A Unified Action Research Strategy in Nursing

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1 This article was downloaded by: [ ] On: 22 March 2014, At: 10:28 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Educational Action Research Publication details, including instructions for authors and subscription information: A Unified Action Research Strategy in Nursing Angie Titchen a & Alison Binnie b a National Institute for Nursing, Oxford, United Kingdom b John Radcliffe Hospital, Oxford, United Kingdom Published online: 11 Aug To cite this article: Angie Titchen & Alison Binnie (1993) A Unified Action Research Strategy in Nursing, Educational Action Research, 1:1, 25-33, DOI: / To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content ) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at terms-and-conditions

2 Educational Action Research, Volume 1, No. 1, 1993 A Unified Action Research Strategy in Nursing ANGIE TITCHEN National Institute for Nursing, Oxford, United Kingdom ALISON BINNIE John Radcliffe Hospital, Oxford, United Kingdom ABSTRACT Our four-year collaborative action research project, 'Patient-centred Nursing in Practice', is a study of major change from traditional, standardised nursing to patient-centred nursing. Our action research partnership was set up to help nurses in an acute medical unit to develop patient-centred nursing, through the work organisation method known as primary nursing. The major thrust of study is the unravelling of the complex organisational, personal and professional changes required for such a practice shift. In this methodological paper, we present our action research strategy which unifies five quite distinct activities: (1) introducing innovation and facilitating change; (2) helping practitioners to research their own practice; (3) facilitating professional learning and reflective practice; (4) working towards the democratisation of health care through the emancipation of nurses who are, traditionally, trapped in a bureaucratic nursing hierarchy and in oppressive doctor-nurse relationships; and (5) generating and testing theory. Background We axe engaged In a four-year action research study of the development of patient-centred nursing in the medical unit of an acute hospital. Early In 1989, one of us (Alison Binnle, a senior sister at the John Radcliffe Hospital) successfully approached the National Institute for Nursing, Oxford, to propose setting up a collaborative study. Angle Titchen was appointed by the Institute in May 1989 as the project researcher. We developed the complementary roles of 'actor', In the form of a change agent/facilitator role, and 'researcher', both within a collaborative partnership. Alison was mainly an 'actor', whilst Angle was mainly a 'researcher'. Over time, we have developed and refined our complementary way of working, fine-tuning our 25

3 ANGIE TTTCHEN & ALISON BINNIE relationship within our practice and our research, becoming what we now see as an effective 'double-act' ftitchen & Binnle. 1992). The project, entitled 'Patient-centred Nursing in Practice', was designed to help the nurses on two study wards to move gradually from traditional nursing to patient-centred nursing, using the work organisation method of primary nursing. The major focus of the study is the unravelling of the complex organisational, personal and professional changes required for such a practice shift. The aim is to provide UK nurses with a 'map' of the processes Involved and to point to the kinds of strategy that are likely to be effective In achieving the change. Primary nursing is a system that devolves to a staff nurse the authority to manage the nursing care of a small group of patients from admission to discharge. Continuity of care allows nurses to practise in patient- and family-centred ways, through the development of close therapeutic relationships. Humanistic values underpin these relationships and care is given in an individualised and holistic way. This style of nursing is a major departure from traditional practice which Is governed by standardised routines and procedures and where authority for key decisions about patient care rests with the sister. Our Action Research Strategy The eclectic nature of our approach arose because we were trying to achieve a variety of goals. We therefore developed several different, but interconnected strategies (which were used in parallel) for: introducing innovation and facilitating change; helping practitioners research their own practice; facilitating professional learning and reflective practice; democratising health care through the emancipation of nurses from the nursing hierarchy and the traditional role of doctor's handmaiden; generating and testing theory. Although these strategies are generally seen as quite separate, we saw them as connected or unified in various ways. For example, we felt that if we could help the nurses and sisters to research their own practice and innovations, and thereby generate and test theory, they would Inevitably develop personally and professionally, as they learned to think critically, analytically and reflectively. We anticipated that a bottom-up change strategy would help nurses to empower themselves and raise their self-esteem. The creation of new roles and a new work organisation design would also mean that nurses would have to leam to think and act in new ways - thus organisational change could lead to personal and professional learning. Moreover, researching or reflecting upon their own practice would help nurses to articulate their unique contribution to health care and might, therefore, help nurses to enter into more collegiate relationships with doctors because their own roles were clearer. We found support for the 26

4 A UNIFIED STRATEGY IN NURSING notion that action research unifies quite distinct activities in the educational field (Elliott, 1991). Introducing Innovation and Facilitating Change Our investigation centred around practitioners' perceived needs to change the cultural norms and values in their ward settings. Our strategy involved not only addressing problems and issues identified by ourselves as the change proceeded, but also the problems identified by the nurses. We studied our effectiveness as change agents and facilitators in: establishing a felt need for change; devising and facilitating a bottom-up change strategy; developing appropriate structures for patient-centred nursing; providing support; creating a non-judgemental climate where creativity is fostered; feeding back data; helping people to look critically at what was happening to them/what they were doing; disseminating information/sharing ideas about the change; facilitating communication and clearing up misunderstandings/ misinformation. In addition, we helped some of the sisters to become change agents, facilitating innovations on their wards. The staff nurses in Alison's wards found that the project helped them to innovate and improve practice because it enabled them to reflect upon and evaluate their work. They found the experience of being asked open questions about their practice and being fed back data on their actions particularly helpful. Several staff nurses also became key change agents in the ward. At the outset of the work, we recognised the potential value of some kind of theoretical framework to help us in three areas. First, we needed a framework to guide us through the complexities of facilitating organisational changes; second, to help us to understand the actors' experiences of the change; and third to help us recognise when the nurses were practising in the new patient-centred way. Taking the first area, there is a huge literature, both theoretical and empirical, on the management and facilitation of organisational and professional change with which we are familiar and which we used In the project, as actors or change agents. Our actions, therefore, could be considered to be 'ideas-in-action', with ideas drawn from the literature, our own data and our personal knowledge and experience. In other words, our actions in managing and facilitating the change were theoretically informed; we were using a theoretical framework. However, very little is known about the other two areas - the experiences of the actors in this particular change and the nature and characteristics of patient-centred nursing. In relation to patient-centred nursing, we initially developed a theoretical framework derived from the literature on primary nursing and from our personal 27

5 ANGIE TTTCHEN & ALISON BINNIE experiences, but we rejected this framework, eventually, on the grounds that much of the empirical work Is methodologically flawed. We decided, therefore, not to develop, at the outset, theoretical frameworks for our study in these two areas, but to suspend our personal theoretical understandings until later In the field work. We doubt whether it is possible to achieve an entirely 'atheoretical' position, but we attempted to suspend or 'bracket' (Schutz, 1962) our personal theoretical understandings by making them explicit and by Angle adopting the role of 'stranger' who goes Into the situation, naively, and without preconceptions of what will be found. Success, or otherwise, at 'bracketing' was monitored and recorded (Titchen & Mclntyre, 1992). Practitioner-as-Researcher The notion of the practltioner-as-researcher Is well described in the educational literature. It has also been described as an ideological movement aimed to bring about a democratisatlon of educational research, with a move away from the assumption that only academics are legitimate generators of knowledge, towards a situation where it is acceptable for practitioners to research their own practice. Carr & Kemmis (1986) suggest that the notion of the practitioner-as-researcher became popular at a time when teachers were developing professionalised roles and seeking opportunities to establish a research role in which they investigate their own practice. This kind of research was seen as more useful and relevant to practice than that carried out by outside researchers and academics. Teachers had also adopted the 'accountability movement' which required a self-monitoring to justify practice and to critique the contexts in which practice is conducted. The current nursing climate is very similar to the one described by Carr & Kemmis. Nurses are seeking professionalised roles (for example, the primary nurse role) in which individuals are accountable for, and have to justify, their own practice. Research carried out by academic nurse researchers has sometimes been seen as Irrelevant for practitioners, although MacGuire (1990) states that there is little research evidence to support this claim. We considered that the adoption of the practitioner-as-researcher strategy would provide a means of personal and professional development, through the process of self-monitoring, and would generate knowledge that would be relevant to practice. Facilitating Professional Learning From the literature and from our different experiences of promoting Innovations in health care, we knew that the change we were anticipating would require considerable personal and professional development of the nurses. They would need to develop new roles and relationships and, to be able to fulfil their new obligations and responsibilities, deepen or refine existing skills and develop new ones. We saw the action research process as 28

6 A UNIFIED STRATEGY IN NURSING a way to help people to learn - either as researchers or as reflective practitioners. We helped the nurses to learn by creating opportunities or seizing unexpected ones and by creating a conducive climate. Specific behaviours we adopted were being sensitive to nurses' readiness to learn, making our own values explicit and valuing the nurses' contributions to the development. We used a variety of learning processes, Including working with individuals and groups, role-modelling and acknowledging effort and progress. In addition, we built time into the working day for reflection and theorisation of practice and we made a conscious effort to articulate our own theorisatiohs of practice experiences. The idea that action research must be educational, in itself, has emerged recently in the literature. It is argued that it must help people to make sense of their everyday practice (McNiff, 1988). Action research improves practice by "developing a practitioner's capacity for discrimination and judgement in particular, complex, human situations" (Elliott, 1991) and helps practitioners to make sense of the social, historical and political content of their work situations. We attempted to create opportunities where the nurses could examine their personal and social assumptions and values. We helped them to look for contradictions and inconsistencies between their espoused values and the values that had shaped the context in which they worked. We hoped that their enhanced understanding of the situation, through seeking explanations for any contradictions and inconsistencies, would enable them to formulate strategies for improvement (O'Hanlon, 1988). Empowerment and Democratisation Traditionally, nurses at the bedside were oppressed by a rigid, bureaucratic nursing hierarchy, which meant that they had very little control over their working lives. The traditional, oppressive 'hand-maiden' role of nurses had also trapped them in an unequal power relationship with doctors. We considered that an environment where nurses could empower themselves might be best achieved by helping the sisters in the medical unit and the staff nurses in Alison's wards to work with us in the kind of way described by Kemmis and his colleagues (Carr & Kemmis, 1986; Kemmis & McTaggart, 1988), that is, as a group of practitioners who question the relationship between the actual and the possible in nursing and embark on a 'critical project' or 'struggle for reform'. Early in the work, we invited the sisters to join us as co-action researchers (as described by Kemmis & McTaggart, 1988). However, although the sisters were supportive, interested and collaborated with the work (by acting as informants when we were collecting data on the effects of our actions and by carrying out action they had planned with our facilitation), it was always seen as 'Alison and Angle's project'. They did not see it as their own. We now realise that this outcome was probably inevitable, because the project was not set up with this strategy in mind 29

7 ANGIE TTTCHEN & ALISON BINNIE and so the sisters were not Involved In the project proposal. Our advice to others who wish to develop a Kemmls & McTaggart co-action researcher model Is that the group needs to be Involved from the very beginning. We were, however, very successful in facilitating a different kind of collaborative group model of action research, where sisters and staff nurses became reflective practitioners and change agents (Titchen & Binnie, 1993). In addition, two staff nurses became researchers in an observational study of their colleagues' views and experiences of a new assessment and care planning strategy, developed by Alison during the project (we call them researchers rather than action researchers because they were not exploring the effects of their own actions). These various experiences, not available in everyday nursing life, provided Insights and skills which contributed to the growth of confidence and maturity, already beginning to transform the nurses' working relationships with health professional and medical colleagues and their control over their work. Theory Generation and Testing We used action research as a strategy for generating and testing theory and, in retrospect, we were able to see that we operated within the following research criteria: 1. Theoretical understandings of the substantive area are initially suspended. 2. Observational studies are used for the generation of theory. 3. In the observational studies, general, open questions are asked to get at the actors' perspectives (to begin to generate theory about appropriate actions to achieve certain goals). 4. Action hypotheses are generated from the data collected in the observational study for testing in the field (i.e. in situations of type X, strategies of type Y will achieve goals of type Z). 5. Theoretical understandings guide one's action planning and carrying out of the action. 6. Questions are generated to determine the effectiveness of achieving the goals. 7. Data are collected on the actions and their effects. 8. Theoretical sampling of people and situations is carried out. 9. An attempt is made to theorise and generalise findings - we used three methods: (i) providing readers with a rich description, interpretation and explanation of the situation, they are able to make judgements about whether the findings of our specific case are relevant to their particular situations because our rich description invites them to say, This is like my situation' or not; (11) drawing on substantive social science theory and existing empirical data where relevant; (ill) establishing abstractions and generalisations across individual cases. Brown & Mclntyre (1988) assert that such "generalisations are better 30

8 A UNIFIED STRATEGY IN NURSING described as naturalistic and as forming hypotheses to be carried from one case to the next rather than as general laws applying across a population". These generalisations together create a provisional theoretical framework to make explicit the participants' experiences of the processes, strategies and outcomes of change. 10. Findings and theorisation are laid open to public scrutiny. We found the formal action research schemes in the literature (Ebbutt, 1985; Kemmls & McTaggart. 1988; Elliott, 1991) to be lacking, in that they tend to under-emphasise the observational studies which are essential for theory generation. Both Elliott and Ebbutt recognise that the Kemmls & McTaggart scheme does not allow for observational studies to take place after the Initial reconnaisance, and they have built, at intervals, such studies Into their schemes. On the other hand, Brown & Mclntyre (1981) suggest that theory generation, through action research, should be based not only on prior observational research In which a theoretical analysis of the situation is carried out,' but should also be combined with an explicit ignorance of some of the problems, that might arise during the action. This position implies a continuing development of the exploratory observational research, running in parallel with the action and its outcomes. We built on Brown & Mclntyre's (1981) ideas and asked open questions when trying to understand the situation we were aiming to change, the changed situation itself, and the actors' experience of change. Our questions were more focussed when we were trying to establish whether our actions had been effective. We were, therefore, generating and testing theory simultaneously. The following is one of our action hypotheses: When Alison works as a full-time team member, if she makes explicit why she is there, Le. not to check up on the nwses, but to facilitate their learning and act as a resource for them, then the nurses will see her presence as useful rather than showing them up by unfavourable comparisons. While gathering evidence to test this hypothesis, we were also asking open questions about the staff nurses' experiences of Alison working on the ward. Data generated from the open questions enabled us to gain a better understanding of the ways of achieving certain goals (theory generation), it also helped us to develop a better hypothesis next time round for theory testing. In a discussion of how we developed this strategy, we had the following conversation: AT: At first, we didn't see ourselves as generating action hypotheses, we simply identified the practical goals we wished to achieve and then investigated the means by which the goals could be attained, that is, the change strategies and processes. Thinking in retrospect now, we were aware that there may be a 31

9 ANGIE TTTCHEN & ALISON BINNIE number of means of achieving the goal and that we had hypothesised, in a crude way, that one particular way would work. If it didn't work, we moved on to the next hypothesis, until we were in a position to refine a hypothesis which was grounded in the data. I only made our research criteria explicit halfway through thefieldwork, after discussions with Donald Mclntyre. Alison, what was your reaction when Ifirst put them to you? AB: My Initial reaction was, Tm not doing that It just feels like a lot of long words'. However, when we started to use the criteria, I felt that they made sense and that it would have been helpful to have had them earlier to guide our action and research. AT: As mainly responsible for data collection, I felt guilty that I had not made the criteria explicit at an earlier stage. The only reasons that I can offer are that we took our research knowledge for granted and that explicit articulations of theory generation and testing in action research have not been well-documented - the notable exception being the paper by Brown & Mclntyre (1981). At that time, what we were doing just felt like common sense we were using tacit knowledge gainedfrom our previous research. AB: Yes. I think what has happened since is a process of making our tacit knowledge of research explicit. Conclusion In this paper, we have outlined our collaborative action research strategy, with its five distinct activities. Firstly, we conclude that the activities, although distinct, are unified. Our strategy helped practitioners to empower themselves and this empowerment brought about a democratisation of professional practice. A major philosophical, organisational and cultural shift was achieved, nurses developed personally and professionally and theory was generated and tested. We went up a blind alley, methodologically, by trying to set up the Kemmis & McTaggart (1988) model of co-action research after the project had been set up. But as we were successful in achieving our goals, as action researchers, we question whether it is necessary for other participants, In a collaborative project, to be co-action researchers to innovate or empower themselves. We found that by helping the sisters and staff nurses to become reflective practitioners and change agents, these goals were achieved. Our experience of action research In nursing, therefore, supports Elliott's (1991) claim that action research unifies quite different activities. Secondly, we suggest that the research criteria we present here may help action researchers to generate and test theory more effectively, than when operating on tacit knowledge. Meeting these criteria can be 32

10 A UNIFIED STRATEGY IN NURSING demanding; however, working In an action research partnership enabled us to meet the challenges of both the action and the research. Acknowledgements We would like to thank warmly all the participants in this study who worked so hard with us to achieve patient-centred nursing. Our thanks also to Donald Mclntyre for his skill in helping us to understand complex methodological issues. Correspondence Angle Titchen, R&D Fellow, National Institute for Nursing, Radcliffe Infirmary, Oxford OX2 6HE, United Kingdom. References Brown, S. & Mclntyre, D. (1981) An action research approach to innovation in centralized educational systems, European Journal of Science Education, 3, pp Brown, S. & McIntyre, D. (1988) The professional craft knowledge of teachers, Scottish Educational Review: Special Issue on the Quality of Teaching, pp Carr, W. & Kemmis, S. (1986) Becoming Critical: education, knowledge and action research. Lewes: Falmer Press. Ebbutt, D. (1985) Educational action research: some general concerns and specific quibbles, in R. Burgess (Ed.) Issues in Educational Research. Lewes: Falmer Press. Elliott, J. (1991) Action Research for Educational Change. Milton Keynes: Open University Press. Kemmls, S. & McTaggart, R. (Eds) (1988) The Action Research Planner, 3rd edn. Geelong: Deakin University Press. MacGuire, J.M. (1990) Putting nursing research findings into practice: research utilisation as an aspect of the management of change, Journal of Advanced Nursing, 15, pp McNiff, J. (1988) Action Research Principles and Practice. London: Macmillan Education. O'Hanlon, C. (1988) Alienation within the profession: special needs or watered down teachers? Insights into the tension between the ideal and the real through action research, Cambridge Journal of Education, 18, pp Schutz, A. (1962) Collected Papers, Volumes 1-3. Dordrecht: Kluwer. Titchen, A.C. & Binnie, A.J. (1992) A double act: co-action researcher roles in an acute hospital setting, unpublished paper, National Institute for Nursing, Oxford. Titchen, A.C. & Binnie, AJ. (1993) Research partnerships: collaborative action research in nursing, Journal of Advanced Nursing (forthcoming). Titchen, A.C. & Mclntyre, D. (1992) A phenomenological approach to qualitative data analysis, unpublished paper, National Institute for Nursing, Oxford. 33