Education and debate

Using qualitative methods in health related action research

Julienne Meyer, professor of adult nursing. 

City University, St Bartholomew School of Nursing and Midwifery, London E1 2EA

Series editors: Catherine Pope and Nicholas Mays

The barriers to the uptake of the findings of traditional quantitative biomedical research in clinical practice are increasingly being recognised. ^{1 2} Action research is particularly suited to identifying problems in clinical practice and helping develop potential solutions in order to improve practice.³ For this reason, action research is increasingly being used in health related settings. Although not synonymous with qualitative research, action research typically draws on qualitative methods such as interviews and observation.

(Credit: LIANE PAYNE)

	What is action research?

Action research is not easily defined. It is a style of research rather than a specific method. First used in 1946 by Kurt Lewin, a social scientist concerned with intergroup relations and minority problems in the United States, the term is now identified with research in which the researchers work explicitly with and for people rather than undertake research on them.⁴ Its strength lies in its focus on generating solutions to practical problems and its ability to empower practitionersgetting them to engage with research and subsequent "development" or implementation activities. Practitioners can choose to research their own practice, or an outside researcher can be engaged to help them identify problems, seek and implement practical solutions, and systematically monitor and reflect on the process and outcomes of change.

Most definitions of action research incorporate three important elements: its participatory character; its democratic impulse; and its simultaneous contribution to social science and social change.⁵

	Participation in action research

Participation is fundamental to action research: it is an approach which demands that participants perceive the need to change and are willing to play an active part in the research and the change process. All research requires willing subjects, but the level of commitment required in an action research study goes beyond simply agreeing to answer questions or be observed. The clear cut demarcation between "researcher" and "researched" that is found in other types of research may not be so apparent in action research. The research design must be continually negotiated with participants, and researchers need to agree an ethical code of practice with the participants.⁶ This is especially important as participation in the research, and in the process of change, can be threatening. ^{7 8} Conflicts may arise in the course of the research: outside researchers working with practitioners must obtain their trust and agree rules on the control of data and their use and on how potential conflict will be resolved within the project. The way in which such rules are agreed demonstrates a second important feature of action researchnamely, its democratic impulse.

	Democracy in action research

"Democracy" in action research usually requires participants to be seen as equals. The researcher works as a facilitator of change, consulting with participants not only on the action process but also on how it will be evaluated. One benefit of this is that it can make the research process and outcomes more meaningful to practitioners, by rooting them in the reality of day to day practice.

Throughout the study, findings are fed back to participants for validation and to inform decisions about the next stage of the study. This formative style of research is thus responsive to events as they naturally occur in the field and frequently entails collaborative spirals of planning, acting, observing, reflecting, and replanning. However, care needs to be taken in this process as it can be threatening: democratic practice is not always a feature of healthcare settings. An action researcher needs to be able to work across traditional boundaries (for example, between health and social care professionals or between hospital and community care settings) and juggle different, sometimes competing, agendas. This requires excellent interpersonal skills as well as research ability.

	Contribution to both social science and social change

There is increasing concern about the "theory-practice" gap in clinical practice; practitioners have to rely on their intuition and experience since traditional scientific knowledgefor example, the results of randomised controlled trialsoften does not seem to fit the uniqueness of the situation. Action research is seen as one way of dealing with this because, by drawing on practitioners' intuition and experience, it can generate findings that are meaningful and useful to them.

The level of interest in practitioner led research is increasing in Britain, in part as a response to recent proposals to "modernise" the NHS through developing new forms of clinical governance.⁹ This and other national initiatives (the NHS Research and Development Strategy, the National Centre for Clinical Audit, the NHS Centre for Reviews and Dissemination, the Cochrane Collaboration, Centres for Evidence Based Practice) emphasise that research and development should be the business of every clinician. Practitioner led research approaches, such as single case experimental designs,¹⁰ reflective case studies,¹¹ and reflexive action research,¹² are seen as ideal research methods for clinicians concerned with improving the quality of patient care.¹³

In considering the contribution of action research to knowledge, it is important to note that generalisations made from action research studies differ from those made on the basis of more conventional forms of research. To some extent, reports of action research studies rely on readers to underwrite the account of the research by drawing on their own knowledge of human situations. It is therefore important, when reporting action research, to describe the work in its rich contextual detail. The researcher strives to include the participants' perspective on the data by feeding back findings to participants and incorporating their responses as new data in the final report. In addition, the onus is on the researcher to make his or her own values and beliefs explicit in the account of the research so that any biases are evident. This can be facilitated by writing self reflective field notes during the research.

The strength of action research is its ability to influence practice positively while simultaneously gathering data to share with a wider audience. However, change is problematic, and although action research lends itself well to the discovery of solutions, its success should not be judged solely in terms of the size of change achieved or the immediate implementation of solutions. Instead, success can often be viewed in relation to what has been learnt from the experience of undertaking the work. For instance, a study which set out to explore the care of older people in accident and emergency departments did not result in much change in the course of the study.¹⁴ However, the lessons learnt from the research were reviewed in the context of national policy and research and carefully fed back to those working in the trust; as a result, changes have already been made within the organisation to act on the study's recommendations. Some positive changes were achieved in the course of the study (for example, the introduction of specialist discharge posts in accident and emergency departments), but the study also shed light on continuing gaps in care and issues that needed to be improved in future developments. Participants identified that the role of the "action researcher" had enabled greater understanding and communication between two services (the accident and emergency department and the department of medicine for elderly people) and that this had left both better equipped for future joint working. In other words, the solutions emerged from the process of undertaking the research.

	Different types of action research

Four basic types of action research have been identified: experimental, organisational, professionalising, and empowering (table).³ Though this typology is useful in understanding the wide range of action research, its multidimensional nature means that it is not particularly easy to classify individual studies. For instance, a study might be classified as "empowering" because of its "bottom up approach" in relation to the fourth distinguishing criterion of "change intervention," but the other distinguishing criteria may be used to classify the same study as a different action research type (experimental, organisational, or professionalising). This situation is most likely to occur if the researcher and practitioners hold differing views on the nature of society. It may be more fruitful to use this typology as a framework for critiquing individual studies and, in particular for thinking about how concepts are operationalised, the features of particular settings, and the contribution of the people within those settings to solutions.¹⁵

	Action research in health care

At a time when there is increasing concern that research evidence is not sufficiently influencing practice development,¹⁶ action research is gaining credibility in healthcare settings.¹⁷ For example, the Royal College of Physicians in England has become involved in an action research study exploring the roles of clinicians, clinical audit staff, and managers in implementing clinical audit and ways of overcoming organisational barriers to audit.¹⁸ The NHS Research and Development Programme has commissioned a systematic review of the action research. Elsewhere Ong has used "rapid appraisal," a type of action research, to engage users in the development of health care policy and practice.¹⁹

Action research has also been used in hospital settings to facilitate closer partnerships between staff and users, notably in a study which focused on the introduction of lay participation in care within a general medical ward of a London teaching hospital (box). This study used a range of methods, including depth interviews, questionnaires, documentary analysis, and participant observation to generate data about health professionals' perceptions of lay participation in care and the difficulties encountered in changing practice. ^{20 21}

In this study, health professionals expressed extremely positive views about user and carer involvement when completing an attitude scale, confirming the results of previous research on health professionals' attitudes towards user and carer involvement in care.²² However, the interview data showed that they had some serious doubts and concerns, and observation of practice revealed that these doubts and concerns were inhibiting the implementation of lay participation. This action research was able to explore the relation between attitudes and practices and explain what happened when lay participation was introduced into a practice setting. It showed that although current policy documents advocate lay participation in care (user and carer involvement), some health professionals were merely paying lip service to the concept and were also inadequately prepared to deliver it in practice. By working closely with practitioners to explore issues in a practical context, the researcher gained more insight into how the rhetoric of policy might be better translated into reality.

	Conclusions

Action research does not focus exclusively on user and carer involvement, though clearly its participatory principles makes it an obvious choice to explore these issues. It can be used more widelyto foster better practice across interprofessional boundaries and between different healthcare settings, for example. ^{14 23} It can also be used by clinicians to research their own practice.¹⁰ It is an eclectic approach to research and draws on a variety of data collection methods. The focus on the process as well as the outcomes of change helps to explain the frequent use of qualitative methods by action researchers.

	Footnotes

   Competing interests: None declared.

This article is taken from the second edition of Qualitative Research in Health Care, edited by Catherine Pope and Nicholas Mays, published by BMJ Books

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