropriate R&D bodies ventions. A team with appropriate expertise, part- •the provision of appropriate information on icularly change management skills, may therefore action research to those involved in policy devel- be needed to provide input during various aspects opment and funding decisions within the NHS of the action research process. •the dissemination of results of action research projects A significant number of action research projects •the adjustment of funding and reporting mech- were undertaken by researchers completing anisms to allow for the action research process higher degrees. Given the complexity of con- •the development of collaborative educational/ ducting action research, there is a clear need healthcare institution action research to provide appropriate supervision for these education programmes new action researchers. •the field-testing of the guidance for assessing action research. The findings also indicate that, in the studies included in this review, users of health services To shift current views of action research and were not as intimately involved with action allow for its acceptance and integration into research projects as might be expected. The current health research programmes requires a review identified several potential reasons for strategy that leads to an understanding of partici- this, including, lack of resources and ‘know-how,’ patory approaches to research; a recognition and the assumption that nurses were the dis- of the value of practical as well as propositional advantaged group in the action research process. knowledge as research outcomes; and the inclusion For the development of relevant and appropriate of other approaches to research and development. healthcare, the contribution of users is necessary. The beginning of this process could include the Further action research needs to explore the role representation of action researchers on relevant of users in action research within the NHS. national and regional committees, the provision of appropriate information to those involved in Given that some researchers, managers and policy development and funding decisions in R&D funders misunderstand the key components programmes, and the wider dissemination of of action research, one of the objectives of this the results of action research projects. review has been to provide a tool to assist in the systematic appraisal of action research protocols The NHS R&D programme could facilitate the and projects. The eight pivotal factors identified in establishment of collaborative partnerships the review were integrated with the definition to between educational and health institutions. These formulate guidance to assess the quality of action partnerships could provide educational programmes research projects and reports. This guidance, that increase the cadre of knowledgeable and ex- which is made up of 20 questions and accom- perienced action researchers. It would also set the panying explanatory notes, will now require stage for future collaborative research projects. The field-testing, and modification as appropriate. findings of this review also indicate that these pro- 59 Conclusions

grammes should include mechanisms to promote •improvements in healthcare, for example, the development of skills in the good management monitoring of the effectiveness of untested and facilitation of action research projects. policies or interventions • development of knowledge and understanding The provision of a method to evaluate action in practitioners and other service providers, for research proposals and projects is essential to the example, promotion of informed decision making future development of the action research process. •involvement of users and NHS staff, for The guidance provided as a part of this review is example, investigation and improvement of seen as a starting point for the development of this situations where there is poor uptake of process. This guidance requires field-testing in a preventative services. variety of settings that might include:

• action research educational programmes Dissemination of the results of •funding bodies that are in position to review this review action research proposals • local research ethics committees The results of this review should be widely •critical appraisal skills programmes disseminated. Targets should include those •short courses and graduate programmes that responsible for developing healthcare research focus on evidence-based healthcare methodologies, healthcare research funding •distance learning or open-learning packages. agencies, national and local research ethics com- mittees, and anyone interested in commissioning or conducting action research. Findings would be Implications for future of interest to people who work in the fields of: action research • medicine and professions allied to medicine Funding of action research would be appropriate • health education and health promotion (but not limited to) the following areas: •medical sociology •anthropology and health •innovation, for example, in the development • health psychology and evaluation of new services • health research.

60 Health Technology Assessment 2001; Vol. 5: No. 23

Acknowledgements

he authors would like to express their peer reviewers and Dr Margaret Edwards, who T gratitude to all the action researchers who provided valuable comments on drafts of the provided them with their research findings and final report. Our thanks are also due to the their opinions about the role of action research members of the advisory panel, who shared their in the healthcare setting in the UK. expertise in the protocol development and final recommendation writing stages of this report. We would like to thank Professor Shôn Lewis for However, the report represents the combined his interest and assistance in the development opinions of the reviewers, for which they take of this project. We would also like to thank the full responsibility.

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Appendix 1 Electronic search strategy and results

Phase 1 Phase 1 was designed to identify action research papers labelled as ‘action research’.

Search terms Comments

‘action near 1 research’ Free text search ‘action near 1 research in ti’ In title ‘action near 1 research in ab’ In abstract ‘action near 1 research in de’ In delimiter NB:‘action research’ does not exist as in MEDLINE or the National Research Register database as a subject heading

Health Used during Sociofile search to limit search to health (Country of study’s origin determined by inspection of author’s affiliation address)

Phase 2

Phase 2 was designed to identify action research papers not labelled as ‘action research’ but by another term.

Search terms #1 CLINICAL DECISION MAKING #12 PARTICIPATORY near1 RURAL #2 CLINICAL near1 INQUIRY near1 APPRAISAL #3 COLLABORATIVE near1 INQUIRY #13 PROCESS near1 EVALUATION #4 DESCRIPTIVE near1 RESEARCH #14 PROCESS near1 CONSULTATION #5 GROUNDED near1 THEORY #15 RAPID near1 RURAL near1 APPRAISAL #6 EVALUATION near1 RESEARCH #16 TRANSFORMATIVE near1 RESEARCH #7 FEMINIST RESEARCH #17 USER near1 INVOLVEMENT #8 FORMATIVE near1 EVALUATION #18 COOPERATIVE near1 INQUIRY #9 ILLUMINATIVE near1 RESEARCH #19 PARTICIPATORY near1 APPRAISAL #10 MANAGEMENT near1 RESEARCH #20 PARTICIPATORY near1 EVALUATION #11 PARTICIPATORY near1 RESEARCH #21 CHANGE near1 MANAGEMENT

#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 #20 or #21

69 Appendix 1

Summary of identification, retrieval and inclusion of action research studies

Source Source of References References Papers Papers Papers Studies Studies Studies reference identified/ retrieved excluded remaining excluded for dataexcluded included requested (round 1) (round 2) extraction (round 3) for analysis

Electronic Electronic 259 172 61 111 63 48 14 34 databases and Phase 1 search strategy

Call Blind request ~200 researchers 9 1 8 3 5 0 5 to action contacted researchers (via RCN)

Hand Handsearching 109 13 1 12 6 4 0 4 search journals

NHS trust Mail-out to 444 NHS trusts 58 34 24 18 6 1 5 NHS trusts contacted: 104 responses; 40 positive, 64 negative

Research- Action 104 researchers 33 5 28 16 12 1 11 ers researchers contacted identified via conference proceedings

Total 285 102 183 106 75 16 59

To tal included: 59 (including action research studies) To tal excluded: 226 (excluded studies, 81; reference only papers, 65; methodology papers, 64) Total number of references retrieved: 285

70 Health Technology Assessment 2001; Vol. 5: No. 23

Appendix 2 Consultative process

Sample of communication sent to NHS trusts

27 May 1998

Dear

Re: NHS R&D HTA Programme project entitled ‘Action research: including standards for judging its appropriateness’

Action research has been identified as a priority for assessment by the NHS R&D HTA Programme. A systematic review is now being undertaken to assess the extent, nature and perceived impact of action research in UK healthcare contexts.

Unfortunately a high proportion of action research studies do not appear in the published literature. In order to identify these studies and increase the comprehensiveness of the systematic review funding agencies, key action researchers, all regional health authorities and NHS trusts are being contacted as part of the systematic review’s consultative process.

We would be most grateful if you could complete and return the enclosed form and, send all available requested information to the review by the end of July 1998.

The final report will include a directory listing action research studies undertaken in UK healthcare settings. Please state if you do not want any of the information provided by you to be included.

We look forward to hearing from you.

Yours sincerely

Dominique Tillen Systematic Review Coordinator School of Nursing, Health Visiting and Midwifery Coupland III Building, Oxford Road, University of Manchester Manchester M13 9PL Tel: 0161 275 7567; Fax 0161 275 7566; Email: [email protected]

71 Appendix 2

NHS R&D Health Technology Assessment Programme

Action research: including standards for judging its appropriateness

Systematic review: consultative process

Source of information: Funding body Key action researcher Regional Health Authority

Heathcare trust Other (specify)

Name and Address:

Please circle the appropriate response above. If available, please retrieve the information requested.

Information requested about action research studies undertaken/ Response funded by you or your organisation for the NHS (circle as appropriate)

1 A list of action research studies (if possible indicate source of funding). Information available Please include completed, uncompleted and current studies Information not available

2 Copies of reports, papers or protocols of action research studies. Information available Please include completed, uncompleted and current studies Information not available

3 Criteria used by you/your organisation for judging action research Information available proposals and/or evaluating action research reports Information not available

4 Names and addresses of any other centres, funding bodies or Information available researchers involved with action research that you are aware of Information not available

Please return this form and all available information to:

Dominique Tillen, Systematic Review Coordinator, School of Nursing, Health Visiting and Midwifery, Coupland III Building, Oxford Road, University of Manchester, Manchester M13 9PL Tel: 0161 275 7567; Fax: 0161 275 7566; Email: [email protected]

72 Health Technology Assessment 2001; Vol. 5: No. 23

Sample letter sent to researchers identified from conference proceedings

30 July 1998

Dear [first name]

Re: R&D HTA Programme. Action research: including standards for judging its appropriateness

Action research has been identified as a priority for assessment by the R&D HTA Programme. A critical review is now being undertaken to assess the extent, nature and perceived impact of action research in UK healthcare contexts.

In order to identify action research studies and to gather information about distinct criteria used for judging action research proposals and reports, funding agencies, key researchers and regional health authorities are being contacted as part of the systematic review’s process.

You have been identified as a key action researcher from your presentation entitled:

[Project title] ......

at the RCN Annual Action Research Conference in association with CARN, London, June 1997.

We would be very grateful if you would submit any reports or papers (together with details of the source of funding) produced from your action research project as presented at this conference to the systematic review.

The final report will include a directory listing action research projects and funding organisations. We are hoping to include your details. Please state if any of the information that you provide should not be included.

We look forward to hearing from you.

Yours sincerely

Dominique Tillen Systematic Review Coordinator, School of Nursing, Health Visiting and Midwifery Coupland III Building, Oxford Road, University of Manchester, Manchester M13 9PL Tel: 0161 275 7567; Fax 0161 275 7566; Email: [email protected]

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Appendix 3 Data extraction sheet

Refman No/s Action research data extraction sheet

Question Variable name Response

1. ID number (collective not RM id) (see file .txt)

Project profile

2. Author’s name

3. Project title

4. Source of title titsour 1 = actual title 2 = other title (e.g. publication title if actual title not provided)

5. Project type protype 1 = PhD 2 = MSc/MA 3 = Diploma/UG thesis 4 = not for academic qual. 5 = Pilot project 9 = no information

6. Project date prodate

7. Project status status 1 = completed 2 = ongoing 3 = stopped (not completed) 9 = no information

8. Project duration duration (months) 0 = no information

9. Project reviewed? reviewed 1 = reviewed 2 = grey literature 9 = no information

10. Distribution distrib 1 = all participants 2 = selected distribution 3 = general public 9 = no information

11. Project received funding? funding 1 = yes 2 = no 9 = no information

12. Name of funding organisation: namefund

13. Total amount of funding amfund

14. Steering committee established? steer 1 = yes 2 = no 9 = no information

15. Membership membship

Researcher details

16. Researcher details provided? research 1 = yes 2 = no 3 = inferred

17. Number of investigators resnumb 75 Appendix 3

18. Professional affiliation prof 1 = academic only 2 = nursing (principal investigator) 3 = medical 4 = other healthcare worker 5 = manager 6 = student 7 = social/community work 9 = no information

19. Academic qualification academic 1 = doctoral 2 = masters 3 = graduate/diploma 4 = none 9 = no information

20. Institution address address

21. Researcher employed employ 1 = inside place of research 2 = outside place of research 9 = no information

Participant details

22. Project participants described? particip 1 = yes 2 = no 3 = inferred

23. Participant 1 = active 3 = passive Type (see code) 2 = no participation

Nurses – hospital nhosp nhosp 1 Nurses – hospital/community nhospcom nhoscom 1 Nurse – community/hospital ncomhosp ncomhos 1 Medical – hospital medhosp medhosp 1 Medical – hospital/community medhoscom mhoscom 1 Managers manager manager 1 Paramedical paramed paramed 1 Ancillary workers ancill ancill 1 Student student student 1 Educators educato educato 1 Voluntary workers vol vol 1 Service users servuse servuse 1

24. Total number of direct partnum (0 = no information) participants

25. Total number of participant parttnum (0 = no information) types

Project location

26. Project location/s described? location 1 = yes 2 = no 3 = inferred

27. Project locations locate1 1 = community 2 = community/hospital 3 = hospital/community 4 = hospital 5 = trust 6 = other 9 = no information

Description of location locate2 –1 = entered into .txt file 9 = no information

28. Number of locations locnum (0 = no information)

76 29. Number of location types loctynum (0 = no information) Health Technology Assessment 2001; Vol. 5: No. 23

Reason for choosing action research

30. Reason for choosing action research reason –1 = entered into .txt file 9 = no information

31. Source of rationale guru Add code 8 = none 9 = no information

Aims and objectives

32. Explicit aims described? explicit –1 = entered into .txt file 9 = no information

33. Implicit aims described? implicit –1 = entered into .txt file 9 = no information

34. Objectives described? objectiv –1 = entered into .txt file 9 = no information

The issue

35. What is the ‘issue’? problem –1 = entered into .txt file 9 = no information

36. Type of ‘issue’? robfoc see/add code

37.

Typology question Category in typology Where did ‘problem’ emerge from? typemerg Who defined the ‘problem’? typdefin Who defined success? typsuces

Change intervention

38. Change intervention/s change –1 = entered into .txt file 9 = no information

39. Target group target 1 = nursing 2 = medical 3 = paramedical 4 = voluntary 5 = multidisciplinary 6 = service managers 7 = service users 8 = other 9 = no information

40. Healthcare speciality special 1 = palliative care 2 = disabled 3 = primary care 4 = ophthalmic 5 = A&E 6 = elderly 7 = medical/surgical 8 = intensive care 9 = maternity 10 = rehabilitation 11 = psychiatric 12 = education

41.

Typology question Category in typology Origin of the change intervention? typorg Change intervention for whom? typaim

Educational input

42. What educational input? educate –1 = entered into .txt file 9 = no information

43. Typology question Category in typology Kind of educative base typedb Aim of educational input typedin Focus of educative base typedfoc 77 Appendix 3

Projects process (cycles, context, politics)

44. Describe project’s process? process –1 = entered into .txt file 9 = no information

45. Number of cycles identified cycle 0 = no information (planning–action–evaluation)

46.

Typology question Category in typology Which cyclic components dominant? typdom What does cycle processes identify? typpro Dimensions of the cyclic process typdimen

Participation

47. Participation: phases in action degree –1 = entered into .txt file 9 = no information research process

48. Involvement of researchers, managers and active participants in each phase of the research cycle Enter 1 = researchers 2 = managers 3 = participants 4 = researchers, managers 5 = researchers, participants 6 = researchers, managers, participants 9 = no information

Issue identification/definition ingenes Analysis inanaly Reflection on issue/planning inreflec Knowledge production inknow Implementation inaction Validation invalid Data collection indatcol Dissemination indissem Evaluation inevalu

49. Project mode of participation mode 1 = co-option 2 = complicance 3 = consultation 4 = cooperation 5 = co-learning 6 = collective action

50.

Typology question Category in typology Groups participants involved in? typgrp Participants membership of group typmemb Researcher–participant relationship? typrelat The origin of ‘research expertise’ typexp Researcher–participant roles typrole Improvement and involvement typimin

Project methods

51. Sampling strategy/rationale provided sample –1 = entered into .txt file 9 = no information

52. Data collection methods described? collect 1 = yes 2 = no Enter 1 = yes; 2 = no Questionnaire Focus group Interview Workshop Reflective diary Group reflection

Observation Survey Enter other ......

Audit Audit describe auditdes –1 = entered into .txt file 9 = no information

53. Data analysis described? analysis –1 = entered into .txt file 9 = no information

54. Method of testing validity of findings valid –1 = entered into .txt file 9 = no information

55. Generalisabiliy gen –1 = entered into .txt file 9 = no information 78 Health Technology Assessment 2001; Vol. 5: No. 23

Projects outcomes

56. Outcomes described? outcome –1 = entered into .txt file 9 = no information (To aid coding later, enter [A] actual, [P] perceived, [UE] unexpected, in .txt file)

Project impact

57. Impacts described? impact –1 = entered into .txt file 9 = no information (To aid coding later, enter [A] actual, [P] perceived, [UE] unexpected, in .txt file)

Strengths and limitations of the project

58. Strengths/limits described? strenlim –1 = entered into .txt file 9 = no information (To aid coding later, enter [S] strength, [L] limitation, [F] factor, in .txt file)

Typology of the action research project

59. Placement in typology of action variety –1 = researcher 2 = inferred 9 = no information research by

60. Typology of project typeAR 1 = experimental 2 = organisational 3 = professionalising 4 = empowering

61.

Problem focus probtyp Change intervention changtyp Educational base edbasetyp Cyclic process cycletyp Individuals in groups grouptyp Research relationship/collaboration relatetyp Improvement and involvement impintyp

62. Appraisal of document (from Popay et al.127)

Enter: 1 2 3 4 5 Yes No

A clear statement of research aims? qaims An action research approach appropriate? qapproac Connection with existing body of knowledge made clear? qbody Articulation of criteria to read/judge? qjudge Study design responsive and flexible? qflex Sampling strategy appropriate to aims? qsample Research relationship adequately considered? qrelation Data collection methods address the issue? qcollect Data analysis sufficiently rigorous? qanalysi Clear statement of findings? qresults Links between data and commentary? qinterp Findings transferable? qgen Research relevant? qrelevan Score score

79 Appendix 3

63. Comments

64. Source of project identify 1 = electronic (phase 1) 2 = conference proceeding 3 = call 4 = NHS trust 5 = researcher 6 = handsearch 7 = phase 2

65. Source of data datsour 1 = report 2 = abstract 3 = thesis 4 = journal paper

66. Name of journal journame

67. Date entered datin

68. Entered by entered 1 = dom

80 Health Technology Assessment 2001; Vol. 5: No. 23

Appendix 4 Interview schedule and topic guide

Focus group discussion Introduction •Duration of discussion: 1–1.5 hours. • Purpose: to collect information for the systematic review on action research. •Topics for discussion – the role of action research – the strengths and weaknesses of action research – guidelines for writing action research proposals and reports.

Ground rules • The role of the focus group leader is to guide the discussion so that all the topics are covered in the time available. • What is said during the focus group meeting is confidential. • Participants’ identities will remain anonymous. •With participants’ permission, the focus group discussions will be taped. • Our interest is in participants’ perspectives of action research relevant to the topics. There are no right or wrong answers.

Topic guide

1. Role of action research 1. Concept of action research • generating change 2. Explicit role • implementing change 3. Implicit role • evaluation •generation of new knowledge • getting new knowledge into policy and practice

2. Strengths and weakness 1. Barriers action research • factors that inhibit change of action research can overcome • sustainability 2. Barriers that action research • knock on effects cannot overcome • deficiencies in resolution/focus 3. Power of effect • unconvincing/not vigorous

3. Guidelines for writing 1. Objectives • key factors contributing to the success/non and reports 2. Context success of proposals/publications 3. Methodologies • contents of reports – had/had no impact 4. Outcomes • making scientific value explicit 5. Analysis – evaluation – action

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Health Technology Assessment 2001; Vol. 5: No. 23

Appendix 5 Advisory panel

Dr Grindl Dockery, Independent Research Karen Spilsbury, City University, St Bartholomew’s Consultant and Liverpool School of Tropical School of Nursing and Midwifery, London, UK Medicine, UK Professor Christine Webb, Professor of Dr Janet Harris, University of Oxford, Health Studies, Institute of Health Studies, Continuing Professional Development Centre, UK University of Plymouth, UK

Professor Julienne Meyer, City University, Professor Richard Winter, Professor of Education, St Bartholomew’s School of Nursing School of Community Health and Social Studies, and Midwifery, London, UK Anglia Polytechnic University, UK

83

Health Technology Assessment 2001; Vol. 5: No. 23

Appendix 6 Data extraction tables

85 Appendix 6 private basis. Little ad hoc ‘Pop-in clinic’ for people with learning disabilities clinic’ for ‘Pop-in No information None stated ollow-up of problems ollow-up Analysis Change innovation Change Objectives opportunity clients, for private to have as advocates workers or their key consultations with the health visitor f Consultations took place with clients, workers; and key carers self-referred/ referrals social worker of communication; effectiveness Increased identification and effective more (30):34–7 11 1997; Nurs Standard Managers and staff specialist health visitor to be implemented health clinic run by Pop-in Clients assess the feasibility of a pop-in health clinic in an adult training centre for people for of a pop-in health clinic in an adult training centre assess the feasibility

op-in health clinic sited Health visitor Cooperation 3 months; clinics held over Weekly out in individual consultations carried ournal publication Community: health visiting sample Probability with learning disabilities Services provision: health visiting Allen E.A people with learning disabilities. health clinic for Lower use of health services of people with learning disabilities and inequalities in healthcare provision for such people for use of health services provision Lower of people with learning disabilities and inequalities in healthcare To 3 months ReflectionDiscussion Researcher Managers No participation ConsultationNone apparent out on an carried Liaison consultation at the health centre J to health concerns approach informal yet structured about a more Agreement P at adult training centre (researcher) health visitor with known No information No information participation No apparent of population under study = 30 people one-third clinic used by Pop-in 71 y details arget of change arget esearch cycle/s esearch Location Sampling methods T Ke Thematic concern Aims Allen, 1997 Length of study Process Phases of action r MethodsInformation gathering Planning Participants ParticipationImpacts Outcomes Dissemination Implementation 86 Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 n continued n evaluation. Primary nursing Change innovation Change Analysis Objectives (9):22–4 9 1989; Senior Nurse professionals, management :413–22 16 1991; high standard of patient care through peer-group innovation and support innovation peer-group through of patient care high standard primary nursing valuation: (see post- expert group, rehabilitation of any Minimal evidence Psychiatric hospital: wards two of wards Nurses assigned to duty rota 2. facilitate implementation of practice that would changes in nursing create To 3. support continued and encouragement to primary give nurses To Nursing approach Care for patients (observed for in the exploratoryCare study) custodial and outmoded, rehabilitation of any minimal evidence with only main aims; three given Nurse preceptor 1. and to develop within defined clinical area care in nursing improvements foster To J Adv Nurs Also:Armitage P. Primary in long-term psychiatric care. nursing B Ward and later changes to two 18-bed changes to two single-sex wards policy meetingsMonthly team, Core key Cooperation operational policy document produced wards Research A) (ward could share and women Armitage P,Champney SJ, K. Andrews in changing long-term mental health care: preceptor of the nurse Primary and the role nursing a Exploratory study Pre-implementation e implementation evaluation) by Staff preparation nurses, patients No information and group Peer preceptor: decision making; clinical super- vision; No information Cooperation quality circles NursesApplication of package No information No information Compliance and social attention type conversational interaction for nurse–resident Inverse least) need received with greatest to need (residents according of care primary identified towards nursing a move Need for larger living space which me to create wards research Amalgamation of two support was at high level Resident peer group enlisted as change agent preceptor and nurse Package of changes proposed Primary imple- nursing A (Ward nurses mented by Compliance housekeepers and ward coordinator of information Introduction ., et al 110 y details arget of change arget esearch cycle/s esearch Location Sampling methods T Ke Thematic concern Aims Armitage Armitage 1991 Length of study Process Phases of action r Methods Information gathering ParticipantsPlanning Participation Outcomes Implementation 87 Appendix 6 h n evaluation. No information : Little difference in work involvement, in work Little difference intrinsic job motivation, : Increased activity and engagement;Increased study from results one of key : Implementation of changes followed by more individual and more by Implementation of changes followed : atient satisfaction Observation Assessors Questionnaire Package of changes regarded as successful where nurse preceptor helped preceptor nurse as successful where Package of changes regarded skills developing through of care their standards existing staff to improve poor staff) (for ‘dumping ground’ consistent with primary and so avoid nursing before change to primarybefore nursing, affected. be adversely job satisfaction may atmosphere: process.Ward nursing attitude towards Favourable post- self-sufficient and independent; seen as more intervention residents climate to rehabilitation; conducive more appeared of care of both wards environment improved said to have P phenomenon (9):22–4 9 1989; Senior Nurse :413–22 16 1991; ursing process, nurses’ ournal publication J Adv Nurs Also:Armitage P. Primary in long-term psychiatric care. nursing Observation of patient Nurses, patients Consultation care and clinical meetingscare (155-item of care Standards and expert Peer checklist and retrospective records) of nursing analysis groups Cooperation (job Questionnaire Nurses primary nursing; in disturbed be due to observed drop suggested this may Cooperation behaviour; (via primary of nurses at nurse) representation increased of introduction autonomous following thought to be more was that residents multidisciplinary team meetings satisfaction, attitudes to n on their role,views atmosphere)ward Patient satisfaction No information No information intervention, B. ward no difference Findings suggest that unless satisfaction hig accountable care intrinsic job characteristics, perceived of and nature needs strength higher order and post-intervention. pre- work satisfaction: Job A before ward higher scores Armitage P,Champney SJ, K. Andrews in changing long-term mental health care: preceptor of the nurse Primary and the role nursing a to sustain change,In order project (12 months) after research contract continued preceptor nurse J ., et al contd 110 esearch cycle/s esearch Process Process Phases of action r MethodsEvaluation Participants Participation Outcomes contd Armitage Impacts Dissemination 88 1991 Health Technology Assessment 2001; Vol. 5: No. 23 tercare :451–5 60 1997; ommercial use;ommercial role splint liaison nurse’s Nurse training programme No information None specified Br J Occup Ther Br J Occup Resource file for splint aftercare for Resource file :435–48 5 1998; esource file suggested esource r

rd Change innovation Change Analysis Objectives Informal splints training programme established splints training programme Informal Wa Educ Action Res therapists esource fileesource ward for freed Resources r

service these patients for therapists) therapists) rd cus groups Nurses, occupational Co-learning developed nurses for programme Training cus groups Nurses action Collective identified involvement nursing Strategy increased for cus group clinical practice identified as a cause of differing occupational therapists raining programme Nurses Co-learning training programme splint-care undertake nurses Ward’s ormally established ormally ournal publication 2. quality of of splints to improve to aftercare approach a collaborative develop To Nurses Hospital ward No information Differences in clinical practice (nurses and occupational therapists) in the aftercare of splints in the aftercare and occupational therapists) in clinical practice (nurses Differences 1. & occupational ( nurses in splint aftercare difference for establish reason To Batteson R.A managing patients with splints. for communication therapist nurse/occupational strategy to improve Also: Batteson R. I can do it myself. I know a second opinion but now I asked Before f J Fo No information Questionnaire; observation;fo Nurses Consultation and nurses strategies between and communication Lack of communication No information attitude:Shift in nurse-manager is sponsored;‘splints training study day’ c for file developed resource formal splint aftercare No information No information No information; at time of writing ongoing project session of training programme Fo therapists of splints; of splints in aftercare of support worker highlighted role T Evaluation during final Nurses, occupational action Collective to af and confidence relating clinical knowledge Nurses’ increased Splint liaison nurseWa training Splint aftercare programme Nurses action Collective established (see Impacts) role Formal and occupational therapists) (nurses working collaborative Increased 73 y details arget of change arget esearch cycle/s esearch T Location Sampling methods Ke Thematic concern Aims Dissemination Planning Batteson, 1997 Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Evaluation Impacts Planning Implementation Evaluation Implementation 89 Appendix 6 esearch. r

investigate the process and outcomes from and outcomes from the process investigate

eflection on practice Descriptive analysis,Descriptive Field analysis Force Lewin’s To r Patient self-medication; analgesia patient-controlled (PCA); operation-specific patient medication erbal skills; confidence, increased motivation and sense of achievement Analysis Objectives innovation Change Nurses devised tool for patient self-medication and information leaflets patient self-medication and information tool for Nurses devised to change v Links to model of nursing varyLinks to model of nursing attainment of nurse with theoretical :129–38 24 1996; eedback to nursing staffeedback to nursing operation-specific patient medication Hospital ward No information Nurses Bellman LM. model:Tierney on the Roper, reflection practice through Changing nursing Logan and to action the enhancement approach J Adv Nurs model has advantages a nursing to support that adapting Lack of evidence the view None specified elitist and distant that research the view and reduced process of research Raised awareness published Paper Three innovations innovations Three implemented reflectionGroup Nurses,Interview multidisciplinary Nurses Co-learning/ action collective Consultation identified as barrier ‘Non-compliance’ of medical staff with innovations hindered) Patient expectations sometimes not met (innovation team cohesion nursing Greater base and patient teaching skills; knowledge Increased written and improved 15 months Patient interviews plan analysisNursing care Nurses self-rating scale presentationGroup (feedback) Patients andExploration of literature f Nurses reflectionGroup Consultation Consultation Co-learning identified – psychological needs of Most significant congruent perception innovations: Identification of three patient self-medication; PCA; surgical patient part selected to take Ward Action plans developed Innovations continue to be addressed following withdrawal of researcher withdrawal following to be addressed continue Innovations of nurses Empowerment 59 y details arget of change arget esearch cycle/s esearch Location Sampling methods T Ke Thematic concern Aims Dissemination Implementation Evaluation Bellman, 1996 Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes 90 Impacts Health Technology Assessment 2001; Vol. 5: No. 23 booklet :111–29 6 1998; No information Group meetings,Group strategies communication (mothers) None specified or mothers, mothers by F Educ Action Res project’s county based on research findings county based on research project’s Analysis Change innovation Change Objectives mothers • mothers in for and support pilot therapeutic funding for group for apply Service users – • of joint production develop an appropriate service to support women through research and service research to support through an appropriate women develop cus groups Service users – of other mothers with similar problems awareness Mothers’ increased

Community (one county) Community of mothers (i.e.Used an existing group opportunistic) to stimulate action to stimulate abused children Mothers of sexually Mothers continue with initiative Mothers continue proceedings,Conference workshops, service publications by paper users (mothers) and researcher Bond M, P. mothers: Walton Knowing to self-help and organisational change. practitioner research from someone trusted abused by Services sexually children for To 24 months DiscussionFo Discussion ofemerging analysis meetingsGroup Manager mothers Manager Co-learningNo information Co-learning of mothers Empowerment No information of existing services Identification of inappropriateness No information to: Managers agree self-esteem Mothers’ increased action to take Mothers’ desire Mothers empowered Mothers prepare/write booklet Radio/TV programme presentations Service users – mothers action Co-learning/collective 96 y details arget of change arget esearch cycle/s esearch Location Sampling methods T Dissemination Bond & Walton, Bond & 1998 Ke Thematic concern Aims Length of study Process Phases of action r Methods Information gathering Planning Participants ParticipationEvaluation Impacts Outcomes Implementation 91 Appendix 6 eduction Colleges of Surgeons and Anaesthetists) Colleges of Surgeons and

ain management None specified No information patients actively involved – patients’ wishes, involved patients actively pain : philosophy of PCA enhanced;philosophy and confidence in acute knowledge nurses’ : ecommendations made to improve protocol,ecommendations made to improve and for resources additional for Objectives innovation Change Analysis pain management improved and nurses empowered to take responsibility for for responsibility to take empowered and nurses pain management improved PCA; experience gained research (nurses) action group collaborative management enhanced on study wards PCA resource audit identified to monitor implementation of protocol; System of annual r communication system to inform those not directly linked to study linked those not directly system to inform communication Service users (patients) criteria; and amount of morphine became overriding intensity score r in psychological distress, enhanced pain control, patient recovery improved – nausea audit in progress major problem nausea remained Nurses cus groups Nurses Consultation groups: Initial focus to tradition PCA discontinuing for linked reason nurses’ rust perceived need to improve nursing management of postoperative pain. management of postoperative nursing need to improve rust perceived and joint report of Royal local knowledge by (Informed Burrows D.Burrows management of acute pain. study on the nursing An action research Buckinghamshire:Trust; 1996 NHS South Buckinghamshire T their decisions and actions; for responsibility to take of nurses Empowerment p patients in effective encouraged them to involve 1. PCA use when deciding to discontinue examine criteria nurses To 2. PCA length of time for examine optimum to be left in place To 3. of PCA discontinuation for and implement a protocol develop To 4. pain practice in assessment and management of post-operative enhance good To Nurses Hospital ward out to identify of change adoption carried and likelihood Cost–benefit analysis change initiative; for ward selected wards two Conferences, publications, action group, (nurses’collaborative local dissemination to other wards researcher) 12 months Fo Patient actively involved;Patient actively patients’ wishes, criteria and amounts of morphine became over-riding pain intensity scores QuestionnairesQuestionnaire, literature search, expert knowledge Co-researcher/ Patient data action group and Cost–benefit analysis of change adoption likelihood Cooperation implementedDraft protocol NursesPatient data Patients of PCA discontinuation for developed Draft protocol Cooperation Nurses to implement protocol Selection of wards Consultation Questionnaires: of variation occurring degree patients change data: Pre in decision making patient not involved 90 y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods Dissemination Burrows, 1996 Length of study Process Phases of action r Methods Information Participants Participation Outcomes Impacts 92 gathering Planning Implementation Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 Luton; 1998 ills effectively in clinical settings ills effectively teaching nursing skills to students teaching nursing lecturers teaching in nurse 1. method for effective implement a more To 2. skills influence a change of attitudes towards To students for Skills workshops analysis Qualitative Objectives Change innovation Change Analysis ursing students ursing staff quickly clinical competencies more Students develop n and lecturers only) (researcher student nurses n Burrows D,Burrows Baillie L. Bridging the theory practice gap; practice. nursing doers” for “knowledgeable developing Luton: of University cus group interviewscus group Nursing students interviews: group Focus from students wanted to practice skills away 44 ormal taught session incorporated into curriculum ormal evaluations Student nurses Consultation lunchtime workshops Suggest introducing ormal taught sessions participant observer, F Report No information QuestionnaireFo Individual interviewsNo information Practicing nurses, lecturing staff Key Consultation to pilot workshops Three techniquesnew Facilitator as No information F of Systematic analysis Cooperation participation No direct field notes participant observer, Questionnaire: initiative proposed attitudes towards meeting had negative Group some lecturers and Lunchtime workshops Identify possible changes; pilot workshops develop f Facilitator as at college clinical setting No information Lecturers Cooperation Cooperation Student nurses, student nurses Consultation Learning packages produced. and piloted with students Each pack peer-reviewed Students less anxious and enter clinical placements with some skills taught skills session to timetable Suggest incorporation of formal Attitude change of lecturers supported skills package introduced lunchtime workshops by of continuous Programme Students and practitioners concern with student’s clinical skill development.Students and practitioners concern with student’s Practitioners often too busy to teach practical sk None specified Nurse teachers; students nurse Educational institute cohorts programme common foundation three Random selection of students from y details arget of change arget esearch cycle esearch Dissemination Burrows & Baillie,Burrows 1998 Length of study Process Phases of action r Methods Information gathering Planning ParticipantsImplementation ParticipationEvaluation Planning Implementation Outcomes Evaluation Impacts Ke Thematic concern Aims T Location Sampling methods 93 Appendix 6 and plan elopment; claimed the literature ev None specified learning Group Thematic content analysis future learning future established portfolio group for raised about portfolios group by on problems meetings focused Remaining group Change innovation Change Objectives Analysis :395–405 21 1995; J Adv Nurs Cayne JV.Cayne Portfolios: influence? a developmental nurses findings to all ward’s obstacles to learning in their clinical area Nurses began addressing of the value experiential learning among nurses awareness Increased and researched both researchers for is personal process that research philosophy researcher’s Reinforced Publication 2 months Situational analysis No information participation No apparent past staff review identified as method to assist nursing Portfolios No information learningGroup Participant observer – field nurses Ward nurses Ward notes; sessions taped; group nurses Ward exploratory questionnaire;interviews; back draft feed participation No apparent Cooperation Compliance participants and nursing selected gained to conduct project Permission Completion of portfolios developing for – contract and framework First session conducted hierarchically reflectivity portfolios Some indications of potential for to develop reflectivity Some factors identified that help/hinder developing enhanced process insight into action research Researcher’s 2. process? What factors influence this developmental Nurses Staff did not plan their continuing education in systematic way, d Staff did not plan their continuing of education on their personal professional effects or record of individuals involved development personal professional impetus for provide of portfolios would preparation 1. in itself developmental? of portfolio preparation Is the process Hospital ward sampling Convenience 93 y details arget of change arget esearch cycle esearch Impacts Dissemination Cayne, 1995 Length of study Process Phases of action r Methods Information Participants Participation Outcomes gathering Planning Implementation Evaluation T 94 Ke Thematic concern questions Research Location Sampling methods Health Technology Assessment 2001; Vol. 5: No. 23 :30–6 2 1998; Clin Effect NursClin Effect Journal of Advanced Nursing Journal of ational level (from year 2). year (from ational level practice development work and work practice development

nments. earning environments arning in practice care developments arning in practice care eekly practice development seminar group practice development eekly No information W (questionnaire response rate = 45.7%) response (questionnaire (see reference above) (see reference Analysis developing practice.developing Results to be published in Change innovation Change Survey results Reasons given for developing practice: developing for Reasons given to internal environment; 54% response to external factor,9.1% response e.g. national guidelines; of 5.1% awareness practices;alternative of professional 13.8% changes in role practice:Facilitating development that explicitly in environments 63% occurred supported practice developments; had no links with 73% of practice development academic institution; 40.3% sought funding; charities and 61% of funding came from ‘other’, and national R&D funding regional trust and 7.8% from with 31.2% from protocol) from (inferred analysis multi-dimensional of a matrix for Development Publication CPDA – a framework to facilitate, – a framework CPDA of R&D development and reward recognise in clinical practice = 474) practice of those developing Profile n ( make explicit the networks and processes to enable healthcare organisations to facilitate professional and organisational le organisations to facilitate professional to enable healthcare and processes explicit the networks make

eekly practice eekly Researchers, Cooperation disseminating learning about – mechanism for Facilitated seminar programme pe-recorded sub-set of pe-recorded Researchers, Cooperation practice: of developing Process concerns identified – management of self key two Questionnaire: Practice and Service participants (at eight sites) identified through of CRD Initiative Development Interviewees: analysis multi-dimensional matrix for participants selected through seminars:Practice development selected through practitioner/researchers of Northumbria, to University proximity geographical Newcastle-upon-Tyne Eight sites in Northern and Yorkshire Health Authority Health Yorkshire Eight sites in Northern and models of practice a range of four Eight identified sites representing University has validated CPDA for 5 years. for has validated CPDA 1) and will be able to operate at intern University accomplished (year event One successful CPDA the research, by been informed partnerships have between projects research Number of free-standing to develop plus an initiative Clarke C.Clarke learning and on organisations as enviro on professional the pervasiveness of practice developments Developing organisations provider and healthcare university presentations,Conference journal publications (2) To 1. learning and organisations as l to their impacts on professional in relation developments of practice care process develop To 2.Authority Regional Health Yorkshire within Northern and practice developments map To 3. groups professional organisational points and across at multiple describe pervasiveness of practice developments To 4. and organisational learning to professional in relation project of practice development process develop To organisations academic staff and related Practitioners and university-based 24 months (inferred) Questionnaires Practitioners Consultation Semi-structured interviewsSemi-structured PractitionersW seminar group development practitioners(18 months) Consultation No information organisations through provider practice to healthcare of developing processes peer learning system of facilitators and collaborative Ta ten seminars practitioners and practitioner, as researcher of and management of uncertainty in process 55 y details arget of change arget esearch cycle/s esearch Location Sampling methods Impacts Dissemination Ke Thematic concern Aims T Clarke, 1998 Length of study Process Phases of action r Methods Information Participants Participation Outcomes Planning Implementation Evaluation gathering 95 Appendix 6 continued ure ursing plement a collaborative programme programme plement a collaborative Educational – open learning books project a research Practical – undertake No information ositive learning experience in developing projects proposals projects learning experience in developing ositive ositive outcomes within trust P Change innovation Change Analysis P collaboratively of value working recognition Increased or visited other trust (staff accessed conferences across in networking Increase development) as partcentres of project seen as positive at conferences Opportunity staff to attend and present for learning experience in trust awareness to increase of newsletter Development trust promoted to have considered GRIP project identified Difficulties to staff shortages,Linked morale due to climate of change transience and low designed for GRIP designed for explore means of ‘getting research into practice ‘ in one acute hospital trust in the West Midlands West ‘ in one acute hospital trust the into practice ‘getting research means of explore cus group interviewscus group educational approach, for Identified preference educational needs and clinical

wards’ in order to identify in order wards’ steering group proposals research support staff developing for Provide 1. in one NHS hospital trust utilisation in nursing Identify a baseline of factors influencing research 2. programmes awareness of research on provision education about research Respond to staff need for 3. development for focus practice that will provide of clinical nursing Identify priority areas 4. priorities identified and, practice from of clinical nursing areas two) on one (possibly Focus with clinical staff, plan and im Clifford C,Clifford S. Murray into practice. Getting research Birmingham: NHS Executive, Midlands); (West R&D Directorate 1998 To 5. Evaluate the impact of project 6. utilisation in n purpose of enhancing research with other practitioners for Utilise experiences gained to extend GRIP project a for priority areas development Open learning books/tutorial support nurses Project Co-learning teams start to implement projects project Five selected; projects Five associate with support to be undertaken of research Research utilisation surveyResearch Fo All nursesIndividual interviews gathering’‘Information See development ‘project Offer team Project and board Project Consultation consultation action/ Collective knowledge Identified educational deficits in research and piloted Open learning texts developed proced grants and instigate application development small project Offer development for problems Nurses Hospital for; applied project a research Nurses to undertake committee selected by Support from researcherSupport from ideas research to develop in confidence and motivation with group Increase 78 y details arget of change arget esearch cycle/s esearch Objectives Ke Thematic concern Aims Implementation Clifford & Murray,Clifford 1998 Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes T 96 Location Sampling methods Health Technology Assessment 2001; Vol. 5: No. 23 luencing t will be offered.There is insufficient

opments will be made on basis of strategy for project team strategy project for needed from within trust for teams to progress with projects; teams to progress within trust for needed from withdrawal develop ork on project to date presented at local and national conferences by GRIP project team and members of nursing staff from trus staff from team and members of nursing GRIP project by at local and national conferences to date presented ork on project view by project project by view development important in facilitating project esearch steering group (eight nursing staff) continues to coordinate R&D activity from nursing and midwifery nursing perspective; R&D activity from to coordinate staff) continues (eight nursing steering group esearch capacity for nursing and midwifery devel nursing for staff in trust to support at this time and decisions about future capacity further developments supported to date completion of projects left: teams have after project continues that project to ensure strategy developed specifically Withdrawal r Initial stage of project being replicated at another hospital being replicated Initial stage of project awards but no further support project indicated continuing GRIP project for of trust have Directors and Executive Non-Executive pre/post test questionnairepre/post update:Project board research project teams listed specific concerns and positive outcomes of GRIP (for re management board)Discussion board Project in one NHS hospital trust utilisation in nursing research Consultation awareness of research provision through education about research Need for with projects; each team to continue determine commitment by identify support in future similar projects any developing seen as crucial for programmes conflict with R&D agenda Organisational change in a trust may of management support was noted that perception in project Staff involved would: fellow and research Chief nurses team; of each project assess progress Clifford C,Clifford S. Murray into practice. Getting research Birmingham: NHS Executive, Midlands); (West R&D Directorate 1998 Education programme: nurses, Project Consultation‘baseline’ of factors inf demonstrated that it is possible to identify a Project open learning will continue,staff education through trust by supported existing education staff employed by W 78 contd esearch cycle/s esearch Impacts Process Process Phases of action r MethodsEvaluation Participants Participation Outcomes Dissemination contd & Murray,Clifford 1998 97 Appendix 6 essure g for under considerable pr attention is paid to organisational change and capacity, when especially None specified of counselling skills to managers Provision No information :268–71 77 1981; made on process, local and top management, between relationships ticipants at seminar identified 80 problem areas that needed further areas consideration ticipants at seminar identified 80 problem Locally there was recognition that, was recognition Locally there DGH), at this stage (transfer to a new there Objectives Change innovation Change Analysis Limitations of counselling skills or Not all managers have May be futile to impart counselling skills by training programmes alone be futile to impart training programmes counselling skills by May Staff of management processes in context of broader Need to be considered smaller,Prefer units, decentralised and intimate work more clearer which provide sense of purpose and identity in institution as a whole Managers of DGH opening,With approach of obtaining full commitment and involvement difficult more managers becomes progressively Recommendations policy, dissemination, participation of group and need to define limits of degree Hosp Health Services Rev team of staff in decisions managers and involvement from seven health seven from authorities all concerned for support problems rather than fresh was need to provide and staff provide shared knowledge in [DGH] commissioning field (inferred) knowledge shared provide

eedback (to commissioning Commissioning be very difficult to solve, that may raise practical problems Counselling may echnical process of planning and building district general hospitals (DGHs)) has detailed consideration but relatively little of planning and building district general hospitals (DGHs)) has detailed consideration but relatively echnical process or middle and first-line or middle and staff ournal publication, seminar (see above) Collin AJ,Collin Edmonstone JD, Sturt JR. Commissioning DGHs:The state of the art. T trauma involved in [DGH] commissioning field knowledge The lack of useful shared To Multidisciplinary DGH No information No information of counselling skills Provision DGH managers f managers at one DGH Consultation/compliance data’‘Collection of relevant No information DGH managers participation No apparent Consultation No information F team) team situation and closure in transfer especially No information Dialogue (inferred) Local commissioning Consultation of helping limit damage to staff: main ways Identified two skilled counsellin None identified J Seminar Management officers Co-learning Par 97 ., 1981 et al y details arget of change arget esearch cycle esearch Ke Thematic concern Aims T Location Sampling methods gathering Planning Implementation Evaluation Collin Length of study Process Phases of action r Methods Information Participants Participation Outcomes Impacts Dissemination 98 Information gathering Health Technology Assessment 2001; Vol. 5: No. 23 pen, busy, epartmental support ed Education, College of Royal l changes: Reflection Thematic content analysis None stated Change innovation Change Analysis understanding of needs mental health user Objectives Organised and developed teaching sessions Organised and developed (i) Conflict – in dominant culture: talking (mental health) and activity (A&E) (ii) Status – staff and organisation gave higher status to technology than mental (ii) Status – staff and organisation gave health knowledge (iii) Dependency/dominance – medical domination style – short(iv) Communication term, mental health problems for inappropriate (v) Relationships (with attendees) – brief, concerned superficial and predominantly with assessment mental health issues,A&E staff coping with more assistance, less call for increased with mental health needs, programme staff development a nursing through alues clarification exercise: opportunistic, i.e. to be on duty happened nurses alues clarification exercise ost-case discussion/ ost action research ost action research Charge nurse/mental action Collective values: – in environmental privacy, quiet and calm (mental health) o eaching sessions Nurses No information Little information; poor attendance at teaching sessions possibly eedback 2. pack on mental health issues an educational resource create To Nurses Researcher identified key people, identified key Researcher i.e. and liaison sister mental health nurse Study away-day: selected) co-researchers randomisation and selectivity (four Hospital (A&E department) V staff initiated and organised first national conference on mental health issues and A&E care; on mental health issues and staff initiated and organised first national conference [Personal communication] Not possible to determine if following directly attributable to action research study or organisationa attributable to action research directly Not possible to determine if following communication] [Personal Written report Crowley J.Crowley A clash of cultures; [MSc]. process an action research through the quality of care improving London:Advanc Institute of Nursing; 1996 1.A&E department to those attending an provided quality of care improve To A&E department, mental health practitioners to complete assessments in of two employment as teaching and d as well Meetings analysisGroup Study away-day selected nurses of groups Different Co-learning 1: analysis Group focused themes for identified nine mental healthcare (6 months into project) development 2: analysis Group working collaborative strategies identified for five 12 months MeetingsField notes P f V Nurses Co-learning and medical staff nurses Identified lack of mental health training for T analysisGroup P Selected nurses Co-learning analysis: Final group of educational innovation themes identified (no evaluation five study audit health unit manager noisy, (A&E) observation number maximum designed for greatest for 74 y details arget of change arget esearch cycle/s esearch T Location Sampling methods Impacts Dissemination Ke Thematic concern Aims Planning Crowley, 1996 Length of study Process Phases of action r Information Methodsgathering Participants Participation Outcomes Implementation Evaluation 99 Appendix 6 of

:57–61 3 ocesses not grasped as major opportunity change; for None specified None; study only first phase of action research No information 1994; J Clin Nurs urses had no sense of ownership, and lack poor understanding of initiatives High levels of job-related stress among senior nurses attributable to lack of power among senior nurses stress of job-related High levels change pr managerially-driven n of enthusiasm; fluctuation in staff arising structural factors with economic basis and day-to-day financial constraints and crisis management from ongoing;Project between will attempt to find common ground researchers agendas of managers and nurses differing ongoing Project traditional senior nurse role to new-style G-grade, to new-style role traditional senior nurse standard-setting, budget-holding manager ward ongoing Project Objectives innovation Change Analysis urse role to new-style ward manager ward to new-style urse role ournal publication including occupational indicatorstress measurementCase study, participant observation, interview staff andwith ward Researcher,documentary analysis staff ward Cooperation Identified factors inhibiting change (nurses): inhibiting change: problem inhibiting change; senior nurses management believed discussed in rarely change process staff of managerially-driven on ward effects constrained agendas and were wished to change but had different senior nurses management by detail with nurses; 2-day diagnostic workshop diagnostic workshop 2-day Senior nurses Consultation cause as to root managers and senior nurses between Conflicting perspectives East L, Robinson J. Change in process: action research. through bringing about change in health care of care standards external reports concerns surrounding unfavourable Health authority received No clear statement; traditional senior transition from to ease senior nurses’ n Multidisciplinary 24 months Interviews Senior management Consultation identified: of project objective Management’s transition from to ease senior nurses’ None identified J Hospital No information 100 y details arget of change arget esearch cycle esearch Planning Implementation East & Robinson, 1994 Ke Thematic concern Aims Length of study Process Phases of action r Information Methodsgathering Participants Participation Outcomes Evaluation Impacts Dissemination T 100 Location Sampling methods Health Technology Assessment 2001; Vol. 5: No. 23 kills egies xperience, for effectively to care :16–22 12 1996; valuate effectiveness of non-midwifery placements in valuate effectiveness e

Midwifery :161–72 To entry) (direct student midwives enabling pre-registration with medical, childbearing women to learn about caring for and needs surgical or mental health problems Non-midwifery placements No information 5 1997; Educ Action Res Change innovation Change Analysis Objective Enhanced student understanding of multi-disciplinary team’s contributions to healthcare Enhanced student understanding of multi-disciplinary team’s Multiple case-study design chosen (student = case) Management,academic supervisor person Academic supervisor to facilitate study as resource agreed staff consent to approach Senior managers of trust gave alue of medical/surgical/mental health placements established ransferability of skills ransferability and Midwives Cooperation ecord of case- ecord Concern that 3-year pre-registration programme for midwives could not equip students from diverse backgrounds, diverse could not equip students from midwives for programme pre-registration Concern that 3-year e with no nursing Student midwives Hospital/educational institution No information journals Publication in two Fraser DM. midwifery programmes: Pre-registration of the non-midwifery case study evaluation a placements. Also: Fraser D. the practitioner researcher. for Ethical dilemmas and practical problems student evaluated) development curriculum data for Provided to individual staff and student response reaction premature Helped to avoid V childbearing women with medical or obstetric problems childbearing women None specified Local survey Local survey (questionnaires)Documentary evidence (types of health problems,educational audit of obstetricians; academic supervisor practice placements, r doctors and Midwives, family study students) Students undertook non- Consultationmidwifery placements in Midwifery studentsmedicine, surgery and mental health CooperationT 5-week tested by placement in labour ward of surgery in areas and midwives learning for What constitutes appropriate interviewSemi-structured observationClassroom Students, Evidence collected as it emerged; midwives, strat used to consider whether alternative each for (Effectiveness midwifery students Consultation and teachers nurses medicine determined student maturity, Increased s of communication confidence and development individual students or course as a whole needed for context to maternity care transferable practical skills that were Students learnt new No information Meetings (inferred) Course team action Collective Course team decided that some placement in an acute hospital essential 94 y details raser, 1996 arget of change arget esearch cycle/s esearch Ke Thematic concern T Location Sampling methods Dissemination Impacts Aims Planning Implementation Evaluation F Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes 101 Appendix 6 cus group interviews:cus group thematic content analysis Implemented clinics; undertook roles/skills new Fo None specified Services delivery: [strengths, SWOT weaknesses, opportunities, analysis threats] Observation: task analysis Change innovation Change Analysis Objectives Adopted new boundaries (skills) of working,Adopted new e.g. health visitor undertakes all immunisations Delineated boundaries of specialist skills and roles Implementing and investigating change within the primary team: nursing healthcare Implementing and investigating an action et al. s group cus group interviews:cus group sample theoretical esearch study.esearch Bournemouth:Authority; Health Bournemouth University/Dorset 1997. Survey of user perceptions:Survey purposeful sample of user perspectives: Survey scale 5-point Likert 2. and responsibilities role Define new 3. as a team model of working new Propose/implement Practice nurses; health visitors Community: GP practice Fo Galvin K,Andrewes C, Jackson D, Cheesman S,T, R, Ferris Fudge r team approach,Lack of coordinated in isolation, tasks performed duplication of tasks. 1. teamwork effective Identify conditions for Survey team working to promote role nurses Identification of a new in other health centres Some implementation of approach/innovations Written report; published paper Patients Consultation leg ulcer clinic of new Patient approval Observation diariesReflective Nurses, GPs Cooperation service childcare and access throughout of care in continuity Improvement Clarification of boundaries specialist skills Implemented clinicsUndertook roles new Nurses Co-learning/cooperation Implemented leg ulcer clinic assessment tool (coronary events) pathway Implemented integrated care 12 months Survey diariesReflective Interviews Focu Nurses, GPs Patients Cooperation Consultation duplication, of role Identified areas needs communication Identified service needs Group meetingsGroup Attend educational sessions Nurses Co-learning/cooperation leg ulcer protocol Developed assessment tool (coronary events) pathway integrated care Developed 69 ., 1997 et al y details arget of change arget esearch cycle esearch T Location Sampling methods Ke Thematic concern Aims Impacts Dissemination Evaluation Implementation Galvin Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes 102 Planning Health Technology Assessment 2001; Vol. 5: No. 23 t on tutor; ervice staff identify criteria constituting a good practice placement identify criteria constituting a good education and serviceidentify how colleagues can work

To identify extent to which practice placements comply with criteria To together to enhance student clinical experience Thematic analysis auditing exercise bridging gap between service between bridging gap and education Change innovation Change Analysis auditing tool Some minor amendments made to new Remit of working group Remit of working :36–9 8 1994; Nurs Standard develop a single audit tool which met the auditing requirements of all a single audit tool which met the auditing requirements develop

orkshop for those orkshop for Service/ Compliance of old placements placements or re-auditing auditing of new New orking groups pilot audit tool; Developed group working by approved Ghazi F. Auditing student practice placements. and responses to and responses given,information and w W service staff) (educational and audit toolpiloting new Written instructions to present Researcher educational staff advise practitioners as audit tool piloted in 20 departments Tutor, for Designated tutor asked managers Educational staffcomments after audit had placetaken approval) (give Consultation of individual practitioners. development new Findings collated and became basis for audit tool tutorial and s by of understanding auditing process level Increasing of auditing as significant Raised profile those engaged in and useable by audit tool that was both effective Developed Data collection: comments – group Working Cooperation data: themes emerged from different Three of mentor; role of designated role Amalgamation of three schools of nursing required replacement of the existing audit systems replacement required schools of nursing Amalgamation of three To Service and educational staff Hospital Non-randomised sample of clinical environments 12 months No information No information No information methods and styles of auditing, of different ‘Illuminating evaluation’ and their effec college audit tool adopted throughout New (pilot study, those involved Final debriefing for party). working publication Journal courses offered by new college, new by courses offered 2000’ course in particular,‘Project the new to audit tool could be devised a new identify how To 87 y details arget of change arget esearch cycle/s esearch Ke Implementation Evaluation gathering Planning Ghazi, 1994 Thematic concern Aims T Location Sampling methods Length of study Process Phases of action r Methods Information Participants Participation Outcomes Impacts Dissemination 103 Appendix 6 None specified No information No information care began to improve’ – improvement recognised by wards reinforced process of change; process reinforced wards by recognised – improvement began to improve’ care Written standard focus attempted to improve patient care attempted to improve focus Written standard ‘ (perceived); staff morale increased staff realised benefit of change and that small-scale innovation can be put into practice benefit of change and that small-scale innovation staff realised Change innovation Change Analysis Objectives (31):29–32 6 1992; Nurs Standard Nurse manager Consultation role; auxiliaries present of nursing general dissatisfaction and devaluation and visitors ournal publication Non-participant observation Role model/guide (researcher) meetingsGroup Auxiliary nursesNo information CooperationNo information Nurses auxiliary nursing practice needed improvement No information No information No information Consultation No information programme Staff development at time of writing ongoing Project 2. support auxiliaries in their challenging role to nursing provide To 3. and that of others of their role auxiliaries perception nursing improve 4. To auxiliaries colleagues, nursing attitudes between improve patients To Nursing auxiliaries Hospital of all auxiliary on ward Random cross-section nurses Gibson K. services people. elderly for Developing No information 1. skills auxiliaries competence in basic patient care enhance nursing To 12 months interviewSemi-structured Nurses Consultation auxiliary: of nursing Baseline assessment of role of the change process accepted total ownership not yet Nurses still have J 84 y details arget of change arget esearch cycle/s esearch Planning Implementation Evaluation T Location Sampling methods Ke Thematic concern Aims 104 Gibson, 1992 Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Impacts Dissemination Health Technology Assessment 2001; Vol. 5: No. 23 continued :183–90 1 1997; J Cancer Nurs None specified Oral assessment guide (OAG), protocol, mouth-care algorithm No information Objectives innovation Change Analysis (ii) children with no oral problem received treatment unnecessarily treatment received with no oral problem (ii) children relationship compliance and parent–child affected care (iii) such inappropriate regimen suggested alternative conference from gathered (iv) information educationalist findings of oral assessment to communicate No common language among nurses pharmacists introduced to assess introduced No information No information of OAG: evaluation formal identified before Problems and score sheet circu- and score

orking party Expert practitioners, Co-learning oral assessment tool Identified absence of structured Gibson F, J, Horsford W. Oral care: Nelson of action research. within a framework ritualistic practice reconsidered Conflicting information (anecdotal evidence and tradition) about oral care; (anecdotal evidence Conflicting information to follow regimens which oral care unsure nurses None specified Multidisciplinary Hospital (1 paediatric oncology ward) No information Preparation of ward for for of ward Preparation oral of new introduction assessment tool: members of Key formal/‘team’: the nursing, teaching sessions,informal OAG Cooperation dentist ward medical staff and identified OAG No information W No information No information No information lated, teaching file on oral updated,care visual aids (poster display, etc) OAG oral status of all patients Systematic review of literatureUse experience and of expertknowledge panel First draft and focused party Working teamquestionnaire Multidisciplinary Nursing staff,Second draft circulated/ Co-learning made at presentations team meetings and forums Cost analysis Cooperation needs of children that reflected and an algorithm protocol of mouth-care Production medical consultants;, variation in outcomes did not reflect regimes (i) mouth care Distribution to team members Pharmacists and children parents booklet for Updating of existing mouth-care Cooperation of chemotherapy protocols receiving 48 1997 et al., y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods Planning gathering Gibson Length of study Process Phases of action r Methods Information Participants Participation Outcomes Implementation Implementation Planning 105 Appendix 6 stomatitis :183–90 1 1997; J Cancer Nurs only used for those children receiving regimens that could potentially result in in result that could potentially regimens receiving those children for used only Use of mouth-care protocol and algorithm resulted in individualised care resulted and algorithm protocol Use of mouth-care Algorithm has facilitated nursing and medical decisions resulting in appropriate intervention in appropriate and medical decisions resulting has facilitated nursing Algorithm ormation OAG increased confidence and competence of staff increased practice no longer ritualised, systemic antifungal agent receiving now children problems in nutritional dental caries and reduction in incidence of patient (children) risk reduction perceived compliance improved, to parents in conflicting advice given reduction ournal publication, local dissemination (presentations, meetings, etc.) Gibson F, J, Horsford W. Oral care: Nelson of action research. within a framework ritualistic practice reconsidered • J No information No information No inf Results of audit (OAG, and algorithm): protocol mouth-care • • • 48 1997 et al., contd esearch cycle/s esearch Dissemination Process Process Phases of action r MethodsEvaluation Participants Participation Outcomes contd Gibson 106 Impacts Health Technology Assessment 2001; Vol. 5: No. 23 continued lative to almost lative describe radical changes to acute medical care in a DGH describe radical changes to acute medical care admissions unit (MAU)

Patient proportions – chi-squared test – chi-squared Patient proportions H test – Kruskall–Wallis Staff questionnaires test comparison and chi-squared – direct Patient questionnaires Staff interviews – no information 2. consultants (1/6 weeks) for rota acute receiving New To 1. into 38-bed medical of six general medical wards Conversion and assess their impact on staff patients :176–84 e-routing of medical admissions through MAU or CCU; MAU of medical admissions through e-routing specialised units; more changed to four emaining 30-bed medical wards Coping with the inexorable rise in medical admissions: a radical reorganisation evaluating patient management Analysis Objectives innovation Change r r budget and charitable contributions) (hospital capital costs incurred £70,000 capital (ii) Changes to system of medical receiving: admissions 1/6 weeks consultant on call for (iii) Organisation of patient management: of consultants in involvement greater (iii) create 30-bed acute receiving ward 30-bed acute receiving (iii) create consultant input to acute receiving (iv) increase to admission alternatives (v) provide specialised wards more (vi) create ward rehabilitation (vii) create efficiency in bed use (viii) increase staff deficiencies identified by key (ix) address of care patient perception (x) improve . 55 et al 1997; Health Bull medical staff transfers and forced boarding (i) reduce y-day Consultant action Collective and refined: developed reorganisation for List of ten objectives a w options relating to reduction of admissions have been properly been properly of admissions have to reduction w options relating valuated or costed Hospital Random sample of 400 patients Fe Organisation and hospital staff e Hanlon P,Beck S, Robertson G, Henderson M, McQuillan R, S, Capewell in a Scottish district general hospital. of acute medical care Reorganisation of wards consultants for rota New No direct information Cooperation (implied) (i) Reorganisation of wards: of 38-bed MAU; creation 12 months Little information; one Hospital medical action Collective ‘Wider discussions’ re 10 years) over 3000 to 8000/year admissions (from increased Greatly No information No information of consultant care continuity (ii) improve source was Information and Statistics Division,NHS Scotland directorateAw 10 years; 5 to 6 over from base (consultants increased static resource of total number beds unchanged) of care Decision to embark on radical reorganisation 50 ., 1997 et al y details arget of change arget esearch cycle/s esearch Location Sampling methods Ke Thematic concern T Implementation Hanlon Length of study Process Phases of action r Methods Information Participants Participation Outcomes gathering Planning 107 Appendix 6 f patients < 0.05), p < 0.01); less concern < 0.05) p p < 0.01); ( stress increased p < 0.05) p < 0.05) p : < 0.01); beds ( blocked concern over more p greater continuity of care for patients, for of care continuity greater staff skills mix to patient appropriate more needs, enhanced support services (e.g. phlebotomy, ECG, radiology) rapid match;ward April 1995; outside medical beds since no boarding no significant changes in length of stay; 84% to 88%) to rise (from of admissions continues number :176–84 atient surveys: 57%) rate (response Coping with the inexorable rise in medical admissions: a radical reorganisation evaluating Results post-intervention (ii) changes to system of medical receiving: of consultant input and leadership, higher level (iii) organisation of patient management: first diagnosis–consultant/specialist improved 64–66%) rate (response Staff views Higher proportion felt ready for discharge ( for ready felt Higher proportion Nursing staff: ( health promotion time for increased particularly in MAU, was main disadvantage P . 55 et al 1997; Health Bull = 26), Non-consultant medical staff: tracking of patients ( improved = 96) ( boarding over n n = 400) Consultation n ursing staff ( medical staff ( n provide evidence supporting will decline evidence case against national policy dictating that acute bed numbers provide

ournal publication Pre- and post-intervention data:Pre- activity data, first diagnosis – consultant match, bed occupancy and length of stay (i) of wards: reorganisation o to care collaboration and team approach improved Hanlon P,Beck S, Robertson G, Henderson M, McQuillan R, S, Capewell in a Scottish district general hospital. of acute medical care groups,6 focus interviews Non-consultant Consultation J To 3 questionnaire surveys3 questionnaire All staff Consultation Consultants: lengthened waiting times (not substantiated) concern over increased 4 postal questionnaire 4 postal questionnaire Patients ( surveys teaching ( in time of staff for increase Perceived 50 ., 1997 et al contd esearch cycle/s esearch Process Process Phases of action r MethodsEvaluation Participants Participation Outcomes Dissemination 108 contd Hanlon Impacts Health Technology Assessment 2001; Vol. 5: No. 23 d ience/skills to implement (2):56–9 1 Importance analysis performance None specified Action learning sets 1998; RCM Midwives J Analysis Objectives innovation Change Recommendations made for supportingRecommendations made for midwifery managers in their role Opportunity ideas, to share practice and good common problems planning activity due to shared saved Time and resources change forward confidence and ability to take Increased trusts Dialogue between efficient use of resources More Clarified educational and support and managers needs of midwives cooperation exchange ideas support heads of midwifery services to implement changes relating

eedback Mixed No information Difference in rate of progression towards government indicator (‘Changing childbirth’); government towards in rate of progression Difference some midwifery managers lack power/exper ‘Changing childbirth’ initiative Midwifery managers To Henderson C.‘Changing childbirth’ and the West Midlands Region 1995–1996.Henderson C.‘ChangingWest childbirth’ London: and the College of Midwives; Royal 1997 Also: Henderson C. Confident, committed managers: to successful change. the key Group discussionGroup Questionnaire/importance analysisperformance F search Literature Heads of midwiferyAction learning sets Consultation/Questionnaire/importance analysisof performance Heads of midwifery Heads of midwifery Identified action learning sets as method of peer support cooperation Consultation Consultation/ support, action learning sets to provide Establishment of four an networking Better peer support on action learning and sets literature of current Review of funding Identified sources locally, Enhanced networks and nationally regionally 12 months Literature interviewsSemi-structured of midwifery Heads Consultation of maternity services profile in region Developed ‘Changing childbirth’ indicators of success made towards progress Determined current Recognised value of learning sets: Department additional 1 year of Health funding for Report, presentations, conference published paper 98 y details arget of change arget esearch cycle/s esearch Location Sampling methods Ke Thematic concern T Aims Planning Implementation Evaluation Henderson, 1997 Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Impacts Dissemination 109 Appendix 6 ; r learning needs Means, critical analysis None specified unable to decide whether their existing knowledge was appropriate to was appropriate unable to decide whether their existing knowledge

re course requirements had confidence in evaluations and felt able to negotiate future sessions future able to negotiate and felt had confidence in evaluations did not feel confident to negotiate change in their learning programme; confident to negotiate did not feel we Analysis Change innovation Change Objectives (3):17–20 11 1991; Senior Nurse improve learning environment for one group of nursing student of nursing one group for learning environment improve ssible empowerment of students ssible empowerment

riangulation of self- eachers’ comments ournal publication Literature searchLiterature T analysed T assessment, peer-assignment Nurse teachersand tutor assessment Afternoon session to Consultationfamiliarise students with intervention Individual student Nursing students implemented profiling developed System of individual student profiling CooperationInterviews Students undertook profiling Nursing students Consultation and weaknesses able to identify their strengths instrument useful and were Students found Howard D.Howard action research. through Student profiles No information Interviews Nursing students Consultation to identify their learning needs; Students did not find assessment appropriate Po J Educational institution No information To Nursing students Course placed emphasis on self-directed learning yet,Course placed emphasis on self-directed components, during theoretical thei unable to identify easily students were 86 y details arget of change arget esearch cycle/s esearch Planning Implementation Evaluation Howard, 1991 Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Impacts Dissemination Location Sampling methods Aims T 110 Ke Thematic concern Health Technology Assessment 2001; Vol. 5: No. 23 continued iptive data on working and results of and results data on working iptive :94–105 51 1993; Quantitative – descriptive statistics, – descriptive Quantitative test chi-squared (inferred) Qualitative Fund-holding Cooperation Health Bull wn health needs, psychological and social well-being Analysis Change innovation Change Mode of participation Computing and managerial allowances and research allowance provided allowance and research Computing and managerial allowances in 11 key drug groups in 11 key Assessing health needs: of their instrument enquiring about patients’ perceptions developed o ‘enablement’ questions and ‘satisfaction’ and outcome instrument using mix of Developed ‘enablement’ score single to give method of amalgamating responses and hospital activity) data (prescribing routine Identified limitations in use of available orking for patients orking for eer review participating doctors all preparations for Prescribing: formulae doses) conversion ‘DDD’ (defined daily developed otal practice population 84,000; of GPs 50 (stable number T study) throughout Practices volunteered budget experiment 1. volume, does holding a fund affect How 2. cost and quality of prescribing? of holding fund on utilisation hospital and other specialist services? effects What are 3. and outcome of consultations? of holding fund on nature effects What are 4. implications of fund-holding on organisation practices? What are 5. of cost and benefit fund-holding unit? of patients and professionals perceptions What are General practices (5 in Grampian;Six general practice fund-holding groups Tayside) 1 in Howie J,Howie DJ, Heaney M. Maxwell fund-holding project: Evaluation of the Scottish shadow first results. Also: J, Howie D, Heaney M. Maxwell General practice fund holding; – an evaluation: project shadow of Edinburgh; University 1995 become fund-holders; in which GPs would of healthcare of internal market Introduction descr was to assemble best available remit 36 months Government White paperW ResearchersDiscussionsP No information in to test mechanisms proposed Independent evaluation White Paper Minister, Cooperation definition of quality Developed 92 ., 1993 et al y details arget of change arget esearch cycle/s esearch Sampling methods Research questions Research T Location Ke Thematic concern Howie Howie Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes 111 Appendix 6 on continued :48–51) using basis 41 rather than on historical 1991; per capita per capita Br J Gen Pract ., based allocations will be difficult et al :94–105 51 per capita 1993; Health Bull eported higher sustained levels of satisfaction than those reporting no social problems eported higher sustained levels Clinical care of patients has remained generally stable generally of patients has remained Clinical care Patients with diabetes, to others when did better in relation bronchitis angina and chronic together considered enablement and consultation length data are longer consultations and received Patients who wished to discuss social problems r did not wish to discuss they problems or having less able had short consultations and were Some patients with psychological problems to cope/understand their illness (conclusions)Administration and patients” (page 31) and prescribing of fundsetting both for Further to evolution thought needs to be given hospital service components of funds Improved information technology systems increasingly available technology information systems increasingly Improved Prescribing (conclusions) budget prescribing and new cautious than non-fundholders in introducing be more Fundholders may quality issue) for this as evidence does not regard (researcher preparations expensive of prescribing) volume maintained (increased Quality of prescribing that budgets should be set on recommend Researchers basis. needed to identify of volume measures sensitive More Referral (conclusions of fundholding) to early stages referring Referral favourable Changes and waiting time outcome generally of setting of process Development (conclusions)Clinical care eal fund for 6 months eal fund for (consultation records) data Administrative (opportunistic questionnaire,interviews and attendance at meetings) quality of care for proxy consultation length as best available practitioners and between of specialist care the nature of negotiating “The process specialists has been novel, from and appropriately significantly of care has shifted ownership secondary to primary care, beneficial to general practitioners and has been conceptually and held paper fund for fund for and held paper by 6 months followed r data (DDD Prescribing formulae)conversion Consultation fund to 6-month shadow real ‘after’ 1-year by fund followed shadow 1-year ‘before’ from fundholding periods and real associated with holding fund and constraints of indicative of prescribing Reduced volume Howie J,Howie DJ, Heaney M. Maxwell fund-holding project: Evaluation of the Scottish shadow first results. Also: J, Howie D, Heaney M. Maxwell General practice fund holding; – an evaluation: project shadow of Edinburgh; University 1995 General practice negotiated GPs Cooperation of computing technology in reducti resulted in provision on time and delays Pressures Referral and hospital Referral activity data (information collected from Health Boards)Content of consultations data Clinical care Fundholding associated with significant change in pattern of use hospital services. access services, in direct trend upward in hospital activity matched by trend Downward e.g. and chiropody physiotherapy study (Howie Confirmed validity of previous 92 ., 1993 contd et al esearch cycle/s esearch Process Process Phases of action r MethodsImplementation Participants Participation Outcomes Evaluation 112 contd Howie Health Technology Assessment 2001; Vol. 5: No. 23 level level :94–105 51 1993; Health Bull doctor–patient relationships negotiating contracts on behalf of patients negotiating erception of costs and benefits (conclusions)erception of costs and benefits managers perceive higher costs and benefits.managers perceive both costs and Non-lead doctors perceived than other groups benefits as lower has been strength independent researchers by work funded evaluative Concept of centrally experiment;‘shadow’ of in future could be repeatable project to features relate of fundholding innovation features positive note that many Researchers of decision in primary(ownership care, planning, innovative management skills, improved be attributed to health service changes in general rather that may better information) than to fundholding of success Areas 1. to change and innovation Practices positive 2. of financial implications their decision-making aware More 3. hospitals and NHS management operate of how expanded knowledge Have 4. of process Fundholding practices able to challenge hospital sector through of difficulty Areas 1. Rate of change is not sustainable 2. determining funds is too simplistic for Process 3. lead to conflict within individual may financial awareness Increased P ceptions of costs and Practices, r incident’ diary cards and questionnaires) consultants study period of satisfaction maintained over of both costs and benefits higher in lead doctors than other doctors; Perceptions fund Howie J,Howie DJ, Heaney M. Maxwell fund-holding project: Evaluation of the Scottish shadow first results. Also: J, Howie D, Heaney M. Maxwell General practice fund holding; – an evaluation: project shadow of Edinburgh; University 1995 Pe benefits (use of ‘critical benefits (use of administrators, GPs and from very Patients generally satisfied with quality of services receive they Fundholding has helped to drive internal market in healthcare internal market Fundholding has helped to drive Report, journal publications (6) 92 ., 1993 contd contd et al esearch cycle/s esearch Process Process Phases of action r MethodsEvaluation Participants Participation Outcomes contd Howie Impacts Dissemination 113 Appendix 6 service users

with HIV/AIDS care in Lothian, with HIV/AIDS care to medically focused system focused to medically

easingly became parteasingly of social system r None specified discussion paper Reflection on informal of statements experience Analysis Objectives innovation Change Analysis needed; this issue needs to be addressed understanding in practice) require and funders of services may ‘need’ among provides of Changing perception structural changes in service system, practice and interaction daily which alter providers’ with clients bring about structural changes arguments do not necessarily Academic and research than service providers suggested than service providers Advisory group trying to understand service are this to help (in order they user experience and to apply :1149–60 44 1997; Soc Sci Med document and evaluate coordination of services coordination people document and evaluate for

eedback Service providers Co-learners need to scrutinise themselves, Providers and perspectives, motives their own in and way elevant serviceelevant providers Lack of primary care involvement would result in gaps and discontinuities in services across hospital–community interface in services hospital–community and discontinuities in gaps across result would Lack of primary involvement care To HIV in the region by affected (GPs) Service providers Community services through (no further recruited information) Service users were Part-time welfare rights post has been funded and a social work post has been unfrozen. rights post has been funded and a social work Part-time welfare peripheral However, rights remain welfare Research had some effect on changing systems of communication, had some effect Research e.g. of meetings in one practice reorganisation Impact on researcher: methodology, using qualitative with participants closer relationships under study and inc formed researcher Huby G.Huby silence, Interpreting documenting experience: to the study of health service users’ experience approach an anthropological Scotland. under study; of study validity and relevance increased Report, journal publication 24 months Diaries (abandoned)Semi-structured/open interviews Service users (HIV)Participant observation Consultation conversations,Informal meetings Service providers Service users (HIV) (GPs) discussion paper Informal rights into services concern to of far greater Lack of integration welfare Co-learners Co-learners of serviceabout culture Service providers in particular provision among setting circulated (GPs) Co-learnersr changed. Study focus rights of concern was lack integration welfare Focus F Report Reflection: on findings within discussion paper GPs reflect (GPs) into services which their position in systems of surveillance conditions their understanding of persons 45 y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods Impacts Dissemination 114 Huby, 1997 Length of study Process Phases of action r Methods Information gathering Planning ParticipantsImplementation Participation Outcomes Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 and

licit, ability hers

:238–44 14 1994; Nurse Educ Today Nurse Educ None specified teachers) nurse by Student-generated data (and evaluation No information :223–7 14 1994; Objectives innovation Change Analysis Nurse Educ Today Nurse Educ valuate students’ experience of student-centred learning valuate students’ experience of student-centred e students (monthly) cus groups and cus groups Students Co-learning data evaluation Students generate own

ormal identification of learning objectives and creation of work book of work and creation ormal identification of learning objectives of student supportormalised structure identified ournal publication, methodology forthcoming journal publication about evaluation Jasper MA. learning. graduates – the students’ experience of student-centred for A shortened programme common foundation Also: G. Rolfe Listening to students: as action research. course evaluation None specified To students Nurse teachers/nurse Educational institution No information publication below)F F J identified to succeed on course to self-motivate sufficiently discussions then led by No information and studentsNo informationFo questionnaire discussion group Recorded Students dataStudents evaluation Students and Nurse teachersNo information teachers nurse No information Co-learning Co-learning (see forthcoming Co-learning Students deeper issues behind students’ choice of subject matter decided to explore Students and subject of their choice methods to explore Nurse teachers design own teachers nurse subject of their choice methods to explore Students design own No method of participation No information teachers and students; by differently learning is perceived Student-centred lack of exp caused students anxiety; objectives externally-set of student data doubts about their about students’ evaluation No information students have discussions (monthly)2. group Agenda for Nurse teachers Co-learning issues; different to explore groups small focus Students decided to form teac nurse at next meeting (no further information) re-evaluated 9 months 1. Large group Nurse teachers action Collective and content of course. Evaluated process Changes suggested incorporated into course 83 y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods Impacts Dissemination Planning Implementation Evaluation gathering Jasper, 1994 Length of study Process Phases of action r Methods Information Participants Participation Outcomes 115 Appendix 6 chers concluded from their chers concluded from r :2–9 4 1990; None specified meetings Basis ward No information Nurs Pract book – well used book – well Objectives Change innovation Change Analysis What bugs me this programme people;Identification of resource topics identified 18 research of care of standards Development No involvement No involvement – no information QUALPAC * book meetings Nurses Cooperation teaching programme: Developed basis of identified to form staff development ten topics for

rd ork presented ohns C, Kingston S. using action research. ward on a children’s of care Implementing a philosophy ournal publication Standards of careStandards MeetingsDiariesField notesSummary of Nurses Cooperation would that project (considered dependent on researchers became and remains Ward achieved not well Monitoring of standards change) (unmotivated for study imposed on nurses Action research and status, withdrew) Highlights issues of power ‘primary’ if researchers nurses collapse largely to up her role sister gives as nursing Wa w researchers. by of action research project.Reappraisal as to whether this was action research researchers Issues raised by Resea and not specific methodology is philosophy experience that action research J and implementation of primary on the ward nursing Development None specified 12 months assessment QUALPAC J Nurses Hospital ward assistance;Nursing sister requests no other information Staff teaching programmeChanging organisation to Nursesprimary nursing people/fileResource What bugs me Cooperation to become established. year struggled throughout programme of No evaluation Teaching feasible was considered this programme files had too little time to read they used as staff considered files poorly Resource to requests Inability of organisation to respond 111 andelt M,Ager J.York:Appleton Century scale (QUALPAC). Crofts; Quality of patient care New 1974 y details arget of change arget W esearch cycle/s esearch ohns & Kingston, Evaluation gathering Planning Impacts J 1990 Ke Thematic concern Aims Length of study Process Phases of action r Methods Information Participants Participation Outcomes Dissemination * T Location Sampling methods 116 Implementation Health Technology Assessment 2001; Vol. 5: No. 23 ice children’s emergency nurse practitioners emergency nurse children’s

study assessments experienced RSCNs made of patients

To None Qualitative/quantitative Change innovation Change Objectives Analysis Study stopped incomplete :13–21 5 1996; J Clin Nurs examine whether role of ENP could be applied to specialist service of ENP could be applied examine whether role

ones S.An action research investigation into the feasibility of experienced registered sick children’s nurses (RSCNs) becoming nurses sick children’s ones S.An of experienced registered into the feasibility investigation action research ournal publication of paediatric casualty department by extending role of experienced of paediatric casualty department extending role by RSCNs (via action research)Nurses period of casualty department over attending children’s 1 month Skills of experienced RSCN could be used more appropriately in paediatric casualty department appropriately Skills of experienced RSCN could be used more To hospital A&E department of children’s sampling Convenience J (ENPs). 1 month Baseline assessment: to see if exercise Paper RSCNs could see and patients to conclusion treat (senior house officers) Nurses and doctors to doctor without reference Cooperation nurses Field diary by kept and doctors RSCNs had necessary skills to become ENPs No impact: no change in practice. Skill mix in department did not lend itself to change in pract and timescale of 1 academic year Intention to implement RSCN ENPs J 51 y details arget of change arget esearch cycle/s esearch ones, 1996 T Ke Thematic concern Aims Location Sampling methods J Length of study Process Phases of action r Methods Information gathering ParticipantsImpacts Participation Outcomes Dissemination 117 Appendix 6 Research-based protocols Research-based No information None stated Change innovation Change Analysis Common interests and goals highlighted and goals Common interests client-centred planning process; in care user involvement risk assessment of suicide; in older people managing aggression Objectives explore use of research-based knowledge and practices by mental and practices by knowledge use of research-based explore cus groups Staff Consultation protocols: of research-based Development

earney J.Theearney of collaboration: realities an experiential paper. at CARN presented Conference; Paper London, 1998 our pilot sites (hospital and community): services, forensic community health practitioners and, in particular, mental health nurses Mental health practitioners F high-dependency ward, unit, specialist community-based elderly adult acute medical ward No information K 24 months No information interviewsSemi-structured StaffFo No information No information in progress Project Consultation meeting Monthly in each pilot site: protocols Decision to generate two one staff-centred, the other in progress Project on staff expectations and perceptions: Information ‘top down’ as project staff viewed Facilitators presentation Conference Cooperation encountering are difficulties they Discuss action plan and any Research utilisation Research To 123 y details earney, 1998 arget of change arget esearch cycle/s esearch T Location Sampling methods K Length of study Process Phases of action r Methods Information gathering Planning ParticipantsImplementation ParticipationEvaluation Outcomes Impacts Dissemination 118 Ke Thematic concern Aims Health Technology Assessment 2001; Vol. 5: No. 23 sed ability to give information, sed ability to give :247–54 17 (sexual health education) 1997; Development of health promotion strategy of health promotion Development Thematic analysis Debbie Nurse Educ Today Nurse Educ Change innovation Change Analysis secondary school pupils use of open and closed questions, as group working health promoters performed Nurses,performed teenage Cooperation Debbie M, to peer education. T. approach creative 2000 student nurses’ Project MacDonald rr erform pilot study erform Nurses, teenage Cooperation teenagers incorporated Suggestions made by or 48 pupils children ournal publication Evaluation form had self-confidence, at 6 months indicates nurses group (focus effect and empowering had educative Claims that initiative increa later) as part activities (2 years recognised of students’ curricular now Initiative children Teenage J Consultation No information organisational skills) health education within educational institution Changes in attitude towards Educational institution No information Student nurses observed gap in service provision concerning sexual health promotion for teenage secondary for school pupils concerning sexual health promotion observed in serviceStudent nurses gap provision 1. in health promotion drama could be effective use of interactive assess extent to which student nurses’ To 2. skills to communication in relation of health promotion students’ knowledge improve To 3. in schools health promotion drama to communicate 2000 course that uses interactive within Project initiative evaluate To 4. on student nurses of involvement effects evaluate To Nurses 6 months No information Nurses Cooperation teenage for concerning sexual health promotion Nurses observed in service gap provision Ke Committee basis Nurses, educator, Co-learning drama selected Interactive Nurses’ preparation for for Nurses’ preparation Nurses Co-learning play, Nurses developed initiative: workshops, and attended lectures performance theatre live P and drama)(workshops Drama children f questionnaire;Pre/post video; at group focus 6 months post Nursesperformance Co-learning benefits: personal and professional Nurses perceived sense of belonging, independence, openness, less inhibition, knowledge, skills, communication improved confidence, raised self-esteem, ability to educate people Observed skills: nurses’ listening, clarifying, reflecting, sharing ideas, thoughts and feelings, & MacDonald, 82 rr y details arget of change arget esearch cycle/s esearch Impacts Dissemination Location Sampling methods Ke 1997 Ke Thematic concern Objectives T Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Planning Implementation Evaluation 119 Appendix 6 ention to v ntrolled trial;ntrolled diabetes care raining programme None specified T No information elevance and feasibility elevance Objectives Change innovation Change Analysis training may feel less discomfort at learning ‘new tricks’ than study group ‘new less discomfort feel at learning training may participants during subsequent training sessions trusting patients’ thinking in participation with primary training programmes team ensures care Developing r tool in on clinical experience is powerful and reflection of progress Regular review skills and maintaining new developing methods during their initial to patient-centred Practitioners and patients introduced :75–86 29 1996; atient Educ Counselling P Practice nurses, GPs Cooperation enable practitioners to offer more relevant advice to patients and be more understanding of responses of patients to advice understanding of responses advice to patients and be more relevant more enable practitioners to offer develop a feasible/theoretically based training programme in patient- based training programme a feasible/theoretically develop st-training session Practice nurses, GPs Consultation well-defined, Developed feasible, inter and theoretically-based empirically-

urses over following year following urses over of telling patient everything; ‘giving up’ responsibility and ‘letting go’ tolerating anxiety of eedback Practice nurses, GPs Cooperation by of requests as result details of training programme to develop continued Trainer ournal publication centred consulting,centred diagnosis from in an RCT of diabetes care evaluation for Nurses, GPs To To 21 GP practices in trial Randomised sample Practitioners implementing approach in practice Practitioners implementing approach from diagnosis in British primaryfrom care. impact on patients in an RCT Plans to evaluate J Kinmonth A,A.Kinmonth in a randomised co Spiegal N,Woodcock evaluation consulting for in patient-centred a training programme Developing experienceResearchers’ review Literature No informationObservation of (taped) 12 consultations with GPs/nurses No information Practice nurses, GPsPilot training programme CooperationF Practice nurses, GPs Cooperation Modified training programme developed care of patient-centred Pilot training programme Po questionnaire follow-up 6-monthly practice sessions for n Practice nurses Cooperation participating by rated highly GPs and nurses programme Training were: care of patient-centred issues in programme Key time constraints; consulting skills; primary consulting by practitioners enable patient-centred care ., et al 103 y details arget of change arget esearch cycle/s esearch T Aims Ke Thematic concern Location Sampling methods Impacts Dissemination Kinmonth 1996 Length of study Process Phases of action r Methods Information gathering Planning Implementation ParticipantsEvaluation Implementation Participation Outcomes 120 Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 :347–58 17 1997; Nurse Educ Today Nurse Educ :309–15 16 1996; None specified Educational programme, clinical supervision, reflection Consultation Content analysis Nurse Educ Today Nurse Educ Recommendations made for clinical supervisionRecommendations made for Objectives Nurse’s initial anxieties about action research project overcome project initial anxieties about action research Nurse’s Change innovation Change Nurses increased self-motivation and enthusiasm;Nurses increased role in new performance improved relationships Building professional about clinical supervisionContribution to knowledge process Mode of particpation Analysis urse teachers Nurses select clinical supervisor and contract developed n charge nurses used successfully TNA tool explained.Tool and Aims of project pilot and evaluate an approach to clinical leadership (reflectivity and to clinical leadership (reflectivity an approach pilot and evaluate er S, Knight S, L, Joyce V. project: Practice-led education and development Nightingale styles in clinical supervision. developing

orkshop F-grade nurses; Compliance Course participants selected Ay Also: Knight S, S, Ayer L, Joyce V. team leader development. Defining a model for Nightingale F-grade nurses need to uptake new primary in clinical practice; new role need to uptake F-grade nurses to do so possible reluctance To Group workGroup study sessions 2-day Five Session evaluation F-grade nursesquestionnaire Observation feedback Informal F-grade nurses Compliance F-grade nursesNo information Consultation Consultation undertook F-grade nurses educational course Researchers, Content of educational course identified and developed adoption enough to bring about role Educational course not considered None apparent Clinical supervision selected 12 months No informationW No information No information needs assessment (TNA) tool developed Training of supervision in unit,Promotion culture supervision participants experiment with peer group Publication clinical supervision) F-grade nurses implemented development nurses cooperation Clinical supervision implemented development QuestionnairesIn-depth interviews Nurses, practice Compliance/ nurses development Nurses, practice Consultation role Clarification of F-grade nurses’ and exchange of ideas Networking Hospital No information 77 ., 1997 et al y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims Implementation Evaluation Planning Knight Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes Impacts Dissemination T Implementation Evaluation Location Sampling methods 121 Appendix 6 esis]. Bristol: of Bristol; University 1996 or recognised training (clinical supervision)or recognised cautious of adopting knowledge from other disciplines; from cautious of adopting knowledge meet those needs? 1. become clinical supervisors? do nurses How 2. their needs? What are 3. help to What interventions/activities/events/experiences 4. tell a need has been met? can we How 5. of development? in process play do I and group What role Reflection No information ursing and nurses should be more should be more ursing and nurses presence or absence of supportpresence can be the one factor that determine success or of clinical supervisor; of development failure building confidence very important; of to development study supports not answer arguments that training courses are clinical supervisors to those undertaking recommendation clinical supervision: following Author makes be part of facilitated group, (past experience, terrain get to know literature), listen to experi- ence of others, wanting to become clinical supervisor, for and reason examine motive system of support,ensure learning forum, provide facilitation of appropriate ensure learning process, on supervisor exist for information to draw of new sources ensure each group member each group Support: group, from a range of experiences support group for supervision their own Research questions Research Change innovation Change Analysis describe developmental and training needs of registered nurses to nurses and training needs of registered describe developmental

eflection begin supervision 9 months searchLiterature planNo formal sessions:Group Researcherr imagerymodels of clinical supervision No information diariesReflective No participation Nurses No informationReflection method Decide on questions and research Thematic analysis plan No formal Co-learning Nurses Researcher Nurses gained support, dialogue and made plans to constructive entered Co-learningNone made explicit in the written report Report Author claims that: and learn more individual characteristics, own models reflecting working values and needs, confidence to continue nurses clinical supervision seemed to give of and role appeared Performing of personal models clinical supervision: Development sense of own developed group n Lee B. becoming clinical supervisors nurses [MSc th needs of registered study of the training and development An action research Nurses appeared to be adopting as their own,Nurses appeared models and ideas of supervision other disciplines. from Lack of access to organised To become clinical supervisors Nurses Hospital ward staff at location to participate by in study interest An expressed Opportunities to practice clinical supervision nurses for during study 43 y details arget of change arget esearch cycle/s esearch Lee, 1996 Length of study Impacts Process Phases of action r Methods Information gathering Planning Implementation Participants ParticipationEvaluation Outcomes Dissemination Ke Thematic concern Aims T 122 Location Sampling methods Health Technology Assessment 2001; Vol. 5: No. 23 ultant nurse role. ultant nurse None specified Advanced practitioner ‘type’ role Advanced practitioner Thematic analysis hia: WB Saunders; 1989. p. 83–104 Objectives organisations, patients and families Preliminary analysis produced conceptual framework for advanced practitioner/consultant role: for conceptual framework Preliminary produced analysis leadership’ highlighted as central to skills of advanced ‘transformational practioner/consultant nurse; beliefs and values, – shared identified to enable role prerequisites three open non- unit and management,hierarchical organisational authority attributed to post advanced practice met: for Claims that outcomes of conceptual framework staff; and empowered developed practice; of nursing development culture transformational research require advanced practitioner/consultant may for Suggests preparation experience at Masters/PhD level outcomes, by those affected should involve Suggests accreditation i.e. practitioners, Change innovation Change achieve these:achieve practitioner selected advanced nurse-consultant new Analysis :179–90 6 1997; model of * o values-clarification Nurses Co-learning Staff development, education, research, and quality assurance practice development cus groups Nurses Co-learning ork diaries Researcher USA); to British context (original model from relevant framework ournal publication Through values clarification,Through advanced practice type post; ITU staff identified need for of such a post the evaluation facilitate does advanced practitioner consultant nurse How W advanced practice undertook Researcher advanced new practitioner ‘type’ role Nurses, researcherFo Co-learning development of nurses and nursing to provide quality service? to provide and nursing of nurses development Nursing practice Manley K.Manley advanced practice: for A conceptual framework operationalising an advanced practitioner/cons project an action research J Clin Nurs Literature – Hamric’s – Hamric’s Literature (1989) Nurses, researcher Co-learning role new (1989) model of advanced practice selected as basis for Hamric’s exercises practice development. for identified as priority areas assistance to Staff requested 36 months Tw None identified in paper J Hospital (ITU) one unit Nurses from 102 y details arget of change arget Hamric A.Hamric CNS evaluation. A model for In:A, Hamric J, Spross editors.The clinical nurse-specialist in theory and practice. Philadelp esearch cycle/s esearch Ke Thematic concern question Research Implementation Evaluation T Planning gathering Manley, 1997 Length of study Impacts Dissemination * Process Phases of action r Methods Information Participants Participation Outcomes Location Sampling methods 123 Appendix 6 continued n y within Morecambe Bay Health Bay y within Morecambe :77–82 5 1997; vidence of advance in theoretical knowledge and knowledge vidence of advance in theoretical pplication to practice; awareness of research promotion J Nurs Manage demonstrated? (e.g. in problem-solving improvement by skills; in both confidence and competence; increase e a findings in practice) and utilisation of research 1. knowledge in practitioner’s of increase evidence Is there 2. (question 1), is such evidence If there is this how Clinical supervision, reflection Qualitative Research questions Research Change innovation Change Analysis supervisors than controlling) facilitative more ; * orkable protocol for action and for orkable protocol eflective diaries to aid supervisioneflective In January 1995, Region outlining R&D strateg policy at that time, in line with Government West to North was forwarded a proposal Trust Authority, in Furness Hospital predominantly region; was granted by study commenced in spring of 1995 after sum money for Preparation 1995 began in July actually research implementation of clinical concerned with effective primarily Research practitioners involved by supervision this is received and how participants at preparatory workshops) research identified by (Aims were Nurses Hospital and community Nurses volunteered of clinical supervision? process through and understanding of practice supervision issues Marrow CE,Marrow DM, MacCauley A. clinical supervision. Crumbie structured practice through reflective Promoting critical incident framework to note and analyse their super- to note and analyse visory skills Diaries of those supervised utilised No information No information devised; workshops 1-day Three Nursing volunteers Co-learning No information diaries to aid supervisio action and reflective for protocol Created No information No information main aims were to debate super-main aims were both a vision issues and create w r diaries:Reflective diary – based on Supervisor’s counselling interventionHeron’s model (Heron, 1990) those supervised Supervisor, Co-learning as supervisors; project part in research to take requested volunteers Workshop a with supervisor sample of ten supervisors to eight) established (later reduced clinical experiences (diary) them and analyses records Practitioner systematically practice (interviewing style became of practitioners’ skills at reflective Development 107 ., 1997 et al y details arget of change arget Heron J.Heron Helping the client: guide. practical a creative London: Sage; 1990 esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods Marrow Marrow Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes * 124 Implementation Health Technology Assessment 2001; Vol. 5: No. 23 :77–82 5 1997; J Nurs Manage ocused discussion groups ocused discussion groups date, supervision.To this clinical outcomes from their discussions indicate positive ournal publication, presentation conference Structured interviews Structured utilising repertory grid technique Supervisor,F supervisors for (monthly for and bi-monthly those supervised Co-learning some logical sessions was that discussions helped to create Common theme between to thoughts and feelings order been noted have developments in professional support mechanism and improvements Supervisor and supervised their experiences of clinical and analysed explored Marrow CE,Marrow DM, MacCauley A. clinical supervision. Crumbie structured practice through reflective Promoting those supervised) None apparent; study ongoing J 107 ., 1997 et al contd esearch cycle/s esearch Process Process Phases of action r MethodsEvaluation Participants Participation Outcomes contd Marrow Impacts Dissemination 125 Appendix 6 f true reflection on underlying value on underlying f true reflection t’s benefit although real benefit is for ourselves benefit is for benefit although real t’s None specified practice) meetings (reflective Written accounts of group Thematic analysis :411–23 1 Objectives innovation Change Analysis macho culture system itself to be argue that seclusion is clinical interventionResponse to this appears and necessary patients themselves for meaning,Surface debate on seclusion has second level code of’ which involves control as supporting of patients appear practices rationale for ‘dangerousness’ to References determined value system forming perpetuating practices is historically Mechanism for 1993; Educ Action Res create change in working practice by inviting initiators of seclusion inviting practice by change in working create

eedback perceptions, negative from of seclusion practice but also special hospital not only egime to reflect on their practice,egime to reflect consider and establish whether they eedback ournal publication Reasons given for use of seclusion for forensic psychiatric patient are propounded on therapeutic basis, on therapeutic propounded psychiatric patient are forensic use of seclusion for for Reasons given o rather than as result level. our actions on both personal and professional systems that drive patien It is often easier to state that an action for To r rather than arising from their decision making to be matter of routine consideration of practices Nurses Special hospital to initiate seclusion volunteer with power Requested nurses Mason T. Seclusion as a cultural practice in special hospital. Mason 36 months No informationNo information meetings:Group written account present No informationand transcripts of meetings; group No information No informationf NursesThematic analysis No informationF No information reflection. change in practice through Aim for Nurses Cooperation practice (nurses) Reflective study at time of writing;Ongoing no impact noted CooperationJ meeting each group written account/transcript following staff as emanating prepares nursing by Researcher to alter seclusion practice perceived External pressures 95 y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods Mason, 1993 Length of study Process Phases of action r Methods Information gathering Planning Implementation Participants Participation Outcomes Impacts Dissemination 126 Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 nership ation ation of problems and documentation of ation of problems :193–9 3 1995; New documentation New No information J Nurs Manage or local modification Objectives innovation Change Analysis during study Should be degree of commonality in documentation across site but allowing flexibility site but allowing of commonality in documentation across Should be degree f sisters’ focus groupssisters’ focus sisters Ward Cooperation ow ensure clinical colleagues did not automatically by Documentation developed

ds volunteered r rd develop skills in relation to care planning prior to introduction planning prior to introduction to care skills in relation develop

orkshops ournal publication Audit report suggested that care planning not carried out to acceptable standard. planning not carried Audit report suggested that care Particular of concern included identific areas and evaluation progress To Hospital Wa of computerisation Nurses McElroy A,V, McLeish K.McElroy Corben plan documentation: care Developing project. an action research Mid-term review forum,Ongoing teachers, nurse facilitated by and document planning process to care discussion of issues relating established for criteria, set up to agree group plan development Care and act as resource developments monitor future J planning document design and all aspects of care criteria for Need to agree Pre-document Pre-document questionnairesAuditWa Nurses Cooperation No information No participation plan documentation suggested no common understanding of care Initial questionnaire planning Shortcomings in documentation of care remained planning skills improved Some nominees stated that their assessment and care No information Literature interviews Unstructured QuestionnairesStudy dayPiloted documentation on six wardsW Nurses Nurses, Nurses Managers teachers nurse Consultation Cooperation Co-learning documentation criticism of current planning and much Little understanding of care action plans, write own pilot wards and other designing short-stay Two one ward documentation long-stay 99 ., 1995 et al y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims Location Sampling methods T Impacts Dissemination Evaluation McElroy McElroy Length of study Process Phases of action r Methods Information gathering Planning Implementation Participants Participation Outcomes 127 Appendix 6 continued nd discussion of findings. iew and methodology. iew test (independent samples) U Wilcoxon matching pairs rank test Wilcoxon None stated Human needs model Mann Whitney No significant difference between wards X and Y X and wards between No significant difference no significant difference between wards X and Y X and wards between no significant difference : : no significant difference between wards X and Y X and wards between no significant difference (33):43–6 : 89 Outcome Process Change innovation Change Analysis Objectives Baseline data wards X and Y X and Baseline data wards Structure 1993; Nurs Times between within :95–113 :79–94 32 32 1995; 1995; patient satisfaction ward monitor, ward : : patient monitor and : experimental ward X and control ward Y ward X and control experimental ward Y ward X and control experimental ward test two null hypotheses: null test two

urse satisfaction, drug scale, attitude towards models questionnaire, patient dependency scale, NOSIE 30, n prescribing Pilot study in adjacent ward planned change Lippitt’s theory: No information practices current examined; in-depth assess- No information No information No information care plan goals care Outcome Int J Nurs Studies No information To (i) changes in dependant variables scores to compare (ii) changes in dependant variables scores to compare Nurses Hospital: psychiatric wards two random selection X chosen by Hospital and ward McKenna HP,Parahoo KA,McKenna psychiatric patient care. long-stay model for of a nursing evaluation JP.The Boore Part a 2 – presentation Int J Nurs Studies Also: H.The McKenna models on quality of care. of nursing effects motivation to change ment for ward atmosphere scale, atmosphere ward Armitage assessment instrument Process Pre-intervention phase:Pre-intervention Structure Researcher Consultation McKenna HP,Parahoo KA,McKenna psychiatric patient care. long-stay model for of a nursing evaluation JP.The Boore Part rev 1 – literature No information managers Ward No information psychiatric patients long-stay model (human needs model) for Selection of nursing ., et al 46,47 y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods 1995 128 McKenna Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Health Technology Assessment 2001; Vol. 5: No. 23 t and ward oach to change adopted nd discussion of findings. iew and methodology. iew and Y in prescribing of psychotropic medication of psychotropic Y in prescribing and significantly improved structure in ward X compared with ward X compared in ward structure improved significantly Y : : significant improvement in care processes in ward X compared with ward X compared in ward processes in care significant improvement Y (33):43–6 : 89 rses considered transition would be easier if collaborative appr be easier if collaborative would transition considered rses no significant difference between wards X X wards between no significant difference approach: considers that use of action research Researcher among staff in research-mindedness led to increase Outcomes Process enriched personal and professional development of all those involved development enriched personal and professional Design 5-page assessment document and care-plan documentation for introduction of introduction documentation for Design 5-page assessment document and care-plan X Ward human needs plan in Structure Nu 1993; Nurs Times ward staff ward :95–113 :79–94 32 32 1995; 1995; patient satisfaction ward monitor,ward ward : : patient monitor and : X staff took up new nursing model (ward X no longer dependent on researcher’s presence) X no longer dependent on researcher’s model (ward nursing X staff took up new

rd escribing urse satisfaction, drug Ward with Y; ormal and informal teaching ormal and informal staff Ward Cooperation change need’ for ‘felt Initiate a ournal publications scale, models attitude towards questionnaire, patient dependency scale, NOSIE.30,n pr with ward X compared in ward significant improvement Y (patient satisfaction scale, X compared satisfaction and NOSIE.30 in ward (not significant) in nurse improvement models questionnaire, attitude towards patient dependency scale); care plan goals care Outcomes Interim post-test 1 and 2: indicators quality care Structure No information No information External facilitation: informal teaching sessions, meetings Researchers/Internal facilitation staff ward Cooperation sisters/ Ward scale,Armitageatmosphere assessment instrument (patien and control external facilitation to internal ownership from Move Process staff) and termination with external change agent Int J Nurs Studies F sessions (human needs model) McKenna HP,Parahoo KA,McKenna psychiatric patient care. long-stay model for of a nursing evaluation JP.The Boore Part a 2 – presentation Int J Nurs Studies Also: H.The McKenna models on quality of care. of nursing effects McKenna HP,Parahoo KA,McKenna psychiatric patient care. long-stay model for of a nursing evaluation JP.The Boore Part rev 1 – literature Wa J ., et al contd 46,47 esearch cycle/s esearch Evaluation Implementation Process Process Phases of action r MethodsPlanning Participants Participation Outcomes contd McKenna 1995 Impacts Dissemination 129 Appendix 6 :1066–72 18 None specified Multidisciplinary meetings Cooperation No information 1993; :57–66 7 1993; J Adv Nurs detected very little change Change innovation Change Mode of participation Objectives Analysis protocol for ‘lay participation in care’; ‘lay for protocol card; medicine reminder primary nursing learning environment in ward Improvement participation in care’ ‘lay attitudes towards professional positive More NB: learning environment, of ward Measures care and quality of nursing process nursing J Interprof Care J Interprof :24–37 2 1995; Nurse Res oster change in practice that would involve patients and their family/ involve oster change in practice that would f

oluntary participation friends in care in hospital with view to better preparation for discharge for to better preparation in hospital with view friends in care Nurses, paramedical staff, medical staff Hospital: one ward V Lay participation in care Lay To Meyer J.Meyer participation in care: Lay multidisciplinary a challenge for teamwork. JE.Meyer in practice: paradigm research New the trials and tribulations of action research. J.Meyer Stages in the process: a personal account. Multidisciplinary meetings participation’‘lay for Protocol cardMedicine reminder staff,Primary nursing medical staff Nurses, paramedical CooperationField notesInterviews Enhanced multidisciplinary communication about protocol No information Nurses, paramedical Consultation staff, medical staff participation not implemented: in care’ ‘Lay of staff to change; reluctance/inability staff but not implemented by developed card Medicine reminder inhibitors of change identified but primary individualised patient care not implemented nursing Increased 12 months review/Literature personal observationParticipant observation field notes learning of ward Measures environment, process nursing care and quality of nursing Interviews Not apparent participatingPatient and family scale care in nursing staff, medical staffDiscussion No apparent on ward participation occurring in care’ ‘lay of Little evidence involvement Nurses, paramedical Consultation it to their situation Staff had serious reservations about applying participation in care’ ‘lay Staff had little idea of concept participation in care’ ‘lay into with research Staff member gained funding to continue CooperationThesis, journal publications, presentations conference participation seen as an idealist concept Lay suggestions for: Staff make 54,112 21 y details arget of change arget esearch cycle/s esearch T Location Sampling methods Ke Thematic concern Aims 1995 Implementation Evaluation 130 Meyer, 1993; Length of study Process Phases of action r Methods Information gathering ParticipantsPlanning Participation Outcomes Impacts Dissemination Health Technology Assessment 2001; Vol. 5: No. 23 continued or 4 wards or 4 wards None stated technologyInformation No information Objectives innovation Change Analysis individuality and diminished nurses’ autonomy individuality and diminished nurses’ spend with patients, nurses, more and need for workload increased patient decreased (3):60–71 2 1995; of nurses Nurse Res R&D department plans means of access to care different urses (trained by hospital urses (trained by external consultants per month) describe, monitor, of information introduction and evaluate develop n

ursing process) raining for new system provided system provided new raining for nurses/ Wards Cooperation intervals 6 months (3 at monthly over planning system introduced Care Newton CA.Newton Action research: in practice. application To technology setting in its own Nurses Hospital (16 wards) and keenness availability Selected on basis of nurses’ No information Management No participation No information Nurses, educators, Consultation three and to create model of nursing Tierney decided to use Roper, Group Logan and Questionnaires (to determine Questionnaires and attitudes about innovation (16 wards) All nurses n 700 problems over plans written for Care T by information system team, information 24-hour technical who provided support after system (4 weeks R&D provided activated/wards)) support (indefinite professional period) repeated Questionnaires (3 months post-implementation)Interviews (3 months post-implementation) Nurses – 16 wards about (1 year) Questionnaires of technologyeffects on Consultation Nurses – 2 wards Nurses – 16 wardspractice, of perceptions system and support plansAudit of care and interviews: Questionnaire or patients themselves benefit for any perceived few to workload practice plans as criticism of current care new viewed nurses many productivity, increasing far from an intolerable burden it had added considered nurses plans: Audit of care system was inflexible, time-consuming, to time available reduced 89 y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods Newton, 1995 Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Planning Implementation Evaluation 131 Appendix 6 significant increases in number of assessments and care plans made of assessments and care in number significant increases : significant improvements in quality of assessment and care-planning significant improvements : Subsequent audits showed further significant improvements Subsequent audits showed about: Findings generated knowledge (poorly); process nursing and applied interpreted nurses the way placed on documentation (unnecessaryvalue they adjuncts to practice); planning; of model-based care infrequency plans associated with poor use of care the fact that staff shortages not necessarily are shift to those would that power propositions and Caputo’s Toffier’s Findings enhanced with technological skills, and Lewin by theories proposed and change innovation At 1 year Kjerniff (refer to paper for references) for to paper Kjerniff (refer Development of more functional pressure area risk-assessment tool area functional pressure of more Development At 3 months (3):60–71 2 1995; Nurse Res planning above planning system re-coded care Entire ournal publication developed audit tooldeveloped documentation maintained, although poor use of some aspects system persisted before, and 3 months post-implementation):1 year hospital quality assurance tool; and evaluation in quality of documenting assessment, and significant improvement planning care Newton CA.Newton Action research: in practice. application Assume as for planning aboveAssume as for Assume as for Consultation computer system R&D learnt to programme from nurses Three Revised computerised systemRevised (examined Nursing records Nurses No information Consultation Cooperation No information J 89 contd esearch cycle/s esearch Process Process Phases of action r MethodsPlanning Participants Participation Outcomes Implementation Evaluation 132 contd Newton, 1995 Impacts Dissemination Health Technology Assessment 2001; Vol. 5: No. 23 :615–24 24 1996; ourse evaluations) dents commencing nurse education? dents commencing nurse J Adv Nurs iety in those students commencing Student quality circles group Student quality circles action Consultation/collective No information biology timetable made available to students biology timetable made available

urse teachers with science degrees undertook this role in place undertookurse teachers with science degrees this role e-reading and teacher availability list and teacher availability e-reading ew r :n :n :p booklists where compiled by teachers compiled by booklists where : xtra voluntary sessions and timetabling of biology in morning :e eaching and learning Evaluation of changes anxiety that changes made could reduce Considered Researchers’ perception of the action research approach teachers and students during research, understanding between Greater during especially group quality circle in learning and teaching of biology, problems of underlying Mutual awareness Change innovation Change Mode of particpation with learning process organisation of course and anxieties that interfere Analysis consideration and modification meetings and committees for to relevant taken Time Resources Student preparation T of biology lecturers; some attended in-service techniques and became training in lecture in peer review involved Curriculum planning = 7) be anxiety in learning of biology always would Consensus that there = 66) preparation, planning and curriculum = 10) n n n ( ( ( identify major causes of anxiety and identify methods of reducing this anxiety in present students, this anxiety in present identify major causes of anxiety and methods reducing as minimising anx as well cus group cus group Nurse students Consultation

oluntary ournal publication Fo their nurse education their nurse 1. at our college? studying biology major causes of anxiety student nurses programme in common foundation What are 2. as minimising anxiety in stu students as well anxiety in present gained help identify methods of reducing can information How Nicoll L, Butler M.The study of biology undertaking as a cause of anxiety in student nurses programme. the common foundation and written c (verbally Biology programme on common foundation as a subject identified cause of anxiety among student nurses No information Delphi technique Nurse students Consultation Causes of student anxiety: time, resources, available teaching and learning, student Alterations to teaching of biology school in nursing J To Nursing education and midwiferyCollege of nursing in South of England V Modified quality circle Nurse students Consultation suggestions to biology teachers their problem-solving Students presented Biology subgroupsStudents’ concerns addressed Nurse teachers Nurse teachers action Collective action Changes Collective students’ recommendations. Nurse teachers considered constructed and Proposals 60 y details arget of change arget esearch cycle/s esearch Evaluation Research questions Research Nicoll & Butler, 1996 Ke Thematic concern Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Impacts Dissemination Aims T Location Sampling methods Planning Implementation 133 Appendix 6 ute of Advanced Education,ute of Royal ing of changes None stated No information Co-learning No information or communication address clinical problem and reflect on past and present practices on past and present and reflect clinical problem address Change innovation Change Mode of participation Analysis Objectives Exploration of issues, sharing strategies and experiences, ideas, generating new solutions, concerns arising addressing Audit tools developed being impartedinformation in systematic manner Author comments patient care, significance for direct Findings have to conduct other nurses releasing activities, savings, along with cost-effective and efficient tool effective more while offering f to opportunity responded to who readily co-researchers Study has implications for improve quality of hand-over and possibly to reduce amount of time taken to reduce and possibly quality of hand-over improve

Nurses Hospital No information O’Sullivan S. handover; effective more practice for Changing nursing study [MSc thesis abstract]. an action research London: Instit College of Nursing; 1996 No information To No information Observation of hand-over measures Quantitative discussionGroup NursesIndividual interviewsAudit tools Cooperation Nurses Structural changes to hand-over Co-learning Consultation at outset of study hand-over in time consumed by Main findings demonstrate reduction with during interventions compared No participation relevant with agreed quality of hand-over Evaluation interviews indicate improved No information exerciseModified quality circle Semi-structured, open- Nursesended interviewsObservation of hand-over measuresQuantitative discussionGroup Consultation was selected Topic Nurses Cooperation to quality, issues relating action cycles to address Developed education and time to purpose of hand-over, issues relating around Focused concerns about hand-over, and then themes; codified into categories Issues raised were basis of these formed hand-over, a good hand-over. what makes action plans.This improving suggestions for all concerned phase also assisted in value clarification for wish to pursue, they identified direction have audit dates and future Co-researchers extension of original review which involves 144 y details arget of change arget esearch cycle/s esearch T Location Sampling methods Ke Thematic concern Aims Dissemination Implementation Evaluation 134 O’Sullivan, 1996 Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes Impacts Health Technology Assessment 2001; Vol. 5: No. 23 continued al area is ineffective in present form in present is ineffective al area eaching programme T No information :816–25 18 nominal group technique in first session nominal group learning environment needed learning environment teaching sessions not taken;and opportunities ward-based for trained staff had poor and primary and little experience of teaching process nursing understanding of nursing practice;methods and research-based was low; self-esteem of nurses workload with teaching interferes 1. teaching role charge nurses’ develop To 2. existing learning environment; improve content decided by teaching programme To Objectives innovation Change Analysis 1993; J Adv Nurs * d-based sessions Charge nurse/ Cooperation r identify model for nurse teacher to develop multi-dimensional role in role multi-dimensional teacher to develop nurse identify model for

eaching programme Nursing staff Cooperation Fieldwork journalFieldwork Discussion of findings No informationT staff All nursing Wa Cooperation action plans: two Developed Weaknesses: shortage of trained staff, supervision occurs structured of students rarely Owen S.Owen teacher in the clinical area. the nurse for Identifying a role with students students Situational analysis Rating questionnaire (Fretwell, 1985) Nurses No information Consultation Strengths: staff motivated, ward in existing that improvements supportive and aware teaching identified of attitudes towards and weakness Strengths Nurse teachers struggling to identify role for themselves in clinical area and evidence suggests that role of teacher in clinic suggests that role and evidence in clinical area themselves for Nurse teachers struggling to identify role To traditional one to replace clinical area Nurses Hospital (one psychiatric ward) to participate to volunteer (during meetings with a ward Invited managers, sisters) ward 101 etwell JE. to change. Freedom London: of Nursing; College Royal 1985 y details arget of change arget Fr esearch cycle/s esearch Planning Implementation Owen, 1993 Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes * Ke Thematic concern Aims T Location Sampling methods 135 Appendix 6 :816–25 -based teaching sessions (ward manager):-based teaching sessions (ward not completed; evaluation manager ward 18 rd eaching programme: on learning environment in ward no significant improvement complete failure, small were changes which occurred T completion of teaching course Wa teaching too demanding on time.Time saying to charge nurse handed teaching over con- with charge nurse second implementation/evaluation for did not allow straints of project completion: 3 months after project’s and student teaching improved;staff teaching sessions continued some comments that going; initiative difficult to keep with some difficulty (lack of time and support) teaching role performing charge nurse on basis of evaluation; in clinical area teacher working nurse for Model proposed three teacher as researcher,elements of model are teacher and change catalyst 1993; J Adv Nurs * ournal publication Owen S.Owen teacher in the clinical area. the nurse for Identifying a role On presentation of final results,On presentation next teaching programme and coordinate to carry on process volunteered one staff nurse J Rating questionnaire Rating questionnaire (Fretwell, 1985) Nurses Consultation not suggests that action plans were Author claims that although outcome evaluation 101 contd esearch cycle/s esearch contd Owen, 1993 Impacts Dissemination 136 Process Phases of action r MethodsEvaluation Participants Participation Outcomes Health Technology Assessment 2001; Vol. 5: No. 23 s :714–21 23 (pre-operative information protocol) information (pre-operative Consultation No information Pre-operative protocol,Pre-operative folder research No information 1996; J Adv Nurs contacted 3 months later, had been rejected. innovation written No protocol vious practice: inconsistent, information-giving pre-operative with no identified rationale behind it ersonality variables: change than junior staff towards positive senior staff more rialability: try it if not useful staff would and reject innovation erceived characteristic of innovation specialist/practice development nurse would help to carry out innovation through support help to carry through would out innovation nurse specialist/practice development staff. and encouragement of ward was not prime aim of study. that innovation Authors considered Emphasis was more findings.Awareness‘utilisation’ than implementation of research research- of need for on significant than practice seemed more and of inconsistency in current based information implementation of tangible, written protocol. hospital or unit to survey managers within their own be useful for Authors suggest it may Mode of participation Analysis When ward When ward Change innovation Change P Relative advantage:Relative optimise practice would protocol Compatibility: seen as building on and assessing existing practice protocol Complexity: as complex not regarded innovation T Objectives Prior conditions Characteristics of ward Norms of social system: taught information-giving were that student nurses assumption at training school Socio-economic characteristics: information-giving, lack of time for reading, research P staff in order to identify a framework of problems or factors affecting use of research findings use of research or factors affecting of problems to identify a framework staff in order Charge nurses Cooperation olunteered (following discussions with managers) (following olunteered v

rd lder of research articles lder of research articles lder of research earcey P,Draper P.Usingearcey model to influence practice: the diffusion of innovation a case study. esearcher once per week esearcher ournal publication Wa Staff to write protocol None stopped uncompleted.Authors Project contact via clinical nurse suggest that increased Hospital (one acute ward) Informal discussions by discussions by Informal r Fo interviews Semi-structured Fo Nurses Consultation article of research sisters using folder ward to be written by protocol Pre-operative non-utilisation and facilitation of research findings in hospital ward non-utilisation and facilitation of research Nurses Discussion Charge nurses Consultation P findings in practice Facilitation of the utilisation research Purpose of exploratory study was to identify factors associated with No information No information Six nurses Consultation None identified J Semi-structured interviews,Semi-structured Student nurses Pre field notes, informal discussion (11 visits to hospital ward) needs: Felt could benefit patients protocol information-giving a preoperative Innovations: findings was new based on research protocol idea of developing 106 y details arget of change arget earcey & Draper, earcey esearch cycle/s esearch Sampling methods Evaluation Location Implementation Planning T P 1996 Ke Thematic concern Length of study Impacts Aims Process Phases of action r Methods Information gathering Participants Participation Outcomes Dissemination 137 Appendix 6 olk st and other childcare agencies st and other childcare in both assessment and provision of services in both assessment and provision Descriptive statistics and thematic analysis Descriptive Children’s Resource Centre (Laurel Centre) (Laurel Centre Resource Children’s esearcher found evidence of effective multidisciplinary working more difficult to quantify multidisciplinary more working of effective evidence found esearcher Analysis Change innovation Change Criteria for admission established Criteria for of activity:Analysis of age 65% users > 3 years of referrals:Sources 65% primary care/GPs problems:Presenting complex difficulties (24% speech and language difficulties) Multidisciplinary working: and multi-agency links and informal variety of formal (education,developed social services, voluntary services, but other health professionals) r Steering group action Collective and matched locality this town of study will see comparison between Final year Parents Parent commentsParent Steering group and parents) Consultation other rural areas for that was appropriate model of care Developed establish children’s resource centre within market town for children with special needs, children for town within market centre resource approach on multi-agency focusing establish children’s

To or children > 3-years-old or children Phillips N,V. interim report. Centre Laurel Myhill D,Thurtle Trust; Ipswich:Allington 1998 NHS communities with special needs in their own children for packages of care coordinated not delivering were they Staff considered 1. Community No information 2. standards, multi-agency develop referral, for procedures To management, care training, audit and records 3. that was seamless, model of care evaluate and their families in rural Suff to needs of children To and appropriate coordinated Service provision 24 months No informationReflectionConsensus basisMultidisciplinary training No information sessionsand development Inception of service No information targeted f team Core No information Steering group No information action Collective Cooperation action Collective 1 of report) (see appendix agreed of reference Terms of education, established (representatives Steering group social services, voluntary sector Reflection satisfaction Parental questionnaire Parents with service.The and wish to continue to centre in their approach tru to be valued by Staff positive also appears April 1996 Centre Laurel by and refurbished acquired Premises team established Core Report satisfaction questionnaire: Parental indications that service well-received Reflection on action: as to value of centre staff positive 70 ., 1998 et al y details arget of change arget esearch cycle/s esearch Ke Thematic concern Objectives Location Sampling methods T Phillips Length of study Process Phases of action r Methods Information gathering Planning ParticipantsImplementation Participation Outcomes Planning Impacts Dissemination 138 Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 in ons e hospital departments. assist department to prepares themselves for King’s Fund King’s for themselves assist department to prepares on quality that the audit achieved assess effect

To Intensive group sessions – quality circles group Intensive No information To ollow-up visit:ollow-up and other members of team staff groups between communications esearch strategies have much more effect on staff attitudes and behaviour that on staff attitudes and behaviour effect more much strategies have esearch ollow-up – manager reported significant improvement as result of project as result – manager reported significant improvement ollow-up Change innovation Change Analysis Objectives priorities; task ‘quality’ becomes just anther discrete under this pressure another hospital top-down approach top-down Operating theatres: finding out clients’ made in staff systematically little progress perspectives; to innovations medical staff a barrier F (including medical and central surgical sterilising department staff) in quality group involved department:X-ray ideas but unorganised; quality and had many to improve staff keen no implementation of ideas noted department:Medical records standards; some raising of staff consciousness towards f quality of service to patients to improve Authors made recommendations Authors concluded that bottom-up strategies, [Dynamic DYSSSY by represented and quality circles, standards] Setting System & Professional Standard and action r = 11) Cooperation n :5–29 7 1994; (other departments) otter C,A. in an acute hospital: Morgan P,Thompson quality improvement Continuous in thre project a report of an action research ollow-up visitsollow-up interest; noted effects some negative ournal paper orientation to rest of unit orientation to rest 2. act as models,‘clients’ To in quality among their raising interest 3. unit throughout a knock-on effect have To Multidisciplinary Audit Organisational Hospital (three departments:Hospital (three medical records, X-ray, operating theatres) departments consideration because of their serviceThree selected for P Assur Qual Int J Health Care 1. services quality of department’s improve To QuestionnaireObservation sessions group Intensive about quality Department Staff and patientsVisit to another hospitalNo information/ Department staff ( f staff groups Consultation Cooperation project, as another paper-based Audit viewed to be handled at senior level, Department generated ideas including: resulting patient questionnaire, developing No information consultati No information Visit to another hospital: organisational change and promoting success in forwarding in each department, setting and development to facilitate standard exchange visit to quality little organisational change to promote Interviews Senior staff Consultation various demands and unable to gain sense of by overburdened Middle-manager of other staff groups with involvement continue Quality groups J 80 ., 1994 et al y details otter arget of change arget esearch cycle/s esearch T Location Sampling methods Ke Thematic concern Aims Planning Implementation Evaluation P Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Impacts Dissemination 139 Appendix 6 ve. continued amongst injecting drug users.

children and drug users with no children No information Community drugs team (CDT),Community sessions (home outreach visits, syringe exchange, other agencies, from referrals work) peripatetic outreach NorthWest, 1982–86. Manchester: Drugs Research Unit; 1989 ) † 1990 r, we CDT needed to contact higher proportion of illicit drugs injectors CDT needed to contact higher proportion Analysis Change innovation Change Data also provided picture of emerging drug trends and patterns in area (see Jones & (see Jones and patterns in area of emerging drug trends picture Data also provided Po history: CDT failed and drugs users with children: – targeting women objectives CDT successful among substance misusers: of HIV infection spread aim – to reduce to do this, in order :13–16 2 1990; (including GPs) * Int J Drug Policy :123–35 3 ., 1989) 1991; et al target drugs users not normally seen by existing agencies in district health authority: seen by target drugs users not normally people, young women, those dependent

er R, of HIV the spread A, aimed at preventing initiatives community-based model for evaluation a process Dale S.Towards Jones previous agency contact previous To w eekly of aims and objectives: extent of achievement able to evaluate Researchers ostal surveys Local services Consultation with CDT work collaborative and demand for Established nature Community Community No information Services Po AIDS Care No information Primary aim: among substance misusers of HIV infection spread to reduce 1. service, community-based provide To established those already distinct from 2. P Semi-structured, face-to-face interviews (duration of study) Drug users No information individuals) (three sessions30 outreach worker CDT outreach No information Consultation Consultation CDT service and demands for Gained insight to views No information meetings: back to weekly and data fed Information CDT able to become responsi Database form Database form (Donmall No information No information on CDT clients and drug information Collected basic socio-demographic Short-term feedback:w Monitoring of caseload worker CDT outreach Consultation on local drug scene able to alert developments CDT to new Researchers treatment drugs users and those with minimal previous – targeting younger objectives 68 ., 1991 et al er y details arget of change arget Jones S, R. Power Observation to intervention. Donmall M,A, D.The services of community-based drug misusers: Webster introduction for J,Tantam Strang impact and outcome in the esearch cycle/s esearch Location Sampling methods T Ke Thematic concern Aims Objectives Planning Implementation Pow Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes * † 140 Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 amongst injecting drug users.

eported from research findings; research eported from to provide clear referral guidelines to avoid referrals with alcohol or prescribed drugs as with alcohol or prescribed referrals guidelines to avoid clear referral to provide main substances of abuse; duplication of existing services; in other agencies and to avoid peripatetic work to reassess practices in light of client and agency needs demands as to examine working r for face-to-face contact with all those services desire to make that expressed work; collaborative strategies in and imaginative appropriate and to develop work to prioritise outreach to contact target groups; order to continue monitoring and evaluation of wide range CDT activities monitoring and evaluation to continue :123–35 3 1991; er R, of HIV the spread A, aimed at preventing initiatives community-based model for evaluation a process Dale S.Towards Jones w ournal publication Po AIDS Care report/End of year feedbackhalf-day CDT CDT managers action Collective aims, Decisions regarding findings: research and strategies made from objectives illicit drugs users, to target only with particular emphasis on injectors; Riverside Evaluation Project continues to use basis of model in number of contexts in its current work of contexts in its current to use basis of model in number continues Evaluation Project Riverside J 68 contd ., 1991 contd et al er esearch cycle/s esearch Process Process Phases of action r MethodsEvaluation Participants Participation Outcomes contd Pow Impacts Dissemination 141 Appendix 6 actitioner :289–93 4 1995; J Clin Nurs ia. h project. nts and carers, rather than construct role Thematic analysis Advanced nurse practitioner role Advanced nurse orkload for some colleagues) orkload for Analysis Change innovation Change Authors make recommendations relating to dementia services relating recommendations Authors make service – development, collaboration and liaison – education, professionals healthcare staff development – outreach,patients and carers intervention, early open access, autonomous practice, expert/specialist service, health education, counselling practitioner came into post Advanced nurse included:Major changes to role abandoning base in GP practice and the open access centre;drop-in setting-up of memory group outcomes (increased negative outweighed practitioner role Benefits of advanced nurse w generalisable than findings,Authors consider method more observations and offer on be of use to other researchers methodology consider may and findings that they and practitioners = 42) role: evaluation established baseline for n orkers ( orkers w :119–27 34 1997; develop role of advanced nurse practitioner grounded in specific needs of particular service practitioner grounded of advanced nurse (dementia) and particular role patie develop generalising from previous research and existing theory research previous generalising from

ournal publications, presentations conference Community No information Confusion in literature as to role of advanced nurse practitioner of advanced nurse as to role Confusion in literature To by Nursing role Int J Nurs Studies Also: G, Rolfe practitioner in dement of an advanced nurse the role Phillips L.An and evaluate to develop project action research Rolfe G,Rolfe practitioner in dementia – an action researc Phillips L.The of an advanced nurse of the role and evaluation development 18 months semi-structured Five interviewsgroup practitioners, Healthcare of findings from Analysis Consultation Researchers support and voluntary practitioner of advanced nurse Anticipated role No information pr advanced nurse job description for Findings used to construct provisional practitioner of advance nurse and negative) expectations (positive Service providers’ practitioner role Setting-up advanced nurse J semi-structured interviewssemi-structured Reflection on actionIn-depth interviews Advanced nurse practitionerInterviewsQuestionnaires Co-learning practitioners Healthcare Patients and carers to needs of in response and modified role practitioner evaluated Advanced nurse aspects to role: Three Consultation practitioner role: Emergent advanced nurse aspects of role, of three with working service users most developed were patients and carers 72 y details arget of change arget esearch cycle/s esearch Location Sampling methods Ke Thematic concern Aims T 1997 Rolfe & Phillips, Rolfe Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes Impacts Dissemination 142 Implementation Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 ion research study. ion research ternational EuroQuon ternational EuroQuon Content analysis Phase 1: of concept generic to raise awareness worker healthcare esponsibility for project esponsibility for Analysis Objectives staff involved in implementation of role staff involved Researchers concluded that role of generic healthcare support worker was regarded was regarded support of generic healthcare worker concluded that role Researchers positively. support from had broad and project could work Staff optimistic that role trained and untrained staff of phase 2:Development to unit as framework establishment of practice development role; and refine develop increasing members of clinical team to take aim is for r = 20) Consultation of generic in establishing role to be encountered likely issues and problems Explored n = 14) implementation of role n = 9 Consultation emergent themes: to following issues described relating and negative Positive n :323–34 36 1999; explore develop and evaluate role of generic healthcare of generic healthcare role and evaluate develop explore

rained staff (group interviews) – purposeful sampling rained staff (group valuation: semi- two boundaries the challenge to professional ournal publication, presentation conference Healthcare supportHealthcare workers in progress – project supportRole of generic healthcare worker Hospital T support worker Conference on Quality and Nursing Practice:Conference 1997; Oslo, Norway: 1997; p. 209–16 Also: G, Rolfe Jackson N, L, Gardner Jasper M,A. Gale support of the generic healthcare worker: the role Developing Int J Nurs Studies phase 1 of an act to best meet needs of patients of support workers group multi-skilled staff and creating skill mix of professional Reviewing To Rolfe G,Rolfe support of the generic health care worker. Jackson N.An the role In:Third to develop project In Biannual action research No information No information11 educational No information Multidisciplinary ( No information No information in progressProject to phase 2; will continue Project Department phase 2 of Health gained for funding from additional J Cooperation programmes support healthcare worker, as attitudes and opinions of trained untrained as well Educational programme Educational programme e group structured interviews interviewsGroup staff ( Trained being a generic worker service outcomes for and patients Project in progress Project 91 y details arget of change arget esearch cycle/s esearch T innovation Change Location Sampling methods Ke Thematic concern Aims Rolfe & Jackson, Rolfe Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes Evaluation Impacts Dissemination Implementation 1997 143 Appendix 6 ge became focal point ge became focal ch. English National Board; no date. r of participants’ learning model of process assessments of topics and concepts Quantitative: statistics descriptive 1. hypothesis: the null between Test no significant difference 3. index assessment of happiness/satisfaction Quantitative 4. of participants’ of effect Analysis pledges on evaluation urse programme produced positive learning environment that was humanistic in nature; learning environment positive produced urse programme pledge process model capable of integrating theory model capable and practice pledge process Change innovation Change Analysis Objectives Author claims that: co planning of relevant model encouraged participation in programmed pledge process to learn; topics and motivated nurses and practice outcomes of topics and concepts, of their nature and explore learning experience and post-course learning outcome the medians of pre- valuation methods Convenience or accidental sample:Convenience study group Qualitative: of significant statements thematic analysis Nurse education Educational institution Randomisation: pilot study group Programme evaluation showed a theory practice gap relating to nurses learning on ENB short a theory to nurses course 941 relating showed practice gap evaluation Programme 1. model on participants learning the impact of process evaluate To Sajiwandani J. course 941: Evaluating the English National Board people: elderly nursing action resea an enhancement collaborative No information No information action plan Developed Students, facilitator and No information action Collective and pled model in which lifestyle of pledge process Development No information No information None identified Report to learning including ‘course enhancers’ Piloted pre-/post- course management teame modelPledge process Student cohortPre-/post-evaluation: 1 Studentshappiness/satisfactionquestionnaire, Studentsinterviews/discussions,critical incident reports, Cooperation responses pledges reports of learning and doing questionnaire: positive Co-learning Cooperation/ Happiness/satisfaction consultation Interviews/discussions: on course information eight themes providing developed of ‘classroom experience’ Pledges reports: to their practice students in relation pledges being made by Critical incident reports: understanding researchers’ increased claims to have researcher 2. of method evaluation assess effectiveness To 3. education nurse continuing and implications for discuss results To programme process when exposed to lifestyle 2. of participants’ nature experience qualitatively Explore 85 y details arget of change arget esearch cycle/s esearch T Location Sampling methods Ke Thematic concern Aims Sajiwandi [n.d.] Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes Impacts Dissemination Implementation 144 Evaluation Health Technology Assessment 2001; Vol. 5: No. 23 No information No identified None stated Analysis Change innovation Change Objectives :61–70 23 1986; Int J Nurs Studies ursing officer n eported Hospital (geriatric ward) No information Smith G. Resistance to change in geriatric care. Nurses No information of the patients” the quality of life improve “To 11 months No informationMeetings No change innovation No informationr No informationMeetings/feedbackObservation of documents Analysis No information Individual discussions Steering group Nurses, patients, discussionsGroup relatives No information Cooperation sisters Ward None identified sisters, Ward unit Cooperation to change identified in resistance Factors resulting to staff),Written report (presented journal publication Consultation Cooperation 105 y details arget of change arget esearch cycle/s esearch Location Sampling methods T Ke Thematic concern Aims Smith, 1986 Length of study Process Phases of action r Methods Information gathering Planning Implementation ParticipantsEvaluation ParticipationImpacts Outcomes Dissemination 145 Appendix 6 ars’ year :148–52 30 1996; Med Educ Thematic analysis None identified practice Reflective lios not found to be effective formal assessment mechanisms because threat of assessment mechanisms because threat formal to be effective lios not found fo rt pproach of summative examinations of summative pproach in development of educational model in development use. practice/portfolio use planned of reflective evaluation Formal a important in consistency of diary process Research use diaries may provide mechanism to map development and provide structure to teaching structure and provide development mechanism to map provide diaries may and learning; relationships; dialogue in difficult trainer/registrar increase by learning style and valued more everyone’s practice not suitable for portfolio/reflective GP trainers than registrars of portfolio effect learning to encourage its further of positive Sufficient evidence development Po assessment influenced type of material collected finding; was key perspective Importance of action research in clarification it resulted Analysis Objectives innovation Change = 20) complacency in training practice; potential to prevent have diaries may n egistrars ( r find out to what extent portfolio learning was useful and

rainers’ workshop rainers’ workshop to lukewarm” ournal publication, meetings at participant and academic group presentation workshops Subsequent model for education will be attempted in another geographical region education will be attempted in another geographical Subsequent model for Snadden D,Thomas ML,Snadden Griffin EM, Hudson H. training. learning and general practice vocational Portfolio-based training practice and GP vocational into reflective Further research J Reflective diaries kept diaries kept Reflective as part of portfolio GP trainers interviewsSemi-structured and registrars GP trainers and Co-learning Co-learning diaries but some fall off during course of GP registr use of reflective Increased Some emergent themes (reported in paper): or to work practice into everyday Authors suggest this due to integration of reflective 36 months No informationEducational discussion (1990)group workshop Interactive GP trainers and No information(1992)T (1993) Co-learning GP registrars No information 1990: learning model using critical incident technique developed 1992: component discussed, concept of portfolios containing reflective documentation and ideas in creative pairs encouraged to explore and GP trainer/registrar created practical way. discuss experiences: GP registrars Four “enthusiastic reports range from 1993: portfolio concept refined; in its to guide trainers/registrars booklet produced two Community No specific information Unmet training need for GP registrars in the area of interpersonal skills and self-management in the area GP registrars Unmet training need for To acceptable to trainers and GP registrars GP trainers and registrars 81 ., 1996 et al y details arget of change arget esearch cycle/s esearch Impacts Dissemination Implementation Evaluation Snadden Snadden Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes Location Sampling methods 146 Ke Thematic concern Aims T Health Technology Assessment 2001; Vol. 5: No. 23 easing :579–84 19 1994; No information Reflection None stated J Adv Nurs Analysis Change innovation Change Objectives disliked subject;disliked rushed) she felt growth:Professional of subject lessened dislike preparation improved with student nurses classroom in her own community initiated self-reflective Researcher Attempted to improve teaching/learning with student nurses Attempted to improve ournal publication No information as part of a course) Self-selection (action research Stark S. action research. through growth experience of personal and professional tutor’s A nurse tutor) (nurse Self-improvement Learning about action research process Learning about action research student participationIncreasing in class room and group questioningand group Class interaction and dialogue/self-reflectionNo information“3 to 4 action steps” (page 585) (no information) No information No information diaryReflective No information No information Researchers Co-learning student participation in classroom her behaviour: for identified reason Researcher interrelated lack of confidence and four knowledge; she lacked (she perceived circumstances class; for unprepared she felt she growth: Personal confidence improved 9 months of researcher Video tape Course participants Co-learning‘teacher talk’; too much Video showed on incr decided to focus researcher Change in attitude J 108 y details arget of change arget esearch cycle/s esearch Location Sampling methods T Ke Thematic concern Aims gathering Planning Implementation Evaluation Stark, 1994 Length of study Process Phases of action r Methods Information Participants Participation Outcomes Impacts Dissemination 147 Appendix 6 ar divisions between school and ar divisions between None stated Thematic analysis No information: project ongoing :259–65 2 1994; Objectives change not a priority, data in transient participant and circulating communication populations, environments initiating change in overburdened Analysis Change innovation Change Educ Action Res perceived fieldwork education fieldwork perceived education planning in fieldwork ersonal observation with supervisors Action planning to be undertaken orums; assessment forms) clinical situations to student needs and unpredictable Steward B.Steward practice in occupational therapy. fieldwork Researching placement, tutors and clinicians, theory and practice seemed unchanged 1. clinical supervisors, how discover To students and other tutors Role of tutor in fieldwork practice appeared to offer little to professional development of student, development little to professional to offer practice appeared Role of tutor in fieldwork supervisor or author; famili Ongoing project Ongoing No information/ongoing project project No information/ongoing and Interviews (before after field placement) Occupational therapy interviewsUnstructured journal (staff Research Supervisors studentsmeeting minutes; student Cooperationf P to Summary of research of themes: Analysis to participantsdate given None identified – little collaboration groups between dyadic and triadic relationships expectations (students, role Report summary to participants, supervisors, journal publication confusion tutors) – role project: for Author identified focus students, between working collaborative flexible responses increased confusions and develop role supervisors to avoid and tutors in order including: Insights to undertaking action research to insider/outsider issues relating position of researcher, exploitation of participants, when generating controversies Educational institution No information 2. action to initiate collaborative knowledge use this shared To students,Occupational therapy tutors and supervisors 104 y details arget of change arget esearch cycle/s esearch Aims Ke Thematic concern Planning Implementation Steward, 1994 Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Evaluation Impacts Dissemination Location Sampling methods 148 T Health Technology Assessment 2001; Vol. 5: No. 23 continued d of staff) RCN Institute; 1997 : rd ery care : Thematic analysis; category saturation Numerous : : : : : : : orked; team meetings; team covers; cross of care; continuity education; parent audit; eam leader eam meetings edesign form for community statistics to improve audit; statistics to improve community for edesign form Analysis Change innovation/s Change summarise action research group’s suggestions group’s summarise action research produce skeleton off-duty roster for team coordinators; for off-duty roster skeleton produce off-duty roster,study new omissions; report back any postnatal care) systems into unit (improve rotation implement new Hand-over to all midwives; hand-over guidelines for circulate and report back to next meeting monitor hand-over Continuity of care of care; definitions of continuity write out group’s women; identifying prior contact with pregnant for suggest procedure management of home birthswrite guidelines for management hoursClaim for worked/time implement of change in timing shifts; summarise problems, to off-duty periods comments and suggestions relating Audit of care; computerise auditing of continuity r plans which to audit all care set date from T supervisoryundertake to identify their training needs interviews with G-grade midwives of changes and build their confidence appreciation T meeting team coordinator’s observe from feedback management Project Meetings 1–7: action: suggestions for off-duty roster; time management; hours claim for w attitude; hand-over; bookings; team leader; team coordinator;expectations; punctuality; acting up; unrealistic orientation to community Off-duty roster ebby B.ebby Action research: of a midwifery model [BSc Hons thesis]. solving in the development to practical problem an approach Oxfo criteria = action research group (midwives; group criteria = action research researcher) Hospital/community to participate:Invitation selection fitting predetermined midwives Midwifery teams not functioning to their full potential 1. midwif to be impeding optimum deficiencies in organisation and management of midwifery teams that most likely identify key To 2. deficiencies those key to rectify changes that most likely implement and evaluate To 3. happy, promote fulfilled and united workforce To Midwives T Series of eight meetings group Action research Cooperation Series of eight meetings group Action research Cooperation Meeting 1: implementation of traditional shift patterns on unit (deplete 79 1997 y, bb y details arget of change arget esearch cycle/s esearch Location Sampling methods Ke Thematic concern Objectives T gathering Planning Te Length of study Process Phases of action r Methods Information Participants Participation Outcomes 149 Appendix 6 RCN Institute; 1997 : rd satisfaction at reducing stress levels; stress satisfaction at reducing : catharsis; development; professional knowledge new : summary not achieved; on discussion with team coordinators : definitions not written; home birth guidelines for not written idwives’ team meetings took place but “pointless because they could “pointless because they team meetings took place but idwives’ : duty roster well-received;duty roster improved; greatly late shift cover no team as :m : supervisory interview commented on : distributed guidelines for effective hand-over; effective distributed guidelines for but improved hand-over : ystems supervisor of care; to test computerised audit of continuity agreed :s maining suggestions for action at last meeting maining suggestions for eep original time schedules et rotated midwives on to unit for more that one or two shifts that one or two more on to unit for midwives et rotated eam leader eam meetings gained from each other;gained from on important focus aspects of care; better coping strategies; patterns; working improved better time management; of action research; knowledge in of adequate staffing levels was provision that most significant effect agreed midwives maternity unit, particularly on late shift; and emancipation of midwives; empowerment and motivation;enjoyment interviewees identified by no significant failures to the action researcher Claimed benefits development;professional and best practice; of problems knowledge on reflection service as whole; insight to specific training needs; smoothly; organisation runs more risk management; use of resources; effective of action research; knowledge practice midwives autonomously; midwives; extending benefits to more plan for supporting clear plan for re to midwives Claimed benefits initiative hard to maintain hard initiative Continuity of care Claim for hours worked/time management: hours worked/time Claim for to duty argued convincingly night and day k Audit redesigned statistics form community T T change” (page 28) any not achieve management Project each team individually Off-duty roster y Hand-over = 6) Consultation n ebby B.ebby Action research: of a midwifery model [BSc Hons thesis]. solving in the development to practical problem an approach Oxfo ournal publication, trust report sent to the healthcare project Interviews ( Midwives T No information eight meetingsOver No information group Action research Cooperation most tasks to undertake appeared Researcher (page 51) will be ongoing” of the group “The work – with initiatives be continuing may None specified although midwives J 79 contd 1997 y, bb esearch cycle/s esearch Process Process Phases of action r Methods Participants Participation Outcomes 150 contd Te Implementation Evaluation Impacts Dissemination Health Technology Assessment 2001; Vol. 5: No. 23 continued tentative tentative nt and Research; 1993 1. 24-hour can primary How be used to provide nursing 2. it and in achieving involved processes What are (pages 29–48);Phenomenological approach still developing this approach esearch approach most appropriate approach esearch Research questions Research innovation Change Analysis r this help could be given care to patient-centred traditional nursing to patient-centred nursing,to patient-centred organisational method of using work primary nursing service? nursing patient-centred o 2-day workshopso 2-day Nurses Co-learning with supervision of primary roles uptake nurse Negotiated orkshop Researchers Co-learning and critical paradigms; in interpretative Located action research decided that action view of documentation)view (page 72) Titchen A.Titchen action research. practice through Changing nursing Oxford: Nursing, National Institute for Practice Developme for Centre Primary nursing Staff nurses Cooperation 1. traditional from gradually move study wards on two help nurses To 2. generate and test set of explanatory principles of action about how To 3. generate theorised account or social theory from about journey To Nurses Hospital (“medical wards”) difficulties encountered? 48 months W Case study data of early Case study data of early Sister/staff nurses Consultation traditional practice and devised Generated theorised account of wards’ Meetings/professional Ward nurses/researcher No information nurses/researcherDouble-act groupsCollaborative No Ward Meetings/professional sessions development Sisters/staff nurses (sister) Researcher/actor Co-learning Co-learning in place of co-action researcher model’ of working ‘collaborative Recommend ‘double act’ model of working Recommend changes towards patient-changes towards nursing,centred i.e. (methods:team nursing participant observation/in-depth interviews/re Researcher/actorLiterature/personal knowledge Tw Co-learning changes: initiating and facilitating early principles for the cultural norm of autocratic, moving and the sister (by the staff nurses centralised between relationship is an attempt to change the power “If there principle – tentative decision making to a norm of participative, decentralised decision making), are nurses ambiguity, to experience role the sister.” by likely devolved if authority is not explicitly 109 y details arget of change arget esearch cycle/s esearch Ke Thematic concern Aims T Location Sampling methods Titchen, 1993 Length of study Process Phases of action r Methods Information Participants Participation Outcomes gathering Implementation Planning 151 Appendix 6 ich led to y-days for whole ward have whole ward for y-days a aw nt and Research; 1993 he art of clinical supervision. :327–34) 4 1995; eflective conversationeflective (page 13) the action and data collection methods.” planning or revising ournal publications (five located),ournal publications (five report 1992, project (report no.6, collection of papers 1993) J r Field notesEvaluation of the work-shop: diaries; reflective nurses Ward conversations; participant observation; interviews; recorded informal conversations; quarterly Consultation and sister) Role clarification (staff nurses democratic leadership and more Flattening of hierarchy uptake) leaders taking on obligations (role Team nurses) Successful transition to primary (all registered nursing and tested series of action hypotheses Developed action plans own – developed of nurses Empowerment of nurses and personal development Professional Titchen A.Titchen action research. practice through Changing nursing Oxford: Nursing, National Institute for Practice Developme for Centre meetings of team leaders Successful transition to primary nursing problems: and resolve to explore ward of opportunities and time out from review continued Recognised value for workshops/ annual J Clin Nurs 2-weekly recorded recorded 2-weekly Actor and researcher Co-learning of data, analysis “Enabled the impressionistic wh and evaluation interpretation become part culture of ward of undertakingContribution to knowledge action research (T ‘opportunistic’ clinical supervision action research strategies for through and tested three developed Later claimed to have 109 contd esearch cycle/s esearch Dissemination Impacts Process Process Phases of action r MethodsEvaluation Participants Participation Outcomes 152 contd Titchen, 1993 Health Technology Assessment 2001; Vol. 5: No. 23 heir trust; patients’

:55–70 3 1995; Educ Action Res No information Counselling skills for nurses Counselling skills for None stated wnership; motivation; education and reflection; anxieties and stress; communication Analysis Change innovation Change Objectives structures and policies structures introduction of idea of action research to nurses of idea action research introduction Nurses accepted certain ideas and concepts, which originated in their chosen teaching sessions other professions affected in practice small and those that minimally Developments Identified factors that constrain or enable change: and ideology; power support; o networks; facilitators; participants’ roles; research of change; execution physical environment; patient numbers; permanency and qualification of staff; wider bureaucratic aterman H,Webb C,WilliamsA.aterman H,Webb change: and nursing Changing nursing project. of an action research a dialectical analysis W study factors linked to nurses’ reticence to change reticence to nurses’ study factors linked

eaching sessions Nurses/auxiliary nurses Cooperation 49 Hospital outpatient department to participate Nurses volunteered Nurses Factors linked to nurses’ reticent approach to change, approach reticent to nurses’ Factors linked worked including context (both local and national) in which they To 16 meetings Nurses/auxiliary nurses Cooperation development; for Identified area t reach to help nurses teaching sessions arranged (every 2 weeks)(every T reflectionGroup Field notes, interviewsParticipant observation Nurses/auxiliary nurses Co-learning Counselling skills: with their ill-equipped to deal adequately remained nurses goals, e.g. counselling skills psychological problems. patients, of distressed care Instead of promoting sessions might inabilities frustration at their own nurses’ to increase served indirectly have 18 months Interviews Patients, outpatient nurses Consultation of outpatient nurses; about roles Perceptions of feelings of mutual development None specified Thesis report, journal publication ., 1995 et al aterman y details arget of change arget esearch cycle/s esearch Location Sampling methods T Ke Thematic concern Aims gathering Planning Implementation Evaluation W Length of study Process Phases of action r Methods Information Participants Participation Outcomes Impacts Dissemination 153 Appendix 6 . (16):46–9 No information Self-medication (4 stages) None stated 86 1990; Nurs Times ould be legally accountable for errors? accountable for ould be legally eaching sessions prepared eached stage 4) Analysis Change innovation Change Objectives Guidelines for nurses drawn up drawn nurses Guidelines for provided Individual medicine cabinets/keys patient to in notes) for medical permission to be sought (recorded for Arrangements to stage 4 proceed of drug sheet developed Modified form idea; – thought self-medication was good positive self- increase expected that it would discharge; patient for and prepare care control be under patient’s would pain relief that had older and on other wards – concern whether appropriate less positive confused patients; time-consuming; more drugs incorrectly; patients might take who w T ‘borrowing’ through r initiate self-medication project in ward for care of elderly people of elderly care for in ward initiate self-medication project o teaching sessions staff Ward Cooperation promptly which were identified minor problems Regular meeting with steering group

ebb C,Addison C, Holman H,A. Saklaki B,Wagner patients. elderly Self-medication for eekly meetingseekly action Collective plan: Four-stage medicines medicines to patient self-administered nurse-administered orm and new drug orm and new ournal publication Hospital (one ward for elderly patients) elderly for Hospital (one ward No information Nurses/patients No information To W psychological well-being patients) to self-medication (two responses verbal of favourable evidence provides Paper Interviews staff Ward Tw prior to 3-month trial:20 patients Guidelines, assessment f sheet distributed Support provided Consultation meetingMid-project Questionnaire on innovation: Nurses’ views staff Ward of measure Bradburn’s Patients staff Ward Consultation progress, Positive addressed, some minor problems e.g. staff shortages Consultation Consultation sorted out almost complete independence; 12/20 patients achieved statistical analysis for too few patient but was time-consuming (less so once patients Self-medication beneficial for 3-month trial period reviewLiterature Contacted UK Central Nursing, Council for Midwifery and Health Visiting about legal issues students Postgraduate W action Collective self-medication for project for protocol Developed None identified J 76 ., 1990 et al y details arget of change arget esearch cycle/s esearch Location Sampling methods T Ke Thematic concern Aims Implementation Evaluation 154 Webb Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes Impacts Dissemination Health Technology Assessment 2001; Vol. 5: No. 23 1996 urses No information None specified of PCA discontinuation for Draft protocol rses’ knowledge of PCA accurate; rses’ knowledge appears side-effects accurate; analgesia appears (as required) of intramuscular/oral/prn rses’ knowledge Analysis Objective innovation Change No post-change evaluation data available at time of writing data available No post-change evaluation of their pain; nu request; of PCA > 12 hours and/or patient’s discontinuation patient for – non-use by – patients should be involved; decision process nu patient education: confident in explaining PCA 98% nurses to patients. 68% patients did surgery; following to use PCA how not know on day PCAselection criteria for – non-prescriptive; if age limits apply unsure appeared nurses data; of total drug consumption chart review of PCA discontinuation for developed Draft protocol staff’s reason for discontinuing PCA discontinuing for = patients; staff’s reason on request;nausea – anti-emetics given use little prophylactic cus group and action research group: and action research cus group no information cus group Nurses Consultation to guide nurses protocol demonstrated need for results Author claim that questionnaire utorials (small group utorials (small group chart discontinuation added) ormat) Implementation wards: high PCA usage; probability-of-adoption score; members of action group presence Hospital Fo 1. pain management of patients while managing their PCA improve To 2. optimise use of valuable resource, To the PCA pump Development of nursing role in pain management (local situation one of over-reliance on medical staff) through empowerment of n empowerment on medical staff) through in pain management (local situation one of over-reliance role of nursing Development Whyborne N.Whyborne into PCA management of pain. and subsequent nursing discontinuation An investigation Trust; NHS South Buckinghamshire Meeting of Probability adoption guide introducedDraft protocol 2 wardsT f Action group Cooperation Cooperation data on PCA to collect formal and subsequent discontinuation Staff questionnaire Some changes made to PCA (visual pain assessment scale and PCA assessment form pain management data collection instrument: Designed pre-change patient questionnaire; demographic No information Meeting: experience;staff reporting; auditFo Staff questionnaire Nurse researcher, action group) by (formulated acute pain nurse staff Ward action Collective Identified PCA that could be studied as area Consultation PCA in decision to discontinue to match findings: does not appear involved = action group part in action research Nurses selected to take patient best judge ask patient and considered would pain assessment – 96% nurses None identified Diploma report Pre-change data collection Pre-change (questionnaire) Consultation data collection instrument demonstrated need for Author claims that pre-change available): (no results protocol 75 y details arget of change arget esearch cycle/s esearch Location Sampling methods Aims T Ke Thematic concern Planning Implementation Whyborne, 1996 Length of study Process Phases of action r Methods Information gathering Participants Participation Outcomes Impacts Dissemination Evaluation 155 Appendix 6 :188–98 56 1997; Health Educ J None stated strategy to (tailored CHD prevention Health promotion individual company) and quantitative Qualitative proposed Cost–benefit analysis esearch projects to reach their maximum usefulness their maximum to reach projects esearch r Standardised intervention programme defined, intervention programme Standardised models, research based on previous practice, good current survey workplaces Bedfordshire and previous time participants to programmes; can give commissioning authorities needed to enable action by familiarity and awareness greater Objectives innovation Change Analysis Steering group action Collective decided on group) Semi-experimental design (intervention and control Wilkinson E, M. Elander E,Woolaway health promotion. workplace and evaluate to stimulate Exploring the use of action research argeted to reach workforces (identified by prior survey) (identified by workforces argeted to reach eports, of evaluation intervention; research ournal publication Implementation in two Implementation in two 1 companies (company No information+ 2, companies; control 2 + 1,company control company) intervention Pre/post self-reported lifestyle No informationquestionnaire Employees interviewsSemi-structured sites” (page 190) to individual work “The intervention was tailored data (field notes,Process of meetings,minutes individual progress r specific intervention activities) ConsultationCost data Evaluation of intervention not completed; paper supplied by results survey only supplied: of action research Initial evaluation development, management, human resource training , marketing, communication, and evaluation.); and quantitative qualitative than time and resources more it requires (organisational multidisciplinary approach requires levels change on different creating interventions; specific behaviour-change delivering for required important in implementing action management framework project within formal working and flexibility; incorporates both rigor approach standardised and in recruitment problems presented have and reorganisation economic pressure sustaining commitment to programme; and amount of lengthening timescale of project 24 months No information No information No information None identified J Community (workplaces) Community T Development of effective workplace health promotion through alignment of business and public health objectives through health promotion workplace of effective Development into local workplace intervention introduced Can health promotion coronary heart in changing risk for disease? be effective in businesses Health promotion 67 ., 1997 et al y details arget of change arget esearch cycle/s esearch Implementation Evaluation Wilkinson Length of study Process Phases of action r Methods Information gathering Planning Participants Participation Outcomes Impacts Dissemination Location Sampling methods 156 Ke Thematic concern question Research T Health Technology Assessment 2001; Vol. 5: No. 23 No information Cooperation Development of tool/strategies but no indication their Development implementation in practice Identify current problems in practice problems Identify current ‘ideal’ practice of Determine health visitors’ perceptions staff to enable them manage change Empower effectively more with staff participation tools of analysis Develop :337–9 71 1998; Analysis Mode of participation Change innovation Change Objectives Highlighted issues of concern to health visitors: of record-keeping; form no standardised and analysis; caseload profiling for no tools available practice determinination of current in future it could be improved and how and against change for Identified forces birth and guidelines; new register developed and analysis profiling caseload/workload template for developed Community Practitioner Community ce field analysis in study develop health visiting practice develop r

orking group meetingsorking group Health visitors Cooperation Action plans: ournal publication Health visitors volunteered Community (one clinic) Community No information To Health visiting Wright S. health visiting practice using action research. Developing W No information No information No information No information 8 months InterviewsFo Health visitors ConsultationNo information oriented to locality, Researcher of working; staff and their ways gained staff interest No information J No information No information No information 88 y details arget of change arget esearch cycle/s esearch Sampling methods Location Ke Thematic concern Aims T Planning Implementation Wright, 1998 Length of study Process Phases of action r Methods Information gathering Participants ParticipationEvaluation Outcomes Impacts Dissemination 157

Health Technology Assessment 2001; Vol. 5: No. 23

Methodology Group

Members

Methodology Programme Professor Ann Bowling Professor Ray Fitzpatrick Professor Theresa Marteau Director Professor of Professor of Public Health Director, Psychology & Professor Richard Lilford Health Services Research & Primary Care Genetics Research Group Director of Research University College London University of Oxford Guy’s, King’s & St Thomas’s and Development Medical School School of Medicine, London NHS Executive – West Midlands, Birmingham Professor David Chadwick Dr Naomi Fulop Dr Henry McQuay Professor of Neurology Deputy Director, Clinical Reader in Pain Relief The Walton Centre for Service Delivery & University of Oxford Chair Neurology & Neurosurgery Organisation Programme Professor Martin Buxton Liverpool London School of Hygiene Dr Nick Payne Director, Health Economics & Tropical Medicine Consultant Senior Lecturer Research Group Dr Mike Clarke in Public Health Medicine Brunel University, Uxbridge Associate Director (Research) ScHARR UK Cochrane Centre, Oxford Mrs Jenny Griffin University of Sheffield Head, Policy Research Professor Paul Dieppe Programme Professor Joy Townsend Director, MRC Health Services Department of Health Director, Centre for Research Professor Douglas Altman Research Centre London in Primary & Community Care Professor of Statistics University of Bristol University of Hertfordshire in Medicine Professor Michael Drummond Professor Jeremy Grimshaw University of Oxford Professor Kent Woods Director, Centre for Programme Director Director, NHS HTA Health Economics Health Services Research Unit Programme, & Professor University of York University of Aberdeen Dr David Armstrong of Therapeutics Reader in Sociology as University of Leicester Applied to Medicine Dr Vikki Entwistle King’s College, London Senior Research Fellow, Professor Stephen Harrison Health Services Research Unit Professor of Social Policy University of Aberdeen University of Manchester Professor Nicholas Black Professor of Professor Ewan B Ferlie Health Services Research Professor of Public Services Mr John Henderson London School of Hygiene Management Economic Advisor & Tropical Medicine Imperial College, London Department of Health, London

Current and past membership details of all HTA ‘committees’ are available from the HTA website (see inside front cover for details) 165

continued Health Technology Assessment 2001; Vol. 5: No. 23

HTA Commissioning Board

Members

Programme Director Ms Christine Clark Professor Jenny Hewison Dr Sarah Stewart-Brown Professor Kent Woods Freelance Medical Writer Senior Lecturer Director, Health Services Director, NHS HTA Bury, Lancs School of Psychology Research Unit Programme, & University of Leeds University of Oxford Professor of Therapeutics Professor Martin Eccles University of Leicester Professor of Professor Alison Kitson Professor Ala Szczepura Clinical Effectiveness Director, Royal College of Director, Centre for Health Chair University of Newcastle- Nursing Institute, London Services Studies upon-Tyne University of Warwick Professor Shah Ebrahim Dr Donna Lamping Professor of Epidemiology Dr Andrew Farmer Head, Health Services Dr Gillian Vivian of Ageing Research Unit Consultant in Nuclear University of Bristol General Practitioner & NHS R&D London School of Hygiene Medicine & Radiology Clinical Scientist & Tropical Medicine Royal Cornwall Hospitals Trust Deputy Chair Truro Professor Jon Nicholl Institute of Health Sciences Professor David Neal Director, Medical Care University of Oxford Professor of Surgery Professor Graham Watt Research Unit Department of Professor Adrian Grant University of Newcastle- University of Sheffield upon-Tyne General Practice Director, Health Services University of Glasgow Research Unit Professor Gillian Parker University of Aberdeen Nuffield Professor of Dr Jeremy Wyatt Senior Fellow Professor Douglas Altman Community Care Dr Alastair Gray University of Leicester Health Knowledge Director, ICRF Medical Director, Health Economics Management Centre Statistics Group Research Centre Dr Tim Peters University College London University of Oxford Institute of Health Sciences Reader in Medical Statistics University of Oxford University of Bristol Professor John Bond Director, Centre for Health Professor Mark Haggard Professor Martin Severs Services Research Director, MRC Institute Professor in Elderly University of Newcastle- of Hearing Research Health Care upon-Tyne University of Nottingham University of Portsmouth

166 Current and past membership details of all HTA ‘committees’ are available from the HTA website (see inside front cover for details)

Health Technology Assessment 2001; Vol. 5: No. 23 Action research ISSN 1366-5278 eedback F our views about this report. our views y look forward to hearing from you. to hearing from look forward

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