Advancing working and learning through critical action research: creativity and constraints

186 Nurse Educa

Article

Loretta BellmanPhD, BSc (Hons),RN, RNTIndependentConsultant, andSenior Researcher,The BayswaterInstitute, 9 OrmeCourt,London W2 4RL,UK.Tel.: +20-7229-2729;fax: +20-7229-2214;mobile: +7870-698124;E-mail:[email protected]

CatherineBywood BSc(Hons), RN, RM,Recovery Sister,Royal ShrewsburyHospitals NHSTrust.

Susan Dale MSc,BA(Hons), PGDipEd, RGNSenior Lecturer,Department ofSpecialist andCritical HealthCare, School ofHealth Care,Oxford BrookesUniversity.

(Requests foroffprints to LB)

Manuscriptaccepted:11 November 2002

Advancing working andlearning through critical actionresearch: creativity andconstraints
Loretta Bellman, Catherine Bywood and Susan Dale
Continuous professional development is an essential component within many health care‘Learning Organisations’. The paper describes the first phase of an initiative to develop aprofessional practice development framework for nurses in an NHS general hospital. The

project was undertaken within a critical action research methodology. A tripartitearrangement between thehospital, a university andprofessional nursingorganisation enabled

clinical, educational and research support for the nurses (co-researchers) engaged in theproject. Initial challenges were from somemanagers, educationalists and the ethics committee

who did not appear to understand the action research process. A multi-method approach todata collection was undertaken to capture the change process from different stakeholders’

perceptions. Triangulation of the data was undertaken. Despite organisational constraints,transformational leadership and peer support enabled the co-researchers to identify andinitiate three patient-focused initiatives. The change process for the co-researchers

included: enlightening personal journey, exploring the research–practice gap, enhancingpersonal and professional knowledge, evolving cultural change and collaborative working,

empowering and disempowering messages. A hospital merger and corporate staff changesdirectly impacted on the project. A more flexible time-scale and longer term funding are

required to enable continuity for trust-wide projects undertaken in dynamic clinical settings.

�c 2003 Elsevier Ltd. All rights reserved.

Introduction

Within an NHS hospital, nurses started tochange and develop themselves, their peersand patient care through an integrativeapproach to shared clinical governance,evidence based practice, accredited work basedlearning, transformational leadership andclinical facilitation. This integrative approachto professional and political initiatives shouldenable nurses to:

update and advance their clinical andresearch knowledge in practice,identify and participate in independentand collaborative patient-focused quality

tion in Practice (2003) 3, 186–194 1471-5

improvement, receive organisationaland academic support and recognitionfor clinical change and development.

The above approach to working andlearning was encompassed within aproposed hospital-wide practicedevelopment framework for nurses, andoperationalised through a critical actionresearch methodology. The objectives ofphase one (12 months) were:

to systematically explore the processof enabling nurse-led accredited changeand development in clinicalpractice, to identify the significance of

953/$ - see front matter�c 2003 Elsevier Ltd. All rights reserved.doi:10.1016/S1471-5953(02)00114-2

mail to: �loretta.bellman@

Advancing working and learning

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the process outcomes for the nurses(called co-researchers) and other keystakeholders, to identify factorscontributing to the development of theframework, to identify factors inhibitingthe development of the framework.

The local Education Consortium (nowWorkforce Confederation) provided financialsupport for phase one of the project,undertaken within the Operating TheatreRecovery area. Information from phase onewould be used to inform the structure andfocus of phase two of the study, i.e.,implementing change and development inother fields of practice in the hospital.

This paper will provide an overview ofphase one of the study and, in particular, willfocus on the change process for the fiveco-researchers who were all Recovery nurses.They were registered nurses aged between 25and 44 years. Two had a first degree and one adiploma in higher education; they had allworked in the Recovery area for between 18months and 3 years.

A critical approach toworking and learning

A new way of working and learning wasrequired to initiate and implement the firstphase of the study. Edmonstone (1995) andZuber-Skerritt (1996) reflect on the extensiveliterature on quality management andorganisational innovation, change anddevelopment which they believe ispredominantly ineffective in practice.These authors advocate the creationof an appropriate organisational culture(Table 1).

The NHS hospital in which the study tookplace appears to have a transitionalorganisational culture, i.e., managers

Table 1 Creating an organisational culture for innovative1996: p. 92)

Corporate management courage and visionUnderstanding the process of empowerment of staff, belieKnowing how to design, lead and manage macro organisaCreating transitional links across boundariesValuing learning and growth in the medium term over painUnderstanding that what has been taken on is not a limite

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considering new ways of working (participantproblem solving, devolved decision making,collaborative learning, etc.). The challenge fornurses and educationalists is how to initiateand sustain a collaborative and systematicchange and development project whilstworking in an organisation withpredominantly hierarchical and bureaucraticstructures. One approach to project leadershipand management is to initiate a critical actionresearch study.

Critical action research

The critical action research approach entails acommitment to a particular philosophy ofhuman nature and knowledge. Positivistapproaches are considered inappropriatewhen exploring social reality and humanaction. The assumptions, concepts, andpropositions of critical theory (Stevens 1989;Carr & Kemmis 1986) underpin critical actionresearch. Not all action research is guided bycritical theory, which has emancipatoryinterests. However, given the nature of currenthealth care issues, the pursuit of emancipatoryinterests is important for nursing (Rasmussen1997, p. 262), where there may be littlerecognition or understanding of the value ofnurses’ work, or support for nurse-ledinitiatives in practice.

The critical action research approach has beenused for the benefit of both patients and nurses(Bellman 2003; Duffy & Scott 1998, Fulton 1997;Stevens & Hall 1992). The emphasis is on acritical approach to social problems andpractices which arise from and are embedded ina social context. Both the process and outcome ofthe research study should be educative,enlightening, empowering and emancipatoryexperiences for nurse participants.

Also fundamental to the approach is theoperationalisation of praxis – shared values

change and development (adapted from Zuber-Skerritt

ving in it and actually doing ittional change projects

avoidance, traditional benefit and ego in the short termd organisational improvement, but a new way of life

Nurse Education in Practice (2003) 3, 186–194 187


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which underpin informed and committedaction. Crane (1991) believes that the purposeof nurse educators, researchers and managersshould be to support the nurse clinician so thatall are equal nurse practitioners engaged inpraxis, and directing the future of nursing(p. 403). Consequently the concept of power isas Stringer (1996, p. 159) advocates: ‘not somuch a transfer of power but as a ‘change inthe nature of power relationships’.

CRASP was the chosen critical actionresearch approach for phase one of the project(Zuber-Skerritt 1996, p. 85) as it reflectedpersonal and professional working andlearning:

Critical and self-critical collaborativeenquiry byReflective practitioners (co-researchers) beingAccountable and making the results oftheir enquiry publicSelf-evaluating practice and engaged inParticipatory problem solving andcontinuing professional development.

Initiating the study

The study evolved from a Sister’s desire toadvance the standard of care in the RecoverySuite by updating her staff and concurrentlyinvolving them in shared learning and practicedevelopment. The term Sister is a UK name(this may differ in countries who no longer usethis term for this role). At the time there was adearth of educational support and norecognition for achievement. The Sister securedmanagement and financial support andidentified the need for education and researchsupport. Clinical, educational and researchsupport for the project was addressed througha tripartite arrangement (Table 2).

The three participant facilitators hadbetween them extensive clinical, education and

Table 2 Tripartite arrangement

Organisation Participant facilitator

Hospital Recovery SisterUniversity Senior LecturerEducation/Research ExternalInstitute Consultant

tion in Practice (2003) 3, 186–194

research experience. They explored the basis oftheir collaboration, i.e., their beliefs and valuesregarding practice development – forindividual nurses, the clinical team, theorganisation, the involvement of users. Theyalso explored the nature of support for oneanother and the co-researchers, andparticularly the need for ongoing support fromsenior managers in all three organisations.

Initial challenges

Coughlan and Brannick (2001, p. 63) cautionthat doing action research is an intenselypolitical act which may be threatening toorganisational norms. The initial challenges tocollaborative practice were from corporatemanagement, the research director, nurseeducators, the ethics committee and humanresources.

At the time the hospital’s organisationalculture was one in which the status of nursinghad for many years been perceived to be in asubordinate role to that of medicine andhuman resource management and was justbeginning to raise its profile with a dynamicDirector of Nursing. Also, each institution(hospital/university/education and researchorganisation) had its own macro-politicalresearch agenda. Challenges included:

explaining the limitations of positivistscience and negotiating the researchmethodology with the medical Director ofResearch. Through reading about criticalaction research she eventually came torecognise the significance of the proposedmethodology;

deterring some of the senior educationalistswho wished to design an evaluation for thestudy. This is incongruent with the actionresearch approach where evaluation isintegral and ongoing and undertaken by theparticipants;

s Expert role

Clinical supportWork based learning & accreditationAction research& practice development




the collective attitude of the ethicscommittee who felt that the approach wasnot within the remit of the committee.They were informed of the evolving natureof the study, the need for consent toparticipate and for consent to be reviewedas the study advanced;

negotiating with the Director of HumanResources the need for long term fundingfor development in clinical practice.

Data collection and analysis

To systematically explore the objectives of thestudy and capture the process and outcomes,five approaches to data collection wereundertaken:

audio-taping of the co-researchers’ actionlearning sets; steering group meetings;project board meetings; other stakeholdermeetingsfield note recordingsresearch journalsaudio-taped group interviewse-mails

The multi-method approach provided anopportunity to use different sources ofevidence in an effort to develop converginglines of inquiry, sometimes termedtriangulation. There is no clear agreement onthe meaning and purposes of triangulation inresearch. Shipman (1988, p. 114) states thattriangulation is the technical term for two ormore methods of collecting data. The goal oftriangulation in any study is to enhance thevalidity and credibility of findings because ofthe weaknesses of any single method (Patton1990, p. 244). Thematic analysis of the data wasalso undertaken as it is an appropriateanalytical approach for applied researchparticularly in nursing, education,

Table 3 Organisational constraints contributing to slippa

Staff shortages exacerbated by influenza over the winter pWinter pressure on intensive care and high dependency beRecovery staff had to provide these care facilities in additiRecovery staff had to work overtime for a six week period tominimum of two hours to meet surgeons’ targets

Increased clinical workload for the Recovery Sister due to s

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organisational behaviour and management(Boyatzis 1998, p. viii).

The evolving process

The ongoing involvement of key stakeholderswas an essential part of the action researchprocess. Within the NHS hospital, the Directorof Nursing was considered both manager andtransformational leader (Dunham & Klafehn1990). She participated in the study at both thestrategic and operational level. By initiallychairing both the Steering Group & ProjectBoard meetings she met with representativesfrom the three organisations and had directfeedback from the co-researchers (who wereinvited to attend all meetings). The opencommunication process both enabled andempowered the front-line co-researchers todirectly influence the development of thestudy.

Within the action learning sets the facilitatorshelped to create a psychologically safeenvironment for individual and collectivecritical thinking and reflection, sharing ofknowledge, identification of knowledge gaps,development and exploration of action plans,ongoing evaluation of clinical developments. Itwas important not to raise false expectations,since the developmental journey wouldunderstandably be different and potentiallychallenging for each co-researcher. An enablingstrategy, undertaken at the first action learningset, was an individual and team valuesclarification exercise. This enabled theco-researchers and facilitators to:

focus on what was personally andprofessionally important to them in practiceconsider how to operationalise theirvalues in the future, particularly whendeveloping practice.

ge of the time-scale

eriodds locally and nationallyon to their normal nursing dutiesaccommodate operating lists which were extended by a

ick leave in the Department


Table 4 Themes reflecting the co-researchers’ expe-rience of change and development in phase one of theproject

Enlightening personal journeyExploring the research–practice gapEnhanced personal and professional knowledgeand understanding

Evolving cultural change & collaborative workingEmpowering and disempowering messages


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A flexible approach to research, working andlearning is required in dynamic clinicalenvironments. Organisational constraintsresulted in slippage of the time-scale (Table 3).

Process outcomes

The co-researchers’ collaborative learning andworking resulted in the initiation of threepatient-focused projects: pre-operativefasting times in the older trauma patient;post-operative patient controlledanalgesia; inadvertent peri-operativehypothermia.

Analysis of the data enabled the explicationof 27 process outcome categories. The 27categories have been grouped into 5 themeswhich reflect change and development for theco-researchers (Table 4).

Enlightening personal journey

Each of the co-researchers demonstratedongoing positive and painful enlightenmentthrough their own personal development andparticipation in the action learning sets. Theyinitially started to challenge traditionalapproaches to nurse education. For example:

There is still this sort of culture of gettinga certificate and that’s it. . .not how hasthis helped you in your practice?

They [colleagues] go to a teaching sessionor study day, their practice still doesn’tchange, why is that?

But isn’t it part of professional practice toactually look at your practice and try toimprove it, advance it. . .

Increasingly the co-researchers acknowledgedthe need for evidence based practice:


There is a lot of information around andlots of stuff we already know so whyaren’t we actually putting it into practice?For example starvation of patients. Thisresearch has been around for over 17years. It’s not to do with the fact thatnurses don’t know about it because nursesdo know about it. . . In pre-op starvationthere are lots of recommendations forgood practice but they’re not being carriedout. It’s that gap, implementing it, that’swhat action research is about.

There’s so much literature [on the chosentopic] it’s unbelievable.

Exploration of theresearch–practice gap

The following examples clearly demonstrateresearch appreciation over time. Work basedlearning has also enabled insight into the needfor realistic approaches for applying researchin practice. For example:

Research. . .makes you question whatyou’re doing.

Action research seems quite daunting butwhen you get down to it, you actually cando it.

It’s [research] seen as elitist. . .that [view]should be changed, more people shouldbe involved.

I want to read more and also think a bitmore. . .but the main outcome would beto try and change practice.

It’s been documented for over twentyyears. . . it’s incredible. . . yet still notimplemented.

We do get patients who are extremelycold. What I’d like to do is an audit tostart with. . .to actually see where they aregetting cold [considering a hypothermiaproject]. If they are cold to start with, or ifthey are cold in the pre-operative periodor. . .Nothing in the literature about awarmth scale.



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I want some definite figures and definiteinformation that patients have starved toolong on the ward.

Enhanced personal and professionalknowledge and understanding

The co-researchers felt able to share their ideas,the gaps in their knowledge, and recognised theimportance of time for thinking and reflectingon nursing research and practice.

Actually it is very interesting. . .this feelingthat you have to churn out so many pagesbefore you’ve achieved anything[traditional academic approach]. It’s thethinking that goes behind anything thatyou do, before you write it down, which isimportant. . .even things I wouldn’t havethought about before I started it [theproject].

Y said that using the audit tool showed acouple of things that hadn’t occurred toher like. . . You may find the same thingafter your first interview, you may wantto adapt your questionnaire. (Facilitator)

Evolving cultural change andcollaborative working

As the sharing of ideas and knowledge withtheir peers progressed the co-researchersstarted to recognise the slowly evolvingcultural change within the department:

Eventually it starts to rub off on thoseothers who are quite sceptical, evenresistant. . .they start to come round.

The impression I got was that [Director ofNursing] was surprised that there wassome positive feedback so soon becausepeople tend to be sceptical, quiteunderstandable. But there is interestand certainly beyond Recovery, in theSurgical Unit.

I think you see what you’ve done, you’vegot yourself some very useful data andnow that’s making you re-think what youwere initially going to do. But it’s much

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more realistic because it’s come from thenurses in the ward and it’s their feelingsabout PCA [patient controlledanalgesia]. . .you must start with wherethey are at and explore that. (Facilitator)

Personal assumptions were shared whichmay be based on unfounded beliefs:

I think sometimes it stops people doingthings because you anticipate you aregoing to get a negative response [frompeers] but often the opposite happens.That’s often the case when you pose theidea in front of medics as well. You thinkthat nobody’s going to be interested, whybother? But often you do get really goodsupport or they certainly appear to beinterested.

Initiating collaboration was central todiscussions within the action learning sets.Ward staff wished to work with theco-researchers to explore patient problemswhich they too recognised as requiringimprovement:

There are three young staff nurses thatare very, very keen to be involved in whatI’m doing.

It [the patient issue] is definitely ownedby them [the ward staff].

They [ward staff] were very keen tochange the practice in this area and theyfeel there is a way to try and improve inthe audit as well. . .

Patients come down and we check themand we ask them and they have quiteobviously been starved from early onand on the checklist it may say 12midnight. . .when you actually askthem. . .sometimes 5 o’clock the daybefore. . .some patients are being starvedfor 12 h. . .they’re being starved 15, 16 h. . .I was wondering how receptive the wardstaff would be to collaborating in theproject. . .[they were] quite enthusiasticand very positive actually.

But I’d really like the patients’ experiencesmore than anything. Although



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physiologically there are implicationswhich are demonstrated in the literaturebut when you’re talking about thesubjective part, you’re talking about thepatients’ experiences.

So having informed Dr Z and got him onboard, at what point are you going to. . .?

It is important to recognise the amount ofpersonal development that has occurred in theco-researchers since the inception of the study.Also the change process and potential impacton the quality of care for patients is not only tobe seen within the Recovery area but has beenrecognised both within the operating theatreand the surgical areas that are collaboratingwith the projects. The senior manager of theacute unit revealed:

I think it’s [the whole study] got hugepotential. . . The culture is changing.There are more people looking to becomeinvolved.

Empowering and disempoweringmessages

Within the study, empowerment in practicewas defined as feeling and being able to initiateaction for personal and professionaldevelopment. Empowering processes reflectedchanges in the nature of the power relationshipbetween the co-researchers, managers, thehealth care team. Personal and peer (includingmedical staff) recognition of the value of thestudy and ongoing developments alsocontributed to feelings of empowerment.

We were talking about empowerment . . .she [Director of Nursing] hasempowered us to undertake the sort ofthings that need to be done in our ownarea. . .

It was interesting when I was speaking toRecovery staff. . . there was quite a lot ofsupport for the project. . . that’s great afterjust a year.

Nothing is quite as transferable as learn-ing to appraise the evidence so that youcan put it into practice. . . And that’s


helped me move my thinking on a longway. . . it’s also helping me to see whereI’m going professionally and focused medown into certain areas, whereas when Istarted the project I really had no idea.

You should have seen V [colleagueco-researcher] in action because it wasfrom the heart wasn’t it?

That’s a very significant piece of work[audit tool for pre-operative fasting] andreally, really valuable.

I’ve done quite an extensive literaturesearch and I’d really like to publish it.

Bottom up stuff–frightening for some

Phase one of the study has been undertakenwithin an organisational climate of competingpriorities, the resignation of the Director ofNursing, and a local merger with another NHShospital. These structural influences candestabilise the work place and certainlyimpacted on the study. The most difficultoutcome for the facilitators and co-researchershas been an overt reduction in corporatemanagement support for the study, including(to date) no financial support for phase two.Of fundamental importance is the need forthe Workforce Confederation and seniormanagers to recognise that Trust-wideeducational developments require at theminimum two years funding. Also, if allpractitioners are to be supported inaccreditation of work-based learning indynamic settings, then an approach to staffdevelopment that recognises the need for aflexible time-scale is required.

But you don’t empower people and thendisempower them. . .in some ways it’svery disconcerting and quite ruthless to dothat and it isn’t how you go about raisingmorale, standards, enhancing the qualityof care. All these things are the aims of thehospital now and certainly come fromGovernment policy in relation to clinicalgovernance and evidence based practice,so it’s really mixed messages. (Facilitator)




What really concerns me about thewhole thing is whether they [corporatemanagement] have any moralobligation. . .if you actually give someonethe chance for self development, to start aproject, & then pull the rug. . .what is thethinking behind that?. . .they can’t ignorethe fact that what you’re doing ischanging yourself, changing yourpractice, changing the organisationalculture. . . (Facilitator)

Whilst there has been management support forthe study, transformational leadership was notconsidered by some of the corporatestakeholders:

It could be some powerful things. . .youthink of collaborative working, and youthink of empowering people. . .bottom upstuff. . .frightening for some. (Manager)

Transformational leadership is needed forsuccessful completion of phase 1. During thetransition phase of the newly merged hospitalsan assurance was given by nurse managersthat the three patient-focused initiatives inphase one would be supported to completion.The co-researchers were, at that time, nearingcompletion of their projects and were preparingfor accreditation submission for first degreeor Masters level credits. The University hasmaintained its commitment to supportingthe co-researchers until the accreditationprocess is complete (according to the universityguidelines). However, hospital support iscurrently ‘on hold’ and constraints havebeen imposed upon facilitation of theco-researchers’ research activities.

Conclusion

The study has demonstrated the commitmentof the co-researchers and the facilitators toadvance personal and practice development inspite of organisational constraints. Aframework for practice development hasbegun to evolve encompassing integratedprocesses for:

greater self-awareness and appreciation ofpeer support,enhanced understanding of the need forevidence based practice and action research,

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involvement in strategies for personal,collective and patient/user empowerment,participation in co-operative andcollaborative working and learning,insight into strategic and operationalleadership and management strategies tosupport practice development.

However, there needs to be a realisticunderstanding by both corporatemanagement of hospitals and the WorkforceConfederation of the organisationalconstraints on project advancement whenundertaking work based learning andinnovation within dynamic clinicalenvironments. These constraints directlyaffect the individual nurse/co-researcherand impact on the time-scale of the projectand on funding arrangements. Short termfunding arrangements are inappropriate fordevelopment purposes.

The process for nurses of undertakingchange and personal, professional practicedevelopment in a hospital is both challengingand potentially empowering. A critical actionresearch methodology enables nurses tosystematically value, critique, enhance andintegrate their experiential and theoreticalevidence based knowledge for undertakingcollaborative patient-focused qualityimprovement. This approach to working andlearning needs wider understanding,recognition and critique.

References

Bellman L 2003 Nurse-led change and development inclinical practice. Whurr, London

Boyatzis RE 1998 Transforming qualitative information.Sage, Thousand Oaks

Carr W, Kemmis S 1986 Becoming critical: education,knowledge and action research. Falmer, London

Coughlan D, Brannick T 2001 Doing action research in yourown organisation. Sage, London

Crane S 1991 Implications of the critical paradigm. In: GrayG, Pratt R (eds.) Towards a discipline of nursing.Churchill Livingstone, Melbourne

Duffy K, Scott PA 1998 Viewing an old issue through a newlens: a critical theory insight into the education–practicegap. Nurse Education Today 18:183–189

Dunham J, Klafehn KA 1990 Transformational leadership &the nurse executive. Journal of Nursing Administration20:28–34

Edmonstone J 1995 Managing change: an emerging newconsensus. Health Manpower Management 21:16–19



194 Nurse Educa

Fulton Y 1997 Nurses’ views on empowerment: a criticalsocial theory perspective. Journal of Advanced Nursing26:529–536

Patton MQ 1990 Qualitative evaluation & researchmethods, 2nd ed. Sage, California

Rasmussen S 1997 Action research as authenticmethodology for the study of nursing. In: Thorne SE,Hayes VE (eds.) Nursing praxis, knowledge and action.Sage, Thousand Oaks

Shipman M 1998 The limitations of social research, 3rd ed.Longman, London


Stevens PE 1989 A critical social reconceptualisation ofenvironment in nursing: implications for methodology.Advances in Nursing Science 11:56–68

Stevens PE, Hall JM 1992 Applying critical theories tonursing in communities. Public Health Nursing 9:2–9

Stringer E 1996 Action research: a handbook forpractitioners. Sage, Thousand Oaks

Zuber-Skerritt O 1996 Emancipatory action research fororganisational change & management development. In:Zuber-Skerritt (ed.) New directions in action research.Falmer, London


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Advancing working and learning through critical action research: creativity and constraints