VOL: 97, ISSUE: 02, PAGE NO: 30
Jackie Bridges, MSN, BNurs, RN, RHV is lead research and development nurse, care for older people, Royal Hospitals NHS Trust
Julienne Meyer, PhD, MSc, BSc, Cert Ed (FE), RN, RNT is professor of adult nursing and Jasmine Smith, RGN, is ward manager, Homerton Hospital, London.Jackie Bridges, MSN, BNurs, RN, RHV is lead research and development nurse, care for older people, Royal Hospitals NHS Trust
Recent media reports have drawn attention to serious shortcomings in the delivery of health care for older people (Health Advisory Service 2000, 1998). Studies of nursing care of older people in rehabilitation settings also highlight a gap between what is known to be best practice and what is actually happening in practice (Sheppard, 1994; Waters, 1994).
Meanwhile, government health policy is leading towards a culture of clinical governance and evidence-based health care. This includes the forthcoming National Service Framework for Older People, which will focus on the need to ensure high-quality health care for this group of patients (Department of Health, 1998; NHS Executive, 1999). The underlying message is that change is needed, quality must be ensured and the gap between theory and practice has to be reduced.
Relatively little is known about the factors in practice settings that mediate change successfully. Also unclear is the knowledge nurses and other health-care professionals use to inform their decisions about patient care. Action research directly addresses these concerns.
What is action research?
Action research is about attempting positive development and generating new knowledge through systematically studying the process and outcomes of change. It is research that is conducted for and with people, rather than on people (Reason, 1988). Its main features are:
- Its participatory nature (whereby researchers and practitioners work together in directing the course of change and the accompanying research);
- Its democratic impulse (whereby grass-roots practitioners and their managers are empowered to change the contexts in which they work together);
- Its contribution to social science and social change (as knowledge that is more meaningful to practice) (Rolfe, 1998; Meyer, 1999).
Action research uses a cyclical approach, whereby findings are fed back to practitioners as they are generated, and are then used to inform further action and data collection.
As part of a plan to build up stronger links between research and practice, action researcher Jackie Bridges was invited to work at a trust by the director of nursing, the senior nurse for medicine and the senior nurse for education. The work was funded from the trust's existing education budget.
The ward where this study took place was a mixed-sex rehabilitation unit for older people. It was designated as a rehabilitation unit in April 1998, a change from its previous function as provider of a variety of services to older people which had included respite and longer-stay care. Ms Bridges was contracted to work on the ward with nursing staff for two days a week for one year to provide additional support in developing nursing practice.
Designing the study
In action research, each study aims to involve and include 'grass-roots' practitioners in determining what change is needed, how it is to be carried out and how the process and outcome of this change should be monitored. Ms Bridges therefore spent the first three months getting to know the staff and patients and how things worked on the ward.
At the end of this initial period, she negotiated a study design with nurses through a series of workshops. Her ideas for the design were based on observations of ward practice, together with the nurses' experience of patient care.
This negotiation of study design is an example of action research's participatory nature and democratic impulse. If practitioners are true partners in a study, deciding the course of events in the light of findings as they arise, then the findings are likely to be more relevant to their practice.
The aim of the study was to explore how patient accounts of their experience on the ward could be used to prompt reflections by nurses on the care delivered. The research questions were:
- What are the experiences and nursing needs of individual older patients on the rehabilitation unit?
- How can the service philosophy, organisation and delivery of nursing care be developed to ensure identified patient needs are met?
- What can be learned from attempts to develop practice in this area?
Nurses chose the patients to be included in the study on the basis of one or more of the criteria shown in Fig. 1. Twenty-six patients were referred to the study, and 13 of these were subsequently included. Patients were excluded because they refused consent (2), were to be discharged over the next week (5) or there was not time to include them (6). Although the number of patients finally included was small, it was envisaged that an in-depth comparative study of these individual cases would allow us to build up a rich picture of patient experience.
The local ethics committee approved the study. However, over time a number of ethical issues arose which had not been previously anticipated, including refusal by most of the health care assistants to sign a consent form allowing the researcher to observe their practice.
There were also difficulties in communicating the complexities of the study to patients with hearing disabilities and ensuring that the best interests of vulnerable patients were served (particularly those with cognitive impairment). Ongoing communication was therefore established with the chair of the ethics committee throughout the study to enable the researchers to have guidance on ethical issues as they arose.
Following referral and patient consent, Ms Bridges interviewed the patients and the nurses caring for them. She then used this data, plus the nursing and medical documentation, to map out the patient experience and the aspects of nursing care influencing this experience. These findings were fed back to the nurses, usually on the same day as the patients' interviews, in a reflective discussion group. It was hoped the reflective discussions would enable nurses to identify changes to care they wished to make and, over time, identify what factors helped or hindered giving best care.
Additional informal reflective sessions were also held with the ward's senior nursing staff to periodically share the study findings and to consider their implications for ward practice. This open and ongoing access to findings throughout the study enabled nurses to respond to the need for care changes as and when they naturally arose.
As a result of mapping out the patients' experience, the needs of patients with a cognitive impairment emerged as an area where nurses felt underskilled. It was therefore decided to employ the services of Christine Carter, specialist nurse/lecturer in the mental health of older people.
Ms Carter joined the study as a co-researcher, enabling the development aspects of the study to focus on these patients. This change demonstrates the flexibility of action research and how it can be adapted in the light of emerging findings.
At a number of points during the study, formal interviews were held with ward nurses to gather more data and validate the emerging themes. This enabled nurses to participate in ensuring the findings reflected a true picture of life on the ward.
The final project was written up in collaboration with nursing staff, reflecting an underlying principle of action research which is that participants should have control over the nature of findings to be shared with a wider audience. This is done to ensure participants' vulnerabilities are protected and that findings are expressed in a way that will be meaningful to other practitioners working in similar settings.
This example demonstrates how the principles of action research informed the development of a study which sought to improve the rehabilitation care of older people. The main principles included the studies' participatory nature, democratic impulse and contribution to social science and social change.