Action Research in Healthcare

Reason & Bradbury (eds) 2008 Page 381

Hughes, I. (2008). Action research in healthcare. In P. Reason & H. Bradbury (Eds.),Handbook for Action Research: Participative Inquiry and Practice (pp. 381-393).London: Sage.

Action Research in Healthcare

I a n H u g h e s

This chapter provides specific recommendations for how to do good action research in thecontext of healthcare. It links to other appropriate AR practices as well as offering guidelinesfor intervention in diverse settings and questions for developing quality.

STATEMENT OF MAIN THEME

In this chapter I attempt to provide specificrecommendations for how to do good actionresearch in healthcare contexts, concreteguidelines for interventions, and explicitlinks to other AR practices. Action researchhas applications in healthcare as diverse asHIV/AIDs education in Tanzania (Mabalaand Allen, 2002) and Ghana (Mill, 2001) andwith prisoners in Malaysia (Townsend,2001); improving care in nursing homes inAustralia (Street, 1999) and the USA(Keatinge et al., 2000) and in British hospi-tals (Burrows, 1996; Crowley, 1996; Johnsand Kingston, 1990); mosquito control inMalaysia (Crabtree et al., 2001); and sup-porting community-based health initiatives inall parts of the world.

The World Health Organization (1946)declares that ‘health is a state of complete

physical, mental and social well-being andnot merely the absence of disease or infir-mity’. Our health as individuals and commu-nities depends on environmental factors; thequalities of relationships; our beliefs and atti-tudes; as well as bio-medical factors. Tounderstand our health we must see ourselvesas interdependent with human and nonhumanelements in the systems in which weparticipate. This holistic way of understand-ing health, looking at the whole person incontext, is congruent with the participativeparadigm informing this Handbook (seeIntroduction, Chapter 1; Reason andBradbury, 2001/2006a). Health professionals,clients and communities are all part of alarger system (or system of systems), whichwe help to shape or influence through ouractions, as it shapes and influences us. Wecannot frame the health professional, theintervention and the client as independent


3 8 2 PRACTICES

Before 1980 1980–1985 1986–1990 1991–1995 1996–2000 2001–2005

Year

Figure 25.1 Publication dates of community-based participatory researchreportsSource: based on Viswanathan et al., 2004a: 59, projected to 2005

and separate entities. They are mutuallyinterdependent and participating actors in alarger system.

There is compelling evidence that factorsincluding poverty, inadequate housing, airpollution, income inequality, racism, lack ofemployment opportunities, and powerless-ness are associated with poor health out-comes and contribute to the growing healthgap between rich and poor, white and non-white, urban and rural, North and South.Excluded communities have skills, strengths,and resources such as supportive relation-ships, community capacity, committed lead-ers, and community-based organizations toaddress problems and support health (Engand Parker, 1994). Systematic reviews showincreased use of participatory action research(PAR) in public and community health(Viswanathan et al., 2004a), healthpromotion (Green et al., 1995), hospitals(Waterman et al., 2001) and institutionalsettings to address these systemic healthinequalities.

In healthcare, the participatory worldviewwhich underlies action research (Reason andBradbury, 2001/2006b) and the positivistparadigm underlying experimental researchare in close relationship witheach other. As I

illustrate in Figure 25.2, there is not a widegulf between positivist or bio-medicalapproaches and participative approaches toresearch, but participation, action andresearch can be combined, merged orseparated in creative and flexible ways. Untilmaybe a decade ago action research andparticipatory approaches were a ‘hidden curriculum’ (Eikeland, 2001) in the health professions, with relatively few publishedreports. This is changing. A systematicreview of community-based participatoryhealth research in the USA shows half of allstudies meeting their criteria have beenpublished after 2000 (Figure 25.1).

CHOOSING ACTION RESEARCH

The contents pages of this volume show thataction research is not one unified thing. Thepath of choices towards an action researchproject cannot be mapped in a simple decisiontree, showing binary choices among alterna-tive ways of doing research or engaging inaction. Participation, action and research arecombined in many ways in healthcare, andresearchers may be confused about whatcounts as action research.


ACTION RESEARCH IN HEALTHCARE

An Example

It is not possible to present a typical exampleof action research in healthcare, because thefield is too varied, and not possible to selectone outstanding example as criteria varyaccording to the purpose and situation of eachproject. Because there is not room for a fullaccount here, I have chosen a project which iswell reported (Maglajlic and RTK PARUNICEF BiH Team, 2004; Maglajlic andTiffany, 2006; Social Solutions, 2003a,2003b; Zarchin, 2004) so that interestedreaders can follow up in greater detail.

In 2003 UNICEF initiated a participatoryaction research project to develop communica-tion strategies for prevention of HIV/AIDSamong adolescents in Bosnia Herzegovina. Ineach of three towns, the UNICEF HeadResearcher worked with a non-governmentorganization, which nominated a team of fiveyoung people as a research team. In theresearch teams, facilitator roles were split intodifferent tasks, such as group process facilita-tor, record keeper and ‘devil’s advocate’, and rotated among team members. Each team initi-ated a local research group of 20 young people.The average age of local research groupmembers was 17, with a range from 13 to 19.(Maglajlic and RTK PAR UNICEF BiH Team,2004).

A toolkit, including PAR guidelines andworkshop activities, was developed as aresource for members of the local researchgroups (Social Solutions, 2003a). Each localresearch group, with the research team,decided what to research, how to research it,with whom and when. The three local researchteams devised four questionnaires andsurveyed adolescents (sample size rangingfrom 212 to 1611). One team also surveyedparents; another conducted face-to-faceinterviews; and the third team collected datathrough ‘comment walls’ during a basketball tournament. Statistical data were analysedthrough SPSS, and each local research groupmade sense of the data through contentanalysis, and worked with the research team todevelop a proposal for a prevention strategy.

The major action outcome came in theimplementation of the prevention strategies

after the end of this action research project.There were two forms of action during theproject. One local research group organized atwo-day basketball tournament because theyidentified boredom and lack of activities as areason for high levels of substance abuse. Thesecond form of action lay in the actionresearch process through which 15 researchteam members and 60 local research groupparticipants received support, education andempowerment (Maglajlic and RTK PARUNICEF BiH Team, 2004).

Why Researchers Choose ActionResearch in Health

Making a choice to use action research for aparticular project or purpose may involve:

Having some sense of what it might mean and itspotential benefits over other approaches.

Evidence from systematic reviews, researchreports, textbooks and other literature.

Information from within your organization, internetsearches and non-peer reviewed sources.

Opinions from peers or experts. Clinical data or other information gathered with

clients, families, stakeholders, or co-researchers. Economic considerations including personnel,

equipment and other resources.

Heather Waterman and her colleagues foundfive main reasons for choosing action researchgiven in 48 British reports (Waterman et al.,2001: 21).

The most common reasons for choosing actionresearch are about encouraging stakeholders toparticipate in making decisions about all stages ofresearch, or empowering and supportingparticipants.

Frequent reasons include solving practical,concrete or material problems or evaluatingchange.

Reasons associated with the research processincluded contributing to understanding, knowledgeor theory; having a cyclical process includingfeedback, or embracing a variety of researchmethods.

Reason & Bradbury (2e)-3562-Ch-25.qxd 9/24/2007 PM Page 384

3 8 4 PRACTICES

In 29 per cent of instances action research waschosen because it educates.

And in a quarter, it was chosen because actionresearch acknowledges complex contexts or canbe used with complex problems in complexadaptive systems.

Ethical Choices, Aims and Purposes

Healthcare practice and research are ethicalactivities. Hippocrates’ injunction that ‘the physician must … have two special objects in view … namely, to do good or to do no harm(Hippocrates, 2004: 6) is cited as a fun-damental ethical maxim for healthcare pro-fessionals. Action researchers in healthcareshould help others, or at least do no harm.Collaboration and participation are valuableethical safeguards.

One difficulty is that bio-medical researchwith obvious benefits that complies withfunding or institutional ethics guidelines mayalso have effects that are harmful to somepeople. Foucault (1975) and others haveshown how medical power and wealth areincreased by building medical knowledge.Research funded by multinational drug com-panies supports an industry that distributesdrugs unevenly round the globe. The researchtopics that receive funding often support anindustry centred on professional interventionsto cure diseases rather than action to buildhealthy and flourishing individual persons andcommunities (Reason and Bradbury,2001/2006b). Those who make decisionsabout research funding in the illness industrieshave vested interests in existing knowledgeand power structures. Participatory actionresearch has a capacity to challenge thesestructures of knowledge and power.Participation of key stakeholders, especiallythose who are usually excluded from decision-making about research (such as clients,patients and community members), leads toprojects that are more relevant to the lives ofordinary people, while good PAR is itself anempowering process.

In the 21 st century, what happens in onepart of the world can affect us all. As we

Choices about Modes of Participation,Action and Research

This Handbook presents a rich diversity ofapproaches to action research. In addition,several authors have offered typologies ofaction research in healthcare. McCutcheonand Jung (1990: 145–7), Grundy (1988:353), Holter and Schwartz-Barcott (1993:301), McKernan (1996: 15–32; Waterman etal., 2001) and Masters (2000) each list three‘modes’ of action research that arise from three underlying paradigms (Hart and Bond,1995, identify four types). The three modesof action research can be labelled ‘technical action research or action experiments’; ‘action research in organizations or work-places’ (see Chapter 5), and ‘emancipatory action research’ or ‘community-based partic-ipatory research’(see Chapters 2, 3, 8).These are not different research methods.The differences lie in the underlying assump-tions and worldviews of the researchers andparticipants that lead to variations in theways projects are designed, and who makesdecisions (Grundy, 1982: 363). Technicalaction research is typically controlled by the

develop global responses to HIV/AIDS andprepare for a bird flu pandemic it is truer thanat any previous time in history that a completestate of health in one place depends uponother parts of the world. PAR can enable us tomake sense of these interrelationships.Participatory understanding can lead ustowards a sense of universal responsibility thatis growing at this historical moment. As we allparticipate in webs of mutualinterdependency, this universal responsibilityis too important and too complex to delegateto professional or elected leaders. Each personhas opportunities to participate in buildinghealthy and whole communities, regardless ofour occupation, formal education or healthstatus. PAR is one way to do this. (For a moredetailed discussion of ethics in action researchsee Chapter 13.)


ACTION RESEARCH IN HEALTHCARE

ActionResearch Research

ParticipativeActionResearch

Participative ParticipativeResearch Action

Participation

Figure 25.2 Relationship between participation, action and research

researcher, in the mode of Lewin’s field experiments (Gustavsen, 2001/2006; Lewin,1943). Action research in workplaces ofteninvolves collaboration or cooperation among agroup of researchers or professionals, with thedual aims of increasing knowledge andcontributing to improved practice.Participatory action research includes keystakeholders, including the disadvantaged, inmaking decisions through all phases of theresearch project.

A more pragmatic classification is illus-trated in Figure 25.2. Following this diagram,an example of participative action is a com-munity health programme designed andimplemented by a coalition of professionals,community members and other stakeholders.Action research includes projects to improveprofessional practices through cycles of actionand reflection, and can extend to clinical casestudies without key stakeholders participatingin decision-making. Participative research isconducted by a coalition of researchers,community members, patients,health

professionals or other stakeholders, and withouta health intervention as an explicit part of thesame project. Participative action researchincludes all three elements, systematicinquiry, professional practice intervention andparticipation in decision-making by keystakeholders. These categories are notdiscrete, but continuous, and the boundaries inthe diagram are permeable or fuzzy. Theproportions of participation, action andresearch are not usually decided in advance,but worked out as each project is designed anddeveloped.

As a case in point, consider a report ofaction research to improve wound care inpaediatric surgery (Brooker, 2000). Facedwith increasing complexity in choosing themost effective of 400 different wound dress-ings, nurses collaborated with surgeons andother hospital staff to educate staff and mon-itor the use and effect of each dressing. Thosewho were most affected by the outcomes ofthe research (who were also the leastpowerful), the burned babies and

3 8 5

Reason & Bradbury (2e)-3562-Ch-25.qxd 9/24/2007 5:36 PM Page 386

3 8 6 PRACTICES

Table 25.1 Hierarchy of levels of evidence in evidence based practice

Level 1: Evidence obtained from systematic reviews of relevant and multiple randomized controlledtrials (RCTs) and meta analyses of RCTs

Level 2: Evidence obtained from at least one well designed RCTLevel 3: Evidence obtained from well designed non-randomized controlled trials or experimental studiesLevel 4: Evidence obtained from well designed non-experimental researchLevel 5: Respected authorities or opinion based on clinical experience, descriptive studies or reports of expert committees

children, and their parents, were not includedin decision-making at any part of the project,and provided data passively (which was col-lected by nurses and medical staff monitor-ing progress). This project was seen ashaving some empowerment potential, fornurses in relation to senior medical staff, but itcould not be described as empowering for thebabies or their parents; nevertheless, this wasa worthwhile project that produced usefulpractical knowledge.

Choices about participation, action andresearch are influenced by the availableknowledge and information. Even with elec-tronic access to literature, the informationthat we act on is heavily influenced by theeducational and professional networks webelong to. A colleague who had been work-ing on a project for two years told me shehad just realized that what she has beendoing is called action research, and there is abody of literature to inform it. She had beenworking in the next building, with access toan excellent academic library, without mak-ing the connection largely because the peoplein her network use a different approach toresearch.

Waterman and her colleagues (2001)found participation was the most commonlylisted reason for choosing action research,but definitions of ‘participation’ vary. Some institutional ethics committees ask researchersto refer to people whose role is to providedata without making decisions about theconduct of research as ‘participants’, not ‘research subjects’. Some researchers use theterm ‘participation’ where others would describe working with health professionals orprofessional researchers as ‘collaboration’. Waterman and her colleagues combinedthese.

Evidence-based choices

Since the 1990s healthcare knowledge sys-tems known as ‘evidence-based practice’ have been developed to support health pro-fessionals in providing the best availablecare. Evidence-based medicine has beendefined as ‘the conscientious, explicit, judi-cious use of current best evidence in makingdecisions about the care of individualpatients’ (Sackett et al., 1996). From medi-cine, these principles were extended to otherhealth professions and more recently, toinclude service development and manage-ment (Ottenbacher et al., 2002; Viswanathanet al., 2004a: 59). Evidence-based practiceasserts that making clinical decisions basedon best evidence, from the research literatureand clinical expertise, improves the qualityof care and the patient’s quality of life.

Most texts on evidence-based practice pre-sent a hierarchy of evidence (see, for example,Holm, 2000; Madjar and Walton, 2001;Moore et al., 1995). Although wordings differ,the constructions are similar to Table 25.1.

Table 25.1 presents an absolute hierarchyof levels of evidence in which qualitative andaction research approaches are ranked asinferior in the quality of knowledge they pro-duce to the ‘gold standard’ randomized con-trolled trials. The argument is that the bestevidence that a treatment or intervention iseffective can only be obtained by controllingall influences on outcome other than thetreatment, measuring the outcome and com-paring that to the outcome without treatment,especially when this procedure is repeated atdifferent places and times. Against this,others argue that we cannot evaluate a treat-ment properly unless we take the patient’s perspectives into account and understand


ACTION RESEARCH IN HEALTHCARE 3 8 7

Figure 25.3 Evidence-based information cycleSource: Hayward, 2005

their experiences in the context of theireveryday lives. Statistical averages obscureimportant effects on some individuals in somecontexts, and treatments must be adapted andtailored to each patient in his or herenvironment (Ovretveit, 1998: 36).

In clinical practice health professionals areadvised to use evidence in ways that reinforcethe hierarchy of evidence. In the evidence-based information cycle (see Figure 25.3),clinicians and policy-makers are invited to askquestions limited to ‘questions that canbeanswered using evidence-based resources’andto acquire evidence only from ‘preappraisedresources’ (Hayward, 2005). If healthcarepractice is restricted only to informationavailable from evidence-based data bases,fulfilling stringent criteria (that is, evidencefrom only one paradigm), this will limit thescope of approved practice strategies (Jonesand Higgs, 2000). When clinical decisions gobeyond patho-physiological concerns andwhen multi-professional teams work withcomplex problems, new situations or wholesystems, evidence-based practice is toonarrowly defined to support credible andeffective practice.

If kinds of evidence are arranged as a con-tinuum or a menu, rather than a hierarchy(Humphris, 2000; Whiteford, 2005: 39), thenpractice-based evidence and evidence generated

through different research paradigms andapproaches become equally available.Depending on the purpose, the nature of theproblem and the situation, we can look for a‘best fit’ between the question, type of evi-dence and research approach. What counts asgood evidence, and the best ways to gather it,depends on the context and purpose of ourinquiry. For example, in residential care ofolder people with dementia, the evidence ofrandomized controlled trials is relevant whenrecommending medication and dosage, but itis not helpful in considering policy or practicerelating to sexual activity among older peoplewith dementia.

Action researchers in health are respondingto the challenge of evidence-based practice ina number of ways. Hampshire and hercolleagues in the UK conducted a randomizedcontrol trial of action research in primaryhealth care (Hampshire et al., 1999). Twenty-eight general practices were randomlyallocated to two groups. Action research toimprove pre-school child health services wasfacilitated in 14. The other 14 practicesreceived written feedback alone (see Figure25.4). Health professionals reportedimprovements in all 14 action researchpractices, and none of the others, but formalmeasures did not show any statisticallysignificant changes. The authors

clinical or policy problems and identify keyissues;

well-built questions that can be answeredusing evidence-based resources;

evidence using selected, pre-appraisedresources;

the validity, importance and applicabilityof evidence that has been retrieved;

evidence to clinical or policy problems.


3 8 8 PRACTICES

Beforemeasures

14Generalpractices

W rittenfeedback

only

Results

Aftermeasures

Figure 25.4 Randomized controled trial of action research

conclude that action research is a successfulmethod of promoting change in primaryhealthcare, but they found it difficult to mea-sure the impact of action research.

The work of Hampshire and her colleaguesdemonstrates some difficulties in conductingrandomized controlled trials of actionresearch. There are recognized difficulties inmaking statistical measures of theeffectiveness of interventions where there aremany variables in complex situations. TheRCT of action research did not use actionresearch cycles in its own method (that wouldinvolve taking repeated measures of both theintervention and control group). Theymeasured the change outcome and not theknowledge outcomes, that is, they evaluatedaction research as a change intervention, butnot as a research approach. PAR would bedifficult to study through RCT, as each localgroup is likely to devise a different projectwith different intended outcomes.

Choices About Quality and Rigour(Validity, Reliability, Relevance)

The claims that multiple randomized controlledtrials are the ‘gold standard’ of evidence aboutthe value of healthcare interventions are beingchallenged. Waterman et al. (2001) derive 20questions to assess the quality of actionresearch proposals and reports from theirsystematic review of 59 action research stud-ies in UK healthcare settings including hos-pitals (56%), educational institutions (14%),community health services (8%) and other

health workplaces (see Table 25.2). Fourquestions (marked with an asterisk in Table25.2) relate to defining characteristics ofaction research. The full report, includingdetailed subsidiary questions, is availableonline from http://www.hta.nhsweb.nhs.uk.

Guidelines for quality of participatory actionresearch in health were prepared by the RTIEvidence-based Practice Center at Universityof North Carolina in a large systematic reviewof Community-Based Participatory Research(CBPR). They identified 1408 published arti-cles and, after systematically applying exclu-sion criteria, reviewed 185 (Viswanathan et al.,2004a). Viswanathan and her colleagues sys-tematically reviewed the quality of researchmethod, the quality of community involve-ment, and whether projects achieved theirintended outcomes.

The reviewers found few complete andfully evaluated CBPR reports, partly becauselength limitations in journals lead to incom-plete documentation (Viswanathan et al.,2004a). Studies which they rated high forresearch quality did not achieve such highscores for participation, and from other datathe reviewers found high-quality scores forparticipation associated with low-qualityscores for research quality. Researchersapplying for funds often failed to addressconventional research quality criteria(Viswanathan et al., 2004a: 44). Despite thistrend, the review uncovered several out-standing examples of high quality researchcombined with high-quality community

14Generalpractices

Actionresearch +feedback

Aftermeasures



Table 25.2 20 questions for assessing action research proposals and projects

1. Is there a clear statement of the aims and objectives of each stage of the research?2. Was the action research relevant to practitioners and/or users?3. *Were the phases of the project clearly outlined?4. *Were the participants and stakeholders clearly described and justified?5. *Was consideration given to the local context while implementing change?6. *Was the relationship between researchers and participants adequately considered?7. Was the project managed appropriately?8. Were ethical issues encountered and how were they dealt with?9. Was the study adequately funded/supported?10. Was the length and timetable of the project realistic?11. Were data collected in a way that addressed the research issue?12. Were steps taken to promote the rigour of the findings?13. Were data analyses sufficiently rigorous?14. Was the study design flexible and responsive?15. Are there clear statements of the findings and outcomes of each phase of the study?16. Do the researchers link the data that are presented to their own commentary and interpretations?17. Is the connection with an existing body of knowledge made clear?18. Is there discussion of the extent to which aims and objectives were achieved at each stage?19. Are the findings of the study transferable?20. Have the authors articulated the criteria upon which their own work is to be read/judged?

Source : Waterman et al., 2001: 48–50

participation throughout the research process(Webb et al., 2004). High quality research isexpected in healthcare, and action researchersmay be advised to pay more attention to waysin which high quality participation canenhance the quality of data collection andanalysis to produce practical outcomes.

Overall, stronger or more consistent pos-itive health outcomes were found with thebetter quality research designs. CBPR can alsolead to unintended positive health outcomes,and to positive outcomes not directly relatedto the measured intervention. (For theguidelines that Viswanathan and hercolleagues propose for the quality of CBPRplease see Viswanathan, 2004a.) A moredetailed checklist (though older and not basedon wide systematic review) developed byLawrence Green and associates (Green andDaniel, 1995) is available online fromhttp://lgreen.net/guidelines.html. Actionresearchers need to provide evidence of highquality in participation and action andresearch. Assertions about the value of PARwill not convince seasoned reviewers ofhealthcare research.Choices about Complexity and

Action Research

Since the turn of the 21st century healthcareresearchers have begun to apply complexitytheory, including the theory of complex adap-tive systems. Action research has specialresilience and value in this emerging field ofinquiry. A full explanation of complex adaptivesystems is outside the scope of this chapter (butsee, for example, Axelrod and Cohen, 1999;Fraser and Greenhalgh, 2001; Plsek andGreenhalgh, 2001; Plsek and Wilson, 2001;Wilson et al., 2001). In brief, complex adaptivesystems include large number of autonomousagents (who adapt to change) and a larger num-ber of relationships among the agents. Patternsemerge in the interaction of many autonomousagents. Inherent unpredictability and sensitivedependence on initial conditions result in pat-terns which repeat in time and space, but wecannot be sure whether, or for how long, theywill continue, or whether the same patterns mayoccur at a different place or time. The underly-ing sources of these patterns are not available toobservation, and observation of the system mayitself disrupt the patterns.


3 9 0 PRACTICES

Because the researcher is part of the complexadaptive system she or he studies, and becausethe sources of change are not all available forobservation, it is impossible for one person tofully describe or understand a complex adap-tive system. We need multiple perspectives,and because the situation may change inunpredicted ways, we need repeatedobservations and systematic feedback.Participatory action research meets thesecomplex requirements. The collaboration andparticipation of coresearchers with differentperspectives and ways of understanding, aswell as iterative cycles of action and reflection,provide a robust model to increase ourunderstanding of complex situations, whiledesigning and monitoring interventions.

Because the action research cycles buildfeedback loops into ongoing research andaction, they can be used for constant moni-toring of complex adaptive systems, to try outinterventions to see if they appear to havepotential to lever disproportionate change, andprovide feedback about interventions that areproducing or not producing their intendedeffects. This leads to the development of localtheories such as theories of change(ActKnowledge, 2003) or living theories(Whitehead, 2005).

Choices About ImprovingHealthcare Practice

Action research processes can be used to mon-itor and improve the quality of health services(Jackson, 2004). Action research cycles havemuch in common with the cycles of continu-ous quality improvement which inform health-care quality management legislation inAustralia, Canada, the UK, the USA and sev-eral other countries (ACCN, 1982; ACHS,1985a, 1985b; ACSA, 2001; CARF, 1999).

Waterman et al. (2001) undertook a sys-tematic review of 59 action research studiesfitting their definition of action research as aperiod of inquiry that describes, interprets andexplains social situations while executing achange intervention aimed at improvementand involvement. It is problem-focused,andfounded on a partnership between action

researchers and participants, is educative andempowering, with a cyclical process in whichproblem identification, planning, action andevaluation are interlinked.

This systematic review shows that actionresearch can be useful for developing inno-vation, improving healthcare, developingknowledge and understanding in practitioners,and involvement of users and staff. Theirfindings indicate that action research is suitedto developing innovative practices andservices over a wide range of healthcare situ-ations and demonstrates how the actionresearch process can promote generation anddevelopment of creative ideas and imple-mentation of changes in practice.

Organizational factors can facilitate or cre-ate barriers to action research. Meyer,Spilsbury and Prieto (1999) reviewed 75reports of action research in health. Key facil-itators and key barriers mentioned in 23 percent or more of reports are summarized inTable 25.3. This review attended only to theaction or change outcomes of action researchand did not attempt to evaluate research rigouror the quality of participation.

CONCLUSION

Action research is increasingly used in variouscommunity and institutional healthcaresettings. Action researchers in health workclose to bio-medical researchers, andparadigm wars are giving way to sorting outthe strengths and weaknesses of differentresearch approaches for varied purposes andsituations. Although the evidence-basedpractice movement has sparked new skir-mishes between quantitative, qualitative andparticipative approaches in healthcareresearch, Waterman et al. (2001) point outhow action research and evidence-basedpractice can work together.

We have seen that there is evidence thataction research can combine research rigour,effective action and high-quality participation.Some well designed studies show high



Table 25.3 Facilitators and barriers to action researchKey facilitators Key barriers

Commitment• Lack of time, energy, resources Talking/supportive culture• Lack of multidisciplinary team work Management support• Reluctance to change

Unstable workforce Lack of talking/supportive culture

quality on all three dimensions. Many studieshave been strong in one dimension, and weakin another, sometimes as part of an explicitresearch design (see Figure 25.2).

Waterman et al. (2001) recommend thathealth research funding will be appropriate foraction research to:

Innovate, for example to develop and evaluate newservices;

Improve healthcare, for example, monitor effec-tiveness of untested policies or interventions;

Develop knowledge and understanding in practi-tioners and other service providers, for example,promoting informed decision-making such asevidence-based practice;

Involving users and healthcare staff, for example,investigating and improving situations with pooruptake of preventive services; and

Other purposes.

Action research ‘seeks to bring together action and reflection, theory and practice, inparticipation with others, in the pursuit ofpractical solutions to issues of pressing con-cern to people, and more generally the flour-ishing of individual persons and theircommunities’ (Reason and Bradbury, 2001: 1/2006a: 1). In the context of health andhealthcare, this is about working towardscomplete physical, mental and social well-being. Experimental design and randomizedcontrolled trials have an important place inhealthcare research. These are most appro-priate in well controlled situations such asdrug trials. Well designed and implementedaction research is the most appropriateapproach for some other healthcare situations,where situations are truly complex or it is notpossible to control many variables. We shouldrecognize that statistical methods are often notthe best way to measure complexsocial

change. Guidelines to inform choices aboutthe quality and rigour of action research inhealth, based on sound evidence, have beenpublished and need to be tested, and furtherrefined. This may be an opportunity for alarge-scale collaborative action researchproject. In the words of Laurence Green: ‘If we want more evidence-based practice, weneed more practice-based evidence’ (Green, 2004/2006).

ACKNOWLEDGMENTS

Table 25.2 ‘20 questions for assessing actionresearch proposals and projects’, Waterman et al. (2001). Queen’s Printer and ControllerHMSE 2001. Reprinted with permission.Figure 25.3 ‘Evidence-based informationcycle’, Hayward (2005). From http://www.cche.net/info.asp, The Centre for HealthEvidence, University of Alberta, Edmonton,Alberta. Reprinted with permission.

REFERENCES

ACCN (1982) A Guide to Quality Assurance: a Manualfor Nurses Working in the Community. Balwyn:Australian Council of Community Nursing, NursingAdvisory Committee.

ACHS (1985a) Quality Assurance for Nursing Homes:Resource Kit. Zetland: Australian Council on HospitalStandards.

ACHS (1985b) Quality Assurance for Nursing HomesInformation Kit. Glebe, NSW: AMA/ACHS PeerReview Resource Centre.

ACSA (2001) Continuous Improvement for ResidentialAged Care. Parramatta: Aged Care Standards andAccreditation Agency.

ActKnowledge (2003) Theory of Change. [http://www.theoryofchange.org/] (retrieved 23 November 2005)


3 9 2 PRACTICES

Axelrod, R. and Cohen, M.D. (1999) HarnessingComplexity: Organizational Implications of a ScientificFrontier.New York: Free Press.Brooker, R. (2000) ‘Improving wound care in a paediatricsurgical ward’, ActionResearchE-Reports,7 (availableat: http://www.fhs.usyd.edu.au/arow/ arer/007.htm.)Burrows, D. (1996) ‘An action research study on thenursing management of acute pain.’ Unpublished manuscript, Buckinghamshire.

CARF (1999) Commission on Accreditation ofRehabilitation Facilities. [http://www.carf.org/default.aspx?site=ccac] (retrieved 13 July 2006)Crabtree, A.S., Wong, C.M. and Mas’ud, F. (2001) ‘Community participatory approaches to dengue prevention in Sarawak, Malaysia’, HumanOrganization,60 (3): 281–7.

Crowley, J. (1996) A Clash of Cultures: Improving theQuaityofCarethroughanActionResearchProcess.London: Royal College of Nursing.Eikeland, O. (2001) ‘Action research as the hidden

curriculum of the Western tradition’, in P. Reason and H. Bradbury (eds), Handbook of Action Research:ConcisePaperbackEditionLondon: Sage.pp. 145–55.Eng, E. and Parker, E.A. (1994) ‘Measuring community

competence in the Mississippi Delta: the interfacebetween program evaluation and empowerment’,HealthEducationQuarterly,21: 199–220.

Foucault, M. (1975) The Birth of the Clinic: anArchaeologyofMedicalPerception.New York:Vintage/Random House.

Fraser, S.W. and Greenhalgh, T. (2001) ‘Complexity science: coping with complexity, educating for capa-bility’, BritishMedicalJournal,323: 799–803.

Green, L.W. (2004/2006) If We Want More Evidence-basedPractice,WeNeedMorePractice-basedEvidence. [http://www.lgreen.net/] (retrieved 12 April2006)

Green, L.W. and Daniel, M. (1995) GuidelinesandCategories for Classifying Participatory ResearchProjects in Health Promotion. [http://lgreen.net/guidelines.html] (retrieved 9 September 2005)

Green, L.W., George, M.A., Daniel, M., Frankish, C.J.,Herbert, C.P.,Bowie, W.R. and O’Neill, M. (1995)Study of Participatory Research in Health Promotion:Review and Recommedations for the Development ofParticipatoryResearchinHealthPromotion.Ottowa: Royal Society of Canada.Grundy, S. (1982) ‘Three modes of action research’,

CurriculumPerspectives,2 (3): 23–34.Grundy, S. (1988) ‘Three modes of action research’, in S.

Kemmis and R. McTaggart (eds), The Action ResearchReader.Geelong: Deakin University Press.

Gustavsen, B. (2001/2006) ‘Theory and practice: the mediating discourse’, in P. Reason and H. Bradbury(eds), Handbook of Action Research: ConcisePaperbackEdition.London: Sage. pp. 17–26.

Hampshire, A., Blair, M., Crown, N., Avery, A. andWilliams,I. (1999) ‘Action research: a useful method ofpromoting change in primary health care?’, FamilyPractice,16 (3): 305–11.

Hart, E. and Bond, M. (1995) ActionResearchforHealthandSocialCare.Buckingham: Open University Press.Hayward, R. (2005) Evidence-basedInformationCycle[http://www.cche. net/i nfo.asp]

Hipprocrates (2004) OftheEpidemics.Whitefish: Kessinger.Holm, M. B. (2000) ‘Our mandate for the new millen-

nium: evidence-based practice’, AmericanJournalofOccupationalTherapy,54 (6): 575–85.

Holter, I.M. and Schwartz-Barcott, D. (1993) ‘Action research: what is it? How has it been used and howcan it be used in nursing?’, Journal of AdvancedNursing,18 (2): 298–304.Humphris, D. (2000) ‘Types of evidence’, in S. Hamer

and G. Collinson (eds), Achieving Evidence BasedPractice:AHandbookforPractitioners.Edinburgh:Bailliere Tindall. pp. 13–32.Jackson,V . M. (2004) ‘Medical quality management: the

case for actionlearning as a quality initiative’,Leadership inHealthServices,17 (2): i–viii.

Johns, C. and Kingston, S. (1990) ‘Implementing a phi-losophy of care on a children’s ward using action research’, NursingPractice,4: 2–9.Jones, M. and Higgs, J. (2000) ‘Will evidence-basedpractice take the reasoning out of prctice?’, in J. Higgs and M. Jones (eds), Clinical Reasoning in the HealthProfessions, 2nd edn. Oxford: Butterworth-Heinemann.pp. 307–15.

Keatinge, D., Scarfe, C., Bellchambers, H., McGee, J.,Oakham, R., Probert, C., et al. (2000) ‘The manifes-tation and nursing management of agitation in insti-tutionalised residents with dementia’, InternationalJournalofNursingPractice,6 (1): 16–25.Lewin, K. (1943) ‘Forces behind food habits and meth-ods of change’, Buletin of the National ResearchCouncil,108: 35–65.Mabala, R. and Allen, K.B. (2002) ‘Participatory action

research on HIV/AIDS through a popular theatreapproach in Tanzania’, Evaluation and ProgramPlanning,25: 333–9.McCutcheon, G. and Jung, B. (1990) ‘Alternative per-spectives on action research’, Theory into Practice, 24(3): 144–51.

Madjar, I. and Walton, J. A. (2001) `What is problematicabout evidence?’, in J.M. Morse, J.M. Swanson andA.J. Kuzel (eds), TheNatureofQualitativeEvidence.Thousand Oaks: Sage. pp. 28–45.



Maglajlic, R.A. and RTK PAR UNICEF BiH Team (2004)‘Right to know, INICEF BiH: developing a communication strategy for the prevention of HIV/AIDSamong young people through participatory actionresearch’, Child Care in Practice, 10 (2): 127–39.Maglajlic, R.A. and Tiffany, J. (2006) ‘Participatory action

research with youth inBosnia and Herzegovina’,Journalof Community Practice, 14 (1–2): 163–81.

McKernan, J. (1996) Action Research: A Handbook ofMethods and Resources for the Reflective Practitioner,2nd edn. London: Kogan Page.Masters, J. (2000) ‘The history of action research’, Action

Research E-Reports, 3.Meyer, J., Spilsbury, K. and Prieto, J. (1999) ‘Comparison

of findings from a single case in relation to those from asystematic review of action research’, NurseResearcher, 7 (2): 37–59.Mill, J.E. (2001) ‘I’m not a “Basabasa” woman: an

explanatory model of HIV illness in Ghanaian women’, Clinical Nursing Research, 10 (3): 254–74.

Moore, A., McQuay, H. and Gray, J.A.M. (1995)‘Evidence-based everything’, Bandolier, 1 (12): 1.

Ottenbacher, K.J., Tickle-Degnen, L. and Hasselkus, B.R.(2002) ‘Therapists awake: the challenge of evidence-based occupational therapy’, American Journal ofOccupational Therapy, 56 (3): 247–9.

Ovretveit, J. (1998) Evaluating Health Interventions.Buckingham: Open University Press.Plsek, P.E. and Greenhalgh, T. (2001) ‘Complexity

science: the challenge of complexity in health care’, British Medical Journal, 323: 625–8.Plsek, P.E. and Wilson, T. (2001) ‘Complexity science:

complexity, leadership, and management in healthcareorganizations’, British Medical Journal, 323: 746–9.Reason, P. and Bradbury, H. (2001/2006a) ‘Introduction:

inquiry and participatiion in search of a world worthy ofhuman aspiration’, in P. Reason and H. Bradbury (eds), Handbook for Action Research: ConcisePaperback Edition. London: Sage. pp. 1–14.

Reason, P. and Bradbury, H. (eds) (2001/2006b).Handbook of Action Research: Participative Inquiry andPractice. London: Sage.

Sackett, D.L., Rosenberg, W., Gray, J., Haynes, R.B., andRichardson, W.S. (1996) ‘Evidence based medicine: what it is and what it isn’t’, British Medical Journal, 312(7023): 71–2.

Social Solutions (2003a) RTK Bosnia & HerzegovinaToolkit Developed as a Resource Kit for Adolescents.[http://www.actforyouth.net/documents/RTKtoolkitBiH.pdf] (retrieved 11 July 2006)

Social Solutions (2003b) RTK Trip and Training Reportfor Bosnia and Herzegovina. [http://www.actfory-outh.net/documents/BiHRTKworkshopreport.pdf](retrieved 11 July 2006)Street, A. (1999) ‘Bedtimes in nursing homes: an action-research approach’, in R. Nay and S. Garratt (eds),Nursing Older People: Issues And Innovations.Sydney: MacLennan & Petty Pty Ltd. pp. 353–68.Townsend, D. (2001) ‘Prisoners with HIV/AIDS: a parti-

cipatory learning and action initiative in Malaysia’, Tropical Doctor, 31 (1): 8–10.

Viswanathan, M., Ammerman, A., Eng, E., Gartlehner,G., Lohr, K.N., Griffith, D., et al. (2004a) Community-based Participatory Research: Assessing the Evidence.Evidence Report/Technology Assessment No. 99 (No.AHRQ Publication 04-E022-2). Rockville, MD: Agencyfor Healthcare Research and Quality.

Viswanathan, M., Ammerman, A., Eng, E., Gartlehner,G., Lohr, K.N., Griffith, D., et al. (2004b) Exhibit 1: CBPRReviewer and Applicant Guidelines (July). [http://www.rti.org/] (retrieved 15 December 2005)

Waterman, H., Tillen, D., Dickson, R. and de Koning, K.(2001) ‘Action research: a systematic review and guidance for assessment’, Health TechnologyAssessment, 5 (23): 1–166.

Webb, L., Eng, E. and Viswanathan, M. (2004)Community-Based Participatory Research: aSystematic Review of the Literature and itsImplications. Paper presented at the CCPH iLinc WebConference, Washington, DC, December.Whiteford, G. (2005) ‘Knowledge, power, evidence: a

critical analysis of key issues in evidence-based prac-tice’, in G. Whiteford and V. Wright St-Clair (eds),Occupation & Practice in Context. Sydney: Elsevier.pp. 34–50.

Whitehead, J. (2005) What Is a Living Educational TheoryApproach to Action Research? [http://www.bath.ac.uk/~edsajw./] (retrieved 23 November 2005).

Wilson, T., Holt, T. and Greenhalgh, T. (2001) ‘Complexityscience: complexity and clinical care’, British MedicalJournal, 323: 685–8.World Health Organization (1946) ‘Preamble to the

Constitution of the World Health Organization asadopted by the International Health Conference, NewYork, 19–22 June 1946’, Official Records of the WorldHealth Organization, 2: 100.

Zarchin, J. (2004) Programme Experiences: RTK–Bosniaand Herzegovina Profile. [http://www.comminit.com/experiences/pdsrtk/experiences-1840.html] (retrieved11 July 2006)

Documents

Action Research in Healthcare