Action research in rehabilitation care for older people
VOL: 97, ISSUE: 05, PAGE NO: 37
Jackie Bridges, BNurs, MSN, RN, RHV, is lead research and development nurse, care for older people, Barts and The London NHS Trust
Jasmine Smith, RGN, is ward manager, Homerton Hospital, London;Julienne Meyer, PhD, RN, RNT, is professor of adult nursing andChristine Carter, MSc, BSc, RMN, is a lecturer, Barts and The London NHS TrustAn action research study was carried out on a rehabilitation ward for older people. After patient selection by the nurses, the study used patient's accounts of their experiences on the ward to prompt reflection by nurses and changes in care (see footnote). The study showed that the psychological needs of a group of patients on the ward had not been met and revealed barriers to the provision of psychological care.
Throughout the study the participating nurses looked at the wider systems of care and used the findings to improve patient care. This led to significant changes in practice on the ward. For example, nurses found that they were more likely to find time to talk to patients and, because they had learned more about them as individuals, approached them with greater sensitivity to their particular needs. The nurses have negotiated the input of a clinical psychologist and are seeking ways to secure the ongoing input of a mental health nurse on the ward, demonstrating a commitment to improving the psychological care of patients. Other improvements in care included allowing new patients time to recuperate before starting a programme of physical rehabilitation (Cotter, 1998) and enhancing the nurses' understanding of individual needs by allocating each half a day a month to talk with patients (out of uniform). A number of factors were identified as enabling successful changes in practice. These can be grouped into three categories: - Ward features; - Study design; - Features of action research. Ward features
A number of the ward's features contributed to changes in practice. First, and most importantly, the ward manager and nursing staff were committed to best practice and exploring the contribution research could make to their nursing care. This meant that they were enthusiastic about taking part in the study and listened to and accepted what patients had to say. Second, a culture of democratic participation fostered by the ward manager ensured that the nurses were able to work creatively together in reflective discussion groups to solve difficult patient problems. A third factor was the wider multidisciplinary team's support for and interest in the project, which made the nurses feel that their work was valued and visible. Finally, the project was supported by the trust's director of nursing and the medical directorate's senior nurse, who allowed it to develop in line with the needs of nurses and patients rather than any pre-existing practice development agenda. Study design
The main features of the study design were: - Patient selection by the nurses; - The generation of patients' account of their nursing care; - The use of reflective discussions based on the patients' experiences and other study findings. Taking the lead in selecting patients for inclusion in the study enabled the nurses to feel in control of the research and to use it in ways that would be of most help to them. They did this by selecting patients they had difficulties caring for and whose care they thought could be explored in a different way using action research. 'We selected patients that we felt there might be problems with ... we felt there was something wrong, we wanted to hear what was wrong so we could actually deal with it,' said a nurse who took part in the study. The study gave staff an opportunity to spend extended periods of time with patients recording accounts of their experiences. This enabled them to overcome some of the difficulties associated with the lack of time to talk to patients and communication problems. One participant said: 'The biggest change has been hearing what patients' needs are or what they're lacking. Because as nurses we come to work and do what we think is necessary for the patients, but at the end of the day it may not actually be what they think nurses should be doing for them.' The literature urges patient involvement in service delivery (Wilson, 1999) and this study shows that patients can play a direct part in the improvement of their care. By encouraging them to talk about their experiences, rather than focusing on changes they would like to see, the study overcame older patients' inherent reluctance to criticise their care (Staniszewska and Ahmed, 1999). The collection of information by the researchers and its presentation in reflective discussion groups sometimes resulted in changes to care being agreed. In other cases the benefits were less tangible, but nurses felt the discussions enabled them to work with patients in a different way, based on a deeper understanding of patients' experiences. The reflective discussion groups also provided a supportive environment in which nurses could talk about the difficulties and pain caused by their work. Studies that have taken a psychoanalytical approach to the emotional trauma of caring highlight the value of creating space for reflection as a way of developing appropriate coping mechanisms (Zagier Roberts, 1994; Halton, 1994). The researchers used the reflective discussion groups to establish links with similar studies and findings, helping to bridge the theory-practice gap. Features of action research
The first paper in this series explored how the key elements of action research were woven into the study design (see footnote), enabling it to be dynamic and adapt in response to participants' needs and the emerging findings. This study's participatory nature and democratic impulse were reflected in the equal partnership between the researchers and the nurses. Ward staff were involved in designing the study and directing any responses to the emerging findings. As in successful change management, staff involvement is most likely to result in positive change. The findings were immediately relevant to the nurses, enabling them to feel confident in applying them to their practice. This is an example of action research's contribution to social science and social change and its ability to generate data at a level that is directly meaningful to practitioners (Rolfe, 1998). By sharing findings in context, readers are invited to assess their relevance to their own practice. In this way findings can be generalised beyond a single case (Meyer et al, 2000). The study's flexibility enabled it to adapt to the participants' needs and the emerging findings were of great value, for examples, the development of informal reflective sessions with senior ward staff and the decision to focus the final data collection on patients with cognitive impairment. This flexibility of design ensured that the study remained highly relevant to nurses while enabling them to target areas that were in the greatest need of change. Conclusion
A number of factors can be identified that enabled this action research study to promote positive changes in patient care and make a useful contribution to nurses' knowledge. These factors - the ward features, study design and features of action research - are likely to be of interest to other practitioners who wish to engage in similar practice developments. - The first three articles in this series appeared in Nursing Times on January 11, 18 and 25. Part one described the study's background and methods, part two presented its findings, and part three revealed the unmet psychological needs of a group of patients on the ward and the existence of barriers to the provision of their psychological care.