Action Research in Healthcare


Elizabeth Koshy, Valsa Koshy & Heather Waterman

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    About the Authors

    Dr Elizabeth Koshy is a General Practitioner who works as a Clinical Research Fellow at Imperial College, London. She studied the use of a range of research methodologies during her studies for a Master's in Epidemiology at the London School of Hygiene and Tropical Medicine (University of London); since then she has been carrying out research whilst on fellowship from the National Institute for Health Research (NIHR). She is currently funded by a doctoral fellowship from the NIHR. In her varied roles, she has realized the potential of the action research approach in the context of healthcare, especially within general practice. Dr Koshy also brings in her experience of working in hospitals, Primary Care settings, and as a former tutor for undergraduate medical students at Imperial College, London. All these roles have given her useful insights into the valuable and unique service provided by healthcare workers and how carrying out action research can enhance their professional development and improve the quality of service provided for users.

    Professor Valsa Koshy is a Professor of Education and Director of a Research and Development centre at Brunel University. She has led several action research projects commissioned by the UK Department of Education and other public bodies. She continues to support practising teachers and advisers in several Local Authorities to undertake action research projects. She teaches on the Master's and Doctoral programmes at the university and supervizes doctoral students. She brings her expertise in training, teaching and evaluating practices into this book. She has a strong interest in participatory research, which she believes empowers practitioners. Professor Koshy has written several books and articles. Her book Action Research for Improving Educational Practice, also published by SAGE, is often described by readers as very accessible and practical.

    Professor Heather Waterman is Professor of Nursing and Ophthalmology at Manchester University. She leads an ophthalmology nursing research team with a special interest in adherence and glaucoma. She has a long-standing interest in participatory research methodologies and has contributed to the development of action research in healthcare in many different roles: as an academic supporting action researchers, as a prolific writer of journal articles on the use of action research in healthcare settings and as an authoritative member of several bodies which review action research proposals and academic papers. She has led a systematic review and guidance for assessment of action research (Waterman et al., 2001) which is widely quoted in almost all publications relating to action research in healthcare settings. Her research portfolio consists of numerous academic and professional publications and she has been either lead or collaborator on externally funded grants from charities, industry, the Department of Health in the UK and the National Institute for Health Research, UK.


    We are indebted to many people and organizations for supporting us in writing this book, which is designed to assist healthcare workers when carrying out action research. Although it is impossible for us to list all the people who have influenced our thinking and experiences over the years, we would like to express our gratitude to all of them. We would wish to send our special thanks to the following:

    • Our colleagues and students who have worked with us on action research projects. We have learnt a great deal from our students, both at undergraduate and postgraduate levels, and have seen first hand the level of enthusiasm, excitement, and commitment of these people which has convinced us of the unique opportunities provided by action research for improving practice.
    • We would thank all the students who have given us permission to use extracts from their work and quote their experiences in this book.
    • We would wish to acknowledge the help given by Catrin Pinheiro-Torres who assisted us with our literature search and with the chapter on data analysis.
    • Our gratitude also goes to Alison Poyner, at SAGE, for her guidance and for understanding the unexpected pressures the authors faced during the writing of this book.
    • This book is dedicated to Elizabeth's daughter and Valsa's granddaughter Colette and to Heather's mother Jo.


    Action research is increasingly being used as a research approach across disciplines in healthcare, social work, and education. This book has been written as a practical guide for health workers who are interested in finding out what action research means and what it entails, either because they are involved in or intend to be involved in action research projects. Those who may be planning to lead action research projects should also find the book useful. In the world we live in – with its increased accountability and financial restrictions – providing the best possible healthcare, which is the ultimate goal shared by all those who are involved, is a major challenge. We believe that action research provides a methodology which offers an effective way for evaluating and reflecting on what we do, with the aim of improving practice. Carrying out action research involves improving our own learning regardless of whatever role we take in this process, whether it be as facilitators in projects or as members of teams within communities undertaking collaborative projects. The action researcher must constantly ask two all-important questions: What am I doing? How can I improve what I am doing? Carrying out sound action research projects does not happen by accident; it requires systematic working and the continual development of effective strategies.

    An important point to make when carrying out action research projects is that these can enhance the professional development of researchers through the learning opportunities these provide. As preparation for writing this book we spoke to a number of health workers and the conversations we had were highly illuminating. Without exception, all of them were inspired at the thought of undertaking research, although some of them also told us that they considered research activities to be largely the sole domain of academics and not really something they were likely to be involved in. When we shared accounts of practitioners' action research projects with one diabetic nurse practitioner (Helen) she had this to say:

    Well, I don't really see myself as a researcher, but listening to you I can see how it would be useful. You see, I do my job, I see diabetic patients and explain to them the importance of controlling their blood sugar readings and exercise. By being involved in an action research project seeking practical ways of helping them to achieve better control, I can see that both my ability to do what I am doing and the quality of how I deal with the patients could be enhanced. The idea of sharing the research with my colleagues and involving patients in projects really appeals to me.

    The perception that research is something undertaken by others ‘out there’ is common amongst practitioners in other disciplines as well. The following statement from another practitioner, who had been part of an action research project with the second author of this book, reflects how practitioners – irrespective of the professional contexts in which they work – may view the opportunity of being action researchers.

    Being involved in action research was gratifying, the experience helped me to consider aspects of my work which needed redirection and rejuvenation. Before that elevating experience, I assumed that all forms of research were the exclusive province of academic researchers in universities. Gaining access to that ivory tower has enabled one practitioner – me – to illuminate sound strategies to work with colleagues in exploring new strategies, implementing ideas, and assessing the effectiveness of the ideas we introduced.

    Our own professional experiences have guided and informed the contents of this book. As a General Practitioner, the first author has experienced the power of collaborative work in family practices in improving patient care. Having had extensive training and experience in traditional research methods, her own strong belief is that action research with its practical orientation and collaborative work has much to offer healthcare professionals, whether this is in implementing new initiatives from the government, or making changes to practices in response to new clinical guidance or new research evidence and other developments. She has also grown to understand, first hand, the effectiveness of all professionals working together to implement change. Her personal belief is that there is more potential in the use of the action research approach within general practice. A literature search supports the view that there are far fewer published action research studies in general practice than, say, in nursing and other healthcare settings.

    There are abundant examples of action research in educational settings. In fact, many of the references used in books and journal articles relating to action research in healthcare come from education. The contents of this book draw on the personal experiences of the second author, spanning more than fifteen years, in guiding action researchers in various educational settings and working with Master's and doctoral students from various disciplines who were carrying out action research. During that time, she has witnessed the enthusiasm of practitioners in conducting action research, the pride they feel in disseminating their findings, and the level of increased professional confidence they display.

    The third author has contributed to the development of action research in healthcare as an action researcher herself in many different roles: as an academic supporting action researchers, as a prolific writer of journal articles on the use of action research in healthcare settings, and as an authoritative member of several bodies which review action research proposals and academic papers. She has led a systematic review and guidance for the assessment of action research (Waterman et al., 2001) which is widely quoted in almost all publications relating to action research in healthcare settings. All three of us have brought our own expertise and experience to bear on this book which we hope will offer support and guidance to our readers.

    As the main purpose here is to offer practical guidance to those who intend to carry out action research and those others who are involved in action research projects, we address four important questions:

    • What is action research?
    • When is it appropriate for practitioners to carry out action research?
    • What are the processes involved in conducting action research?
    • How can action researchers disseminate their experiences?

    We have attempted to address all four of these questions in this book. To begin with, it would be useful to consider the reasons why we may wish to undertake action research. Doing such research facilitates evaluation and personal critical reflection in order to implement necessary changes in practice with greater understanding. Those who are involved in action research construct their own understandings through their practical involvement in the process which is quite different to just reading about various aspects of healthcare. They feel empowered through their active involvement. As new initiatives are introduced with greater frequency within healthcare all over the world, practitioners can often be left with conflicting viewpoints, doubts, and dilemmas which need exploration, evaluation, and reflection. Evaluating and reflecting on one's own practices is an integral part of applied disciplines such as healthcare, social work, and education.

    In this book, we hope to address the needs of those who wish to undertake action research as an aspect of their practice. These projects may be facilitated by external funding or may be the outcome of a local necessity to change practice; they may also be a result of an evaluation of the effectiveness of an innovation or a new initiative. In addition action research may be carried out as part of obtaining an educational qualification. Undertaking an action research project involves looking at issues in depth, gathering and assessing the evidence, and then critically reflecting as new ideas are implemented with a view to changing practice. We believe that carrying out action research is all about developing the act of knowing through observation, listening, analysing, questioning, reflecting, and being involved in generating knowledge. The new knowledge and experiences that result can then inform the researchers' future direction.

    We have designed this book in such a way that it can provide guidance on all the key aspects involved in carrying out action research. As one single book cannot address every issue in any great depth, we have included a range of references and further reading, directing the reader to suitable sources if they feel they need greater detail in any of the aspects. We have tried to create a book which offers step-by-step guidance for healthcare practitioners serving the needs of a range of the readership: individual researchers, managers, and leaders who facilitate action research groups and tutors and educators in healthcare. We have also tried to introduce an interactive element into the book, inviting readers to join the authors in exploring various aspects of what is involved in conducting action research. We have carried out an extensive search of the literature of books and recent publications and have included examples and case studies, from different contexts in healthcare, in the book.

    The information is presented in seven chapters. Chapter 1 explores the concept of action research and considers how it is distinctive from other forms of research. Readers are provided with an overview of how action research has developed over the past few decades, its background, and the key concepts of action research – planning, action, evaluation, refinement, reflection, and theory building. Drawing on expert views, the different perspectives and uses of action research are considered. A range of definitions and established models of action research is provided, which should support action researchers to plan their work and also help them to justify the rationale for the choice of action research as a methodology. Key characteristics of the action research approach are discussed. In addition this chapter also includes a discussion of the theoretical underpinnings of action research in order to support the researcher to articulate his or her positioning in terms of ontological and epistemological assumptions. The chapter concludes with a set of examples of action research projects, carried out by practitioners from a variety of healthcare contexts and dealing with a range of topics, encouraging the reader to consider the features of action research.

    Chapters 2 to 6 address the various stages of action research. In Chapter 2, we discuss why researchers will select action research as their approach, along with a discussion of the advantages and perceived limitations of this approach. We address some of the criticisms raised against action research as a methodology and set the scene for the practical aspects of undertaking action research. We then explore the views of experts to consider the role of action research in the professional development of the researcher, the relationship between theory and practice, and the notion of change which constitutes a key element in carrying out action research. We also take a look at the processes involved in conducting action research and invite the reader to consider if and how the processes are embedded within the practical examples provided.

    In Chapter 3 we discuss the process of undertaking a literature review for the purpose of the action research topic to be studied. A rationale for undertaking research reviews is provided and guidance on how to gather, organize, analyse, and make use of what is reviewed is presented. The selection and use of electronic sources for a literature search are dealt with in this chapter, along with some practical guidance on how to evaluate the sources of literature that can obtained from the Internet.

    Chapter 4 offers practical guidelines to action researchers, whether they are about to start a project or are already involved in a project. Quality issues are discussed. We then explore the contexts which are suitable for action research. Although we believe that the stages of action research are not strictly linear, we also believe these should help researchers to think in terms of planning projects in stages, with a built-in flexibility to refine, make adjustments, and change direction within a given structure. Detailed practical guidance is provided on the various steps in action research, taking the reader through all the stages from identifying a topic, planning an action, reflecting, and evaluating. The process of action planning is discussed in detail and a practical planning sheet is provided. Special consideration is given to the important aspect of ‘when things don't go according to plan’ and this also looks at how to anticipate any potential problems when you are conducting collaborative research.

    In Chapter 5 we try to locate the action research approach as a research methodology and discuss its position within three frequently used paradigms. We discuss the different types of instrumentation for gathering data, using practical examples of data collection from healthcare settings. The advantages and limitations of using different methods are discussed. The need to be systematic in the data-gathering process is emphasized. Ethical considerations are also dealt with.

    Chapter 6 focuses on one of the most complex issues in any form of research – the analysis of data. Guidance is provided on how the data may be analysed and presented as themes. The use of computer software packages is also discussed. Examples of healthcare practitioners' accounts of data analysis are provided within this chapter, which concludes with a discussion of using evidence and generating knowledge. In addition issues relating to validating claims to knowledge are addressed.

    The type of report written by action researchers will depend on their circumstances. Funded research requires a certain format to be followed, whereas a report in the form of a dissertation or thesis for an accredited course will need to follow a different (and often pre-set) format. Examples of writing reports and the processes involved in writing or disseminating any findings are provided in Chapter 7, along with a discussion of the different ways in which we can disseminate such findings. Guidance on how to publish action research in various forms (newsletters, conference presentations and journal articles) is also provided.

    What we have attempted to do in this book is to provide the reader with a clear set of practical guidelines for undertaking action research. The examples of action research, in the various healthcare settings, provided within the text, bear testimony to its potential to improve the quality of care for the users as well as helping with the enlightenment and learning processes of those who work within it.

  • Glossary of Key Terms

    • If the reader feels mystified by some terms in the research language, here are some explanations. These are only meant as a starting point in order to explore them further as the reader proceeds with any research.
    • Action research is an approach employed by practitioners for improving practice as part of a process of change. The research is context-bound and participative.
    • Coding is a process used for data analysis. It involves assigning a code to help with the interpretation of segments of the data.
    • Data are the information researchers collect. They may generate a lot of it as tape-recorded interviews, questionnaires, field diaries, and documentary evidence. It is very important that researchers design an effective, personal system to organize the data.
    • Data analysis in general terms, is the process of making interpretations of the data collected and, possibly, of constructing theories based on interpretations.
    • Documentary analysis relates to the process of analysing and interpreting the data that are gathered via documents. For example, government documents, health policies, the minutes of meetings, diaries or health records are studied and analysed to make observations.
    • Emergent quality in action research means an investigator making adjustments to their plans in response to on-going assessments. The cyclic nature of action research allows them to take account of a quality which has emerged that was not exhibited in a previous cycle.
    • Epistemology is about theories of knowledge and about how we come to know these.
    • Ethics is concerned with ethical principles and adherence to professional codes. These principles need to be at the centre of the whole research process.
    • Field notes and field diaries are entries made by researchers based on their observations and thoughts. Field notes do not have to be in written form and audio tapes and video tapes can be employed to gather authentic data. In participant observations, the use of field notes can be particularly helpful.
    • Focus group interviews are a commonly used data-gathering method, where a small group of people is interviewed together and led by a facilitator/moderator.
    • Objectivity is a complex term, but in practice it involves the attempted avoidance of any intrusion of a researcher's preconceptions or value judgements. Objectivity is a means of avoiding bias and prejudice in interpretations.
    • Ontology is the theory of being. It is the study of how things exist in the world, whether they exist subjectively or independent of the observer.
    • Participant observer is used when researchers are involved in what is being studied. In action research we are likely to be involved in the project as participant observers.
    • Qualitative/quantitative methods simply put, describe qualitative data as being in the form of descriptions using words whereas quantitative data will involve numbers. The debate as to which methods are more valid goes on; we recommend selecting methods which are likely to provide appropriate data for the purpose at hand.
    • Reflexivity is the process by which researchers will reflect on their values, biases, personal background, and situations in shaping their interpretations.
    • Reliability means we can describe a study as reliable if it can be replicated by another researcher.
    • Subjectivity means the personal views and the commentaries of a researcher can sometimes be viewed as bias, but this does not have to be the case. If they declare the possible subjective nature of their statements or personal judgements and provide justifications for these then this can be powerful in constructing arguments within action research.
    • Triangulation a way of establishing the validity of findings. The researcher collects data from multiple sources involving multiple contexts, personnel, and methods. The process of triangulation involves sharing and checking the data with those involved. This should lead to researchers being able to construct a more reliable picture.
    • Validity of the data is achieved by sound and robust data collection, sharing all the data sources with participants, and a consensus on accurate interpretations. Different interpretations of a situation may add to a debate and lead to the personal and professional development of the researchers involved. The action research cycle is a validating process in itself.

    Useful Websites

    Centre for Applied Research in Education (CARE) in the University of East Anglia, which provides guidance and links to other networks.

    Participatory Action Research Network, which offers useful resources and links.

    Action Research at Bath University. See also (Action Research, an academic journal which publishes studies of interest to action researchers).

    Action Research resources at Southern Cross University, Australia.

    The Collaborative Action Research Network provides details of research publications and research conferences.

    SAGE publishes a number of useful journals.

    A university-based site.

    National Institute for Health and Clinical Excellence in the UK, for evidence and clinical guidance.

    Provides health-related research and development activities in England.

    INVOLVE, a national advisory group funded by the UK government's Department of Health, aims to promote public involvement in the National Health Service.

    Department of Health website which provides information on research and development and government-supported research programmes.

    Gives journal details of Educational Action Research.


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