Joumal of Advanced Nursing, 1993,18, 305-311

Action research and quality of care: amechanism for agreeing basic values as aprecursor to change*

Mike Nolan BEd MA MSc PhD RGN RMNSenior Lecturer in Nursing Research, Research Division, School of Nursing and MidwiferyStudies, Faculty of Health Studies, Upper School, St David's Hospital

and Gordon Grant BSc MSc PhDDirector, Centre for Social Policy Research and Development, University of Wales, Bangor,Gwynedd, Wales

Accepted for publication 8 June 1992

NOLAN M. & GRANT G. (1993) Journal of Advanced Nursing 18, 305-311Action research and quality of care: a mechanism for agreeing basic valuesas a precursor to changeThis paper describes the trend apparent in nursing and other practice disciplinestowards more participative and collaborative methods of enquiry as exemplifiedby action research. In so doing it notes the conceptual similarities between actionresearch, change theory and quality initiatives. Particular attention is focused onthe need to establish the basic values which provide the impetus and directionfor subsequent activity. The difficulties this may pose are illustrated by referenceto the application in two continuing care hospital wards for elderly patients of achecklist operationalizing a typology of care. A mechanism to facilitate and makeexplicit the values underpinning care in any given environment is suggested.

INTRODUCTION

There is nothing more difficult to carry out, nor more doubtfulof success, nor more dangerous to handle than to initiate anew order of things.

{Machiavelli, The Prince)

Machiavelli's observation is as pertinent today as it wasover 4 centuries ago and is particularly true of changeinitiatives that question long-established practices andchallenge taken-for-granted assumptions. Yet the situationis essentially paradoxical in that to resist change andthereby fail to evolve in response to new demandsthreatens the continued viability of institution, professionor species. This would certainly seem to be the case in

'Based on a paper given al Ihe Brilish Society of Gerontology Annual Conference,UMIST, September 1991.Correspondence: Dr M. Nolan, Senior Lecturer in Nursing Research, Research Division,School of Nursing and Midwifery Studies, Faculty of Health Studies, Upper School,St David's Hospital, St David's Drive, Bangor, Gwynedd LL57 4SL, Wales.

relation to the provision of institutional care for frail elderlyindividuals.

Research has roundly and consistently criticized suchenvironments over the past 30 years (Townsend 1962,Robb 1967, Booth 1985, Willcocks et al. 1987). However,this large and cumulative body of objective evidenceappears to have had precious little impact in terms ofstimulating an improvement in institutional regimes.Indeed, recent studies suggest that in continuing carehospital environments care may have become more ratherthan less rigid (Waters 1991) and is still dominated by staffroutines largely designed to get the work done (Waters1991, Reid 1991).

This paper argues that responsibility for this failure mustpartly be shouldered by researchers and academics who,in pointing out the shortcomings of institutions, haveremained largely aloof from the practitioners intimatelyinvolved in the day-to-day routines. It is suggested that,if there is to be any substantive change in the current

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position, the 'top down' generation of knowledge socharacteristic of traditional research will need to be sub-stituted with a more open and participative 'bottom up'approach such as action research. It is also contended thatif the present emphasis on establishing quality controlmechanisms (Welsh Office 1990) is to achieve its aim ofimproving standards then a mechanism for making explicitthe values seen to underpin good quality care in particularenvironments is required.

CHANGING PRACTICE: THE ROLE OFRESEARCH?

The manifest failure of the theoretical and research-basedliterature to make substantial inroads into the world ofpractice has become known as the theory-practice gap, aphenomenon noted in relation to most practice disciplines,including nursing (Hunt 1981, Hunt 1987, Bircumshaw1990, MacGuire 1990), social work (Barbour 1984, Pilias1986, Reay 1986, Marshall 1990) and teaching (Carr 1989,Elliot 1991). This position has been cogently summarizedby Marshall (1990) who notes:

... innovations in practice are very seldom based on researchevidence; they are much more likely to be based on imitationsof other practical projects .. . a well written description in theSunday newspapers or Community Care seems to be worth ahundred reports of research.

Numerous authors have attempted to account for thereluctance of practitioners to use the literature, offering avariety of explanations (Hunt 1981, Hunt 1987, MacGuire1990) which highlight the difficulties in accessing literatureand introducing change. Whilst such accounts undoubt-edly illuminate the situation, it has been suggested that amore fundamental explanation lies in the tendency forresearchers to lay the blame at the feet of practitioners,thereby exacerbating the problem:

The perceived gap between theory and practice originates notso much from demonstratable mismatches between ideal andpractice but from the experience of being held accountablefor them.

(Elliot 1991)

This has led to a number of questions being raised aboutthe value of traditional research approaches and the utilityof the knowledge which they generate. Therefore, it hasbeen suggested that it is inadequate for research merely to'tell it as it is' and leave it at that as this results in prac-titioners seeing such knowledge as being largely irrelevantto their needs (Greenwood 1984). This leads to a situation

in which research is viewed as an esoteric activity (Webb1989) divorced from the realities of everyday life.

Both qualitative and quantitative approaches suffer simi-lar limitations in this regard as they each cast the researcheras the 'expert' and create a relationship between researcherand subject which is essentially hierarchical, controllingand exploitative (Webb 1990), a relationship based on the'epistemological hegemony of academe' (Elliot 1991). Thisdistancing of researcher and subject and the passive role ofthe latter in the generation of knowledge is seen to createand sustain the theory—practice divide:

Whether the techniques generate psychometric measures,ethnographies or grounded theories does not matter. Theyare all symbolic of the power of the researcher to define validknowledge.

(Elliot 1991)

WHY ACTION RESEARCH?

Dissatisfaction with the knowledge generated by researchis not new and was the impetus behind the growth ofaltemative approaches such as action research. Actionresearch developed in the USA in the 1940s as a specificresponse to the theory-practice gap (Wallace 1987, Carr1989) and is now a generic term used to describe a varietyof strategies whose principle aim is to improve a practicalsituation (Susman 1983, Greenwood 1984, Hunt 1987,Wallace 1987, Carr 1989, Webb 1990, Elliot 1991).

In contrast to traditional research the distance betweenresearcher and subject is minimized. Indeed, the presence ofan outside researcher may not be required at all. Thus,action research is seen as being democratic, creating agenuinely collegial and collaborative relationship (Wallace1987) which empowers practitioners, encouraging devel-opment and change whilst simultaneously enhancing thecapacity to discriminate and make judgements (O'Neill1986, Webb 1990, Elliot 1991). It therefore has a differentepistemological basis from traditional science, aiming toproduce knowledge which is held to be valid 'on its useful-ness in helping people act more intelligently and skilfully'(Elliot 1991).

Within such a paradigm knowledge does not reflectan extemal reality but is context specific and situational(Susman 1983, Hunt 1987) with theory and practice form-ing 'mutually constitutive elements in a dynamic relation-ship' (Carr 1989). Thus, it is reasoned that there is lesschance that inquiry is merely scholastic and self-serving,increasing the possibility that theory can actually directpractice (Susman 1983). Action research is, in essence, a'bottom up' approach to the generation of knowledge(Wallace 1987).

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Recently, action research has been utilized in a variety ofpractice situations relevant to the care of older people(Armitage 1990, Webb et al 1990) including institutionalprovision (Dixon 1986, 1991) in an attempt to improvethe quality of care delivered. A brief consideration of thestages in an action research approach serves to illustratethe similarities it shares with change theory and variousapproaches to the development of quality initiatives.

Action research is typically described as a cyclical pro-cess involving a number of stages (Susman 1983, Dixon1986,1991, Coates & Chambers 1990, Elliot 1991) includ-ing diagnosing a problem area, developing a plan of action,implementing the action plan and evaluating its effectsso that the lessons leamed can be applied to the originalproblem. The conceptual similarities between this cycleand that which constitutes the quality or audit cycle (Sale1990, Welsh Office 1990) are immediately apparent.Moreover, recent analyses of quality programmes indicatethat the use of 'top down' packages using standardizedinstruments are less likely to be effective than 'bottom up'methods which incorporate insider perspectives (Redfem& Norman 1990, Kellaher & Peace 1990).

This mirrors the arguments previously posited abouttraditional and action research approaches and, as changetheorists contend, provides for a sense of ownershipamongst those involved in the endeavour. Indeed, itappears that for both action research and quality pro-grammes to be successful a number of requirements mustbe met. These may be summarized as follows:

1 that there is a shared and explicit set of values acting asa guide for practice;

2 there is recognition that a problem area exists;3 that there is a common understanding of the problem;4 there is a perceived need for change;5 that the situation is seen as amenable to change;6 that there is a focus on involvement and team building.

It is apparent that the first and crucial step is to establish ashared and explicit set of values which act as a referencepoint for all subsequent activity. As Fitzgerald (1991)points out, it is of little use giving attention to strategies forchange if the content of such change is not clear. Agreeingsuch basic values sounds deceptively simple. Indeed, theyare often taken for granted:

There are fundamental values idealised yet central to the prac-tice of nursing, frequently given lip service, rarely explained.

(Wilson-Bamett 1988)

The dangers of such assumptions were highlighted dur-ing a recent attempt to measure the staffs' perceptions of

the environment of care in two continuing care hospitalsfor elderly patients (Nolan 1991, Nolan & Grant 1992).

ESTABLISHING BASIC VALUES

As part of a study examining the provision of respite carewithin continuing care hospitals (Nolan 1991, Nolan &Grant 1992), the authors wished to obtain nursing staffs'perceptions of the care they gave and the extent to which itaccorded with one of the four models advocated by Wadeand colleagues (Wade 1983, Wade ei al 1983). Thesemodels constitute a typology formed by the intersection oftwo continua which are considered to reflect essentialcharacteristics of institutional environments for frail elderlyindividuals. One continuum asks whether the regime ofcare is person-centred with a focus on the psychosocialneeds of the individual or task-centred with a routine estab-lished for the convenience of staff. The second addressesthe degree to which there is an open regime which encour-ages the active involvement of the wider community or aclosed order which inhibits such involvement. The fourmodels within this typology are termed the supportivemodel, the protective model, the controlled model and therestrained model.

Using these criteria it is suggested (Wade et al 1983)that the best institutional environments are 'supportive'(open and person-centred). Such environments are charac-terized by consultation and choice, possibly resultingfrom the deliberations of a staff/resident committee, theprovision of salient and therapeutic activities whichare suggested, where appropriate, by elderly peoplethemselves, together with unrestricted access and fullinvolvement of visitors and volunteers.

In trying to operationalize these concepts and applythem to a continuing care hospital environment, a checklistwas developed (Nolan 1991, Nolan & Grant 1992) whichasked staff to consider if their own ward reflected thecharacteristics of a supportive environment. The checklistcontained a series of statements which staff consideredfrom two differing standpoints, providing their responsesin two separate columns. In column A a rating was made ofthe extent to which each statement was a feature of thepresent care regime (all or most of the time/some of thetime/rarely or never), whilst column B reflected staffperceptions of how desirable and achievable each of thecriteria were (each criterion was rated on a three-point scaleas being both desirable and possible to achieve, desirablebut not possible to achieve, or not desirable).

The checklist was completed by 10 qualified nursingstaff in two different wards as one component of detailedcase studies of staff perceptions of care in these areas

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(Nolan 1991, Nolan & Grant 1992). The results highlightthe fallacy of assuming a shared set of values underpinningthe care delivered in any particular ward.

Despite the small numbers completing the checklist,there was little agreement on each criterion in eithercolumn of the checklist. In fact, out of the 26 statementscomprising the checklist consensus was only reached onthree in one ward and on two in the other. Even on appar-ently objective criteria, such as the choice patients had onwhen to rise or go to bed or when to have a bath, there wasno agreement. Therefore, some staff considered that thesewere regular features of the care regime whereas othersworking on the same ward considered that such choiceswere rarely, if ever, offered.

Similar divergence of views was apparent in relation tothe desirability or possibility of achieving each criterion.For example, some staff considered that it was both desir-able and possible that patients should have a named nurseof their own, that they should attend all case conferences atwhich they were discussed and that they should be activelyinvolved in planning a programme of activities for theward. Other staff indicated that these features were desir-able but that they were not possible to introduce, whilststill others felt that these were not desirable.

It was noted above that the first stage in a quality pro-gramme or action research study is to establish the basicvalues which underpin the care in a given area. The resultsfrom the study suggest just how difficult this is likely to beand highlight the importance of reaching agreement onsuch fundamental issues if change is to be achieved. It is feltthat the checklist approach offers a useful mechanism whichchallenges staff to look critically at the taken-for-grantedassumptions which underpin their care. Whilst the checklistused was developed with a particular environment andconceptual model in mind, the general format and designcould easily be adapted for differing environments andmodels. To illustrate this point, a revised and extendedversion of the checklist for Wade et al. (1983) typology isreproduced as the Appendix.

Column A establishes the degree to which staff perceivetheir current regime of care as meeting the criteria on thechecklist. This is obviously important for, if staff considerthey are already largely meeting the criteria, there is likelyto be little or no impetus for change. Moreover, staff mayconsider that their practice reflects the criteria when inactuality it does not, illustrating the disparity betweenperceived and actual practice (Bland 1991, Dixon 1991).Therefore, in a recent study of quality of care in Scottishinstitutions for elderly individuals, staff considered thatresidents had free access to their rooms at all times. How-ever, on the basis of observation it was noted that in reality

residents were not allowed to enter their rooms for much ofthe moming period whilst cleaning was taking place (Bland1991).

Perhaps even more fundamental, however, is the infor-mation contained in Column B (see Appendix). First, thereneeds to be agreement on the basic desirability of criteria,otherwise there will not be a shared set of values. Secondly,if a criterion is deemed desirable but not possible toachieve, then despite the perceived need for change thesituation will not be viewed as amenable to change, socreating another legitimate barrier. Thus it is argued that ifthe checklist is completed by all the individuals involved, itconstitutes a potentially useful devise in the early stages ofa quality programme or action research study.

Of course, in terms of classical approaches to the pro-duction of instruments the checklist has not been subjectedto any rigorous test of either its reliability or its validity.This, however, is not the issue. There are numerous instru-ments for measuring institutional regimes which conformto these canons and can be used to produce 'objective'scores. It is this latter characteristic that is probably thevery reason for their failure to effect any real change inpractice. Such instruments are typically administered by anoutside researcher or completed by the senior officer in theinstitution under scrutiny, thereby failing to consider amyriad of potentially conflicting perceptions.

The format of the checklist described in this paper offersa solution to this problem. Indeed, the present checklist wasdesigned to reflect a certain set of theoretical assumptionsand was operationalized with a specific environment inmind. One would expect that it should be changed ifapplied to a different environment. The format couldequally be adapted to other existing checklists, for examplethe analysis of daily practice schedule (Evans et al 1981) orthe institutional regime questionnaire (Booth 1985) with-out losing its essential features of checking not only theregime of care but also which features of the regime aredeemed to be desirable and possible. Logically, ciny suchchecklist should also be completed by residents and otherrelevant groups if a complete picture is to be obtained.

However, obtaining a complete picture should be thefirst step in the process of change and not the last step in aresearch project. 'Telling it how it is' should be the begin-ning not the end. Booth's (1982) assertion that over 20years of research-based criticism would appear to havehad little real impact on institutional care might nowbe more accurately stated as over 30 years of research-based criticism having had little impact. As Dixon (1991)points out, however, it is the very fact that research criti-cizes and does nothing else that is the root cause of thisfailure.

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Action research creates a dynamic interaction between

research and organizational change but still requires

recognition that it is equally important to utilize existing

knowledge as it is to create new knowledge (Hunt 1987).

This may dictate a fundamental redefinition of the purpose

of research and of the role of the researcher with a move

away from the 'epistemological hegemony of academe'

(Elliot 1991) towards more refiective models relying on the

close involvement of practitioners (Benner 1984, Schon

1987, Elliot 1991) and, we suggest, service users. A failure

to ulitize theory cannot be solely attributed to individual

practitioners (MacGuire 1990) but might more properly be

attributed to the manner in which theory is produced:

In all fields of scientific endeavour the time-lag betweenknowledge and practice is proportional to the distancebetween the creation of theory and the position of thepractitioner.

(MacGuire 1990)

Despite the current emphasis on community care it is

increasingly realized that some form of institutional pro-

vision for frail elderly individuals will be required for the

foreseeable future (Higgs & Victor 1991). Let us hope that

in a further 10 years it cannot be said that over 40 years of

research-based criticism appears to have had little impact

on the quality of such care.

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APPENDIX: TYPOLOGY OF GARE GHEGKLISTBelow is a series of statements which have been made about the ways in which care might be organized in hospitals for the elderly. Please

read each statement and then indicate in Golumn A the extent to which you feel that statement applies to the unit in which you work. InGolumn B indicate if you feel it is desirable and possible for care to be organized in this way. Give your response by placing a tick in theappropriate box.

GOLUMN A GOLUMN BThis is a feature of care in this unit I feel that organizing care in this way is

all/most some desirable desirableof the of the rarely, and but not nottime time if ever possible possible desirable

Work is organized according to a set routineStaff are allocated a series of tasks rather than being

responsible for identified patientsPatients are able to choose:(a) when to have a bath(b) at what time to eat(c) from a choice of menu(d) when to get up(e) when to go to bed(f) what to wear from amongst their own clothes(g) from a single room or which dormitory to

sleep in(h) from a range of activities(i) to do nothing if they desirePatients can bring in and keep personal itemsEach patient has an identified nurse of his/her ownPatients are fully involved in planning their own

carePatients are always consulted about any change that

might affect them

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APPENDIX: Continued.

GOLUMN A GOLUMN BThis is a feature of care in this unit I feel that organizing care in this way is

all/mostof thetime

someof thetime

rarely.if ever

desirableandpossible

desirablebut notpossible

notdesirable

Patients attend all case conferences in which theyare discussed

There is a patient/staff committee to discuss theway things are run

There are regular meetings between staff andpatients to discuss the way things are run

Relatives are encouraged to be involved in thepersonal care of patients if they wish

Relatives are fully involved in planning patient careand attend case conferences

Visitors can come at any time, without prior noticeRelatives/visitors are encouraged to organize

activities for patientsThere is a regular programme of activities/outings

organized by patients themselvesFacilities are available for patients to pursue their

own hobbiesThe unit has regular visits from volunteer groupsVolunteers are actively involved in the unitStaff organize a programme of activities/outings for

patientsThere is a full range of therapeutic input by, or, if

required, access to:(a) physiotherapy staff(b) occupational therapy staff(c) speech therapists(d) a chiropodist(e) a social worker(f) a hairdresserPatients have sufficient opportunities for privacyPatients have somewhere to lock personal itemsFacilities are available for patients to receive visitors

in privatePatients have access to a payphonePatients who are able to have free access to the

groundsPatients have access to a designated smoking area

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