Education and debate

Qualitative research in health care

Using qualitative methods in health related action research
Julienne Meyer

This is the last The barriers to the uptake of the findings of traditional
in a series of quantitative biomedical research in clinical practice are Summary points
three articles increasingly being recognised.1 2 Action research is
particularly suited to identifying problems in clinical Action research is increasingly being used in
City University, practice and helping develop potential solutions in healthcare settings
St Bartholomew order to improve practice.3 For this reason, action
School of Nursing
and Midwifery, research is increasingly being used in health related It is a style of research rather than a specific
London E1 2EA settings. Although not synonymous with qualitative method
Julienne Meyer research, action research typically draws on qualitative
professor of adult
nursing methods such as interviews and observation. Three elements are important: the participatory
character of action research; its democratic
Series editors:
Catherine Pope and impulse; and its simultaneous contribution to
Nicholas Mays social science and social change
What is action research?
BMJ 2000;320:178–81
Action research is not easily defined. It is a style of
research rather than a specific method. First used in
Participation in action research
1946 by Kurt Lewin, a social scientist concerned with
intergroup relations and minority problems in the Participation is fundamental to action research: it is an
United States, the term is now identified with research approach which demands that participants perceive
in which the researchers work explicitly with and for the need to change and are willing to play an active
people rather than undertake research on them.4 Its part in the research and the change process. All
strength lies in its focus on generating solutions to research requires willing subjects, but the level of com-
practical problems and its ability to empower mitment required in an action research study goes
practitioners—getting them to engage with research beyond simply agreeing to answer questions or be
observed. The clear cut demarcation between
and subsequent “development” or implementation
“researcher” and “researched” that is found in other
activities. Practitioners can choose to research their
types of research may not be so apparent in action
own practice, or an outside researcher can be engaged
research. The research design must be continually
to help them identify problems, seek and implement
negotiated with participants, and researchers need to
practical solutions, and systematically monitor and agree an ethical code of practice with the participants.6
reflect on the process and outcomes of change. This is especially important as participation in the
Most definitions of action research incorporate research, and in the process of change, can be
three important elements: its participatory character; threatening.7 8 Conflicts may arise in the course of the
its democratic impulse; and its simultaneous contribu- research: outside researchers working with practition-
tion to social science and social change.5 ers must obtain their trust and agree rules on the con-
trol of data and their use and on how potential conflict
will be resolved within the project. The way in which
such rules are agreed demonstrates a second
important feature of action research—namely, its
democratic impulse.

Democracy in action research

“Democracy” in action research usually requires
participants to be seen as equals. The researcher works
as a facilitator of change, consulting with participants
not only on the action process but also on how it will be
evaluated. One benefit of this is that it can make the
research process and outcomes more meaningful to
practitioners, by rooting them in the reality of day to
day practice.
Throughout the study, findings are fed back to par-
ticipants for validation and to inform decisions about
the next stage of the study. This formative style of
research is thus responsive to events as they naturally
occur in the field and frequently entails collaborative
spirals of planning, acting, observing, reflecting, and
LIANE PAYNE

replanning. However, care needs to be taken in this

process as it can be threatening: democratic practice is

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Copyright © 2000. All rights reserved.

 Education and debate

not always a feature of healthcare settings. An action Practice) emphasise that research and development
researcher needs to be able to work across traditional should be the business of every clinician. Practitioner
boundaries (for example, between health and social led research approaches, such as single case experi-
care professionals or between hospital and community mental designs,10 reflective case studies,11 and reflexive
care settings) and juggle different, sometimes compet- action research,12 are seen as ideal research methods
ing, agendas. This requires excellent interpersonal for clinicians concerned with improving the quality of
skills as well as research ability. patient care.13
In considering the contribution of action research
to knowledge, it is important to note that generalisa-
Contribution to both social science and
tions made from action research studies differ from
social change those made on the basis of more conventional forms of
There is increasing concern about the “theory-practice” research. To some extent, reports of action research
gap in clinical practice; practitioners have to rely on their studies rely on readers to underwrite the account of the
intuition and experience since traditional scientific research by drawing on their own knowledge of human
knowledge—for example, the results of randomised con- situations. It is therefore important, when reporting
trolled trials—often does not seem to fit the uniqueness action research, to describe the work in its rich contex-
of the situation. Action research is seen as one way of tual detail. The researcher strives to include the partici-
dealing with this because, by drawing on practitioners’ pants’ perspective on the data by feeding back findings
intuition and experience, it can generate findings that to participants and incorporating their responses as
are meaningful and useful to them. new data in the final report. In addition, the onus is on
The level of interest in practitioner led research is the researcher to make his or her own values and
increasing in Britain, in part as a response to recent beliefs explicit in the account of the research so that
proposals to “modernise” the NHS through develop- any biases are evident. This can be facilitated by writing
ing new forms of clinical governance.9 This and other self reflective field notes during the research.
national initiatives (the NHS Research and Develop- The strength of action research is its ability to influ-
ment Strategy, the National Centre for Clinical Audit, ence practice positively while simultaneously gathering
the NHS Centre for Reviews and Dissemination, the data to share with a wider audience. However, change
Cochrane Collaboration, Centres for Evidence Based is problematic, and although action research lends

Action research typology (adapted from Hart and Bond)3

Consensus model of society ß © Conflict model of society
Rational social management Structural change
Action research type:
distinguishing criteria Experimental Organisational Professionalising Empowering
1 Educative base Re-education Re-education or training Reflective practice Consciousness raising
Enhancing social science or administrative Enhancing managerial control and Enhancing professional control and Enhancing user control and shifting
control and social change towards consensus organisational change towards individuals’ ability to control work balance of power; structural change
consensus situation towards pluralism
Inferring relationship between behaviour and Overcoming resistance to change or Empowering professional groups; Empowering oppressed groups
output; identifying causal factors in group restructuring balance of power advocacy on behalf of patients or
dynamics between managers and workers clients
Social scientific bias, researcher focused Managerial bias or client focused Practitioner focused User or practitioner focused
2 Individuals in groups Closed group, controlled, selection made by Work groups or mixed groups of Professional(s) or (interdisciplinary) Fluid groupings, self selecting or
researcher for purposes of measurement, managers and workers, or both professional group, or negotiated natural boundary or open/closed by
inferring relationship between cause and effect team boundaries negotiation
Fixed membership Selected membership Shifting membership Fluid membership
3 Problem focus Problem emerges from the interaction of Problem defined by most powerful Problem defined by professional in Emerging and negotiated definition of
social science theory and social problems group; some negotiation with users group; some negotiation with users problem by less powerful group(s)
Problems relevant for social science or Problem relevant for Problem emerges from professional Problem emerges from members’
management interests management/social science interests practice or experience practice or experience
Success defined in terms of social sciences Success defined by sponsors Contested, professionally determined Competing definitions of success
definitions of success accepted and expected
4 Change of intervention Social science experimental intervention to Top down, directed change towards Professionally led, predefined, process Bottom up, undetermined, process
test theory or generate theory, or both predetermined aims led led
Problem to be solved in terms of Problem to be solved in terms of Problem to be resolved in the Problem to be explored as part of
management aims management aims interests of resolved in the interests the process of change, developing an
of research based practice and understanding of meaning of issues
professionalisation in terms of problem and solution
5 Improvement Toward controlled outcome and consensual Towards tangible outcome and Towards improvement in practice Towards negotiated outcomes and
definition of improvement consensus definition of improvement defined by professionals and on pluralist definitions of improvement:
behalf of users account taken of vested interest
6 Cyclic processes Research components dominant Action and research components in Research and action components in Action components dominant
tension; action dominated tension; research dominated
Identifies causal processes that can be Identifies causal processes that are Identifies causal processes that are Changes course of events;
generalised specific to problem context or can specific to problem or can be recognition of multiple influences
be generalised, or both generalised, or both upon change
Time limited, task focused Discrete cycle, rationalist, sequential Spiral of cycles, opportunistic, dynamic Open ended, process driven
7 Research relationship, Experimenter or respondents Consultant or researcher, respondent Practitioner, or researcher or Practitioner researcher or
degree of collaboration or participants collaborators coresearchers or co-change agents
Outside researcher as expert or research Client pays an outside consultant— Outside resources or internally Outside resources or internally
funding “they who pay the piper call the tune” generated, or both generated, or both
Differentiated roles Differential roles Merged roles Shared roles

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Copyright © 2000. All rights reserved.

Education and debate

itself well to the discovery of solutions, its success Different types of action research
should not be judged solely in terms of the size of
change achieved or the immediate implementation of Four basic types of action research have been
solutions. Instead, success can often be viewed in identified: experimental, organisational, professionalis-
relation to what has been learnt from the experience of ing, and empowering (table).3 Though this typology is
undertaking the work. For instance, a study which set useful in understanding the wide range of action
out to explore the care of older people in accident and research, its multidimensional nature means that it is
not particularly easy to classify individual studies. For
emergency departments did not result in much change
instance, a study might be classified as “empowering”
in the course of the study.14 However, the lessons learnt
because of its “bottom up approach” in relation to the
from the research were reviewed in the context of
fourth distinguishing criterion of “change interven-
national policy and research and carefully fed back to
tion,” but the other distinguishing criteria may be used
those working in the trust; as a result, changes have
to classify the same study as a different action research
already been made within the organisation to act on
type (experimental, organisational, or professionalis-
the study’s recommendations. Some positive changes
ing). This situation is most likely to occur if the
were achieved in the course of the study (for example,
researcher and practitioners hold differing views on
the introduction of specialist discharge posts in
the nature of society. It may be more fruitful to use this
accident and emergency departments), but the study
typology as a framework for critiquing individual stud-
also shed light on continuing gaps in care and issues
ies and, in particular for thinking about how concepts
that needed to be improved in future developments.
are operationalised, the features of particular settings,
Participants identified that the role of the “action
and the contribution of the people within those
researcher” had enabled greater understanding and
settings to solutions.15
communication between two services (the accident and
emergency department and the department of
medicine for elderly people) and that this had left both
Action research in health care
better equipped for future joint working. In other
words, the solutions emerged from the process of At a time when there is increasing concern that
undertaking the research. research evidence is not sufficiently influencing
practice development,16 action research is gaining
credibility in healthcare settings.17 For example, the
Lay participation in care in a hospital setting: an action Royal College of Physicians in England has become
research study involved in an action research study exploring the roles
of clinicians, clinical audit staff, and managers in
Participation
implementing clinical audit and ways of overcoming
• Careful negotiation to recruit willing volunteers to examine practice and organisational barriers to audit.18 The NHS Research
initiate lay participation in care
and Development Programme has commissioned a
• “Bottom up” approach to change via weekly team meetings
systematic review of the action research. Elsewhere
• Researcher as facilitator and multidisciplinary team member
Ong has used “rapid appraisal,” a type of action
Democracy research, to engage users in the development of health
• Goal of empowering practitioners and lay people in this setting care policy and practice.19
• Working collaboratively with multidisciplinary team Action research has also been used in hospital
• Participants given “ownership” of the data to determine how it might be settings to facilitate closer partnerships between staff
shared with wider audience and users, notably in a study which focused on the intro-
duction of lay participation in care within a general
Contribution to social science and social change
medical ward of a London teaching hospital (box). This
• Case study of multidisciplinary team on one general medical ward in
London teaching hospital using: study used a range of methods, including depth
Qualitative methods to highlight key themes emerging in the project interviews, questionnaires, documentary analysis, and
Quantitative methods for comparison of subgroups participant observation to generate data about health
professionals’ perceptions of lay participation in care
Main action-reflection spirals
and the difficulties encountered in changing practice.20 21
• Reorganising the work of the ward:
Changes in patient care planning
In this study, health professionals expressed extremely
New reporting system, including bedside handover with patient positive views about user and carer involvement when
Introduction of modified form of primary nursing system completing an attitude scale, confirming the results of
• Multidisciplinary communication: previous research on health professionals’ attitudes
Weekly team meetings instituted towards user and carer involvement in care.22 However,
Introduction of a handout for new staff and team communication sheet the interview data showed that they had some serious
Closer liaison with community nurses before discharge doubts and concerns, and observation of practice
• Lay participation in care: revealed that these doubts and concerns were
Development of resources for patient health education inhibiting the implementation of lay participation. This
Introduction of medicine reminder card system
Patient information leaflet inviting patients to participate in care
action research was able to explore the relation
between attitudes and practices and explain what hap-
Results pened when lay participation was introduced into a
• Insights into health professionals’ perceptions of lay participation in care practice setting. It showed that although current policy
• Some positive changes achieved (for example, improved attitudes to lay documents advocate lay participation in care (user and
participation in care, patient education, improved ward organisation) carer involvement), some health professionals were
• Identified barriers to changing healthcare practice merely paying lip service to the concept and were also
inadequately prepared to deliver it in practice. By

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Copyright © 2000. All rights reserved.

 Education and debate

2 Hicks C, Hennessy D. Mixed messages in nursing research: their

contribution to the persisting hiatus between evidence and practice. J Adv
Further reading Nurs 1997;25:595-601.
3 Hart E, Bond M. Action research for health and social care: a guide to practice.
Hart E, Bond M. Action research for health and social care. Buckingham: Open University Press, 1995.
A guide to practice. Buckingham: Open University Press, 4 Reason P, Rowan J. Human inquiry: a sourcebook of new paradigm research
1995. Chichester: Wiley, 1981.
5 Carr W, Kemmis S. Becoming critical: education, knowledge and action
Susman GI, Evered RD. An assessment of the scientific research. London: Falmer, 1986.
merits of action research. Administrative Science 6 Meyer JE. New paradigm research in practice: the trials and tribulations
Quarterly 1978;23:582-603. of action research. J Adv Nurs 1993;18:1066-72.
7 Webb C. Action research: philosophy, method and personal experiences.
J Adv Nurs 1989; 14:403-10.
8 Titchen A, Binnie A. Changing power relationships between nurses: a
case study of early changes towards patient-centred nursing. J Clin Nurs
working closely with practitioners to explore issues in a 1993;2:219-29.
practical context, the researcher gained more insight 9 Secretary of State for Health. The new NHS. London: Stationery Office,
1997. (Cm 3807.)
into how the rhetoric of policy might be better 10 Carey LM, Matyas TA, Oke LE. Sensory loss in stroke patients: effective
translated into reality. training of tactile and proprioceptive discrimination. Arch Phys Med Rehab
1993;74:602-11.
11 Stark S. A nurse tutor’s experience of personal and professional growth
through action research. J Adv Nurs 1994;19:579-84.
Conclusions 12 Titchen A, Binnie A. What am I meant to be doing? Putting practice into
theory and back again in new nursing roles. J Adv Nurs 1993;18:1054-65.
Action research does not focus exclusively on user and 13 Rolfe G. Expanding nursing knowledge: understanding and researching your
carer involvement, though clearly its participatory own practice. Oxford: Butterworth Heineman, 1998.
principles makes it an obvious choice to explore these 14 Meyer J, Bridges J. An action research study into the organisation of care of
older people in the accident and emergency department. London: City Univer-
issues. It can be used more widely—to foster better sity, 1998.
practice across interprofessional boundaries and 15 Lyon J. Applying Hart and Bond’s typology; implementing clinical super-
vision in an acute setting. Nurse Researcher 1999;6:39-53.
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It can also be used by clinicians to research their own 1995;105:28-9.
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20 Meyer JE. Lay participation in care: a challenge for multi-disciplinary
helps to explain the frequent use of qualitative This article is taken
teamwork. J Interprofess Care 1993;7:57-66.
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Wilson-Barnett J, Macleod Clark J, eds. Research in health promotion and edition of
nursing. London: Macmillan, 1993:86-100. Qualitative Research
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An unusual treatment
Feeding the fish

The revival of the use of living organisms to help in treating told me that the practice of bathing limbs in pools for fish to help
illnesses has grabbed the attention of the media recently. Reports healing was widespread; in particular, mothers brought their
of the use of leeches in plastic surgery and maggots in children to be cured of scabies. The fish live in polluted water
dermatology raise the question of which other animals may be of where they survive by both aerial and gill respiration, possessing
benefit, a concept some call “biotherapy.” While there are accessory labyrinthine organs. Their preferred food is mosquito
promising studies of the use of maggots to help the healing of larvae, and as they eat constantly they do not need starving
necrotic and infected wounds, those wounds with high moisture before use, unlike some species of maggots. Once drawn to the
content defy even the larvae. Rumours of healing fish had limb by substances which diffuse from the wound into the water,
reached Professor John Church, chairman of the International they eat, enjoying living and dead tissue equally. Although they
Biotherapy Society. Perhaps organisms which live in an aquatic nibble at the necrotic tissue faster, the eating of the living tissue
environment could help to heal “wet wounds,” he mused. We
can be quite painful. Perhaps we are not all ready to have our
received anecdotes of the widespread use of such fish in southern
British wounds nibbled away, but with the use of local anaesthetic
India, and so, while travelling through the region, I decided to
cream before treatment, the day may yet come where
hunt down the practice in order to see if it worked. To my
surprise, the practice was well known, particularly in rural areas. dermatology departments offer maggot treatment for the drier
Locals with skin infections, infestations, and wounds would bathe lesions, and the “biopool” for the wetter ones.
the affected limb in the pond, while certain fish would be drawn Jonathan Cohen, senior house officer, Enfield
to the lesion and nibble at it, thereby removing diseased tissue.
After some searching I discovered Rishimangalam Tank, a local We welcome articles of up to 600 words on topics such as A
“holy pond” in the centre of Trivandrum, Kerala State. Through memorable patient, A paper that changed my practice, My most
the services of an interpreter, some local boys were happy to unfortunate mistake, or any other piece conveying instruction,
collect some fish they recognised, using their dhotis as fishing pathos, or humour. If possible the article should be supplied on a
nets. My intention had been to pickle them in a jar of gin for later disk. Permission is needed from the patient or a relative if an
identification. However, by coincidence, that very evening I met identifiable patient is referred to. We also welcome contributions
Professor Padmanabham of the fish biology department at the for “Endpieces,” consisting of quotations of up to 80 words (but
University of Kerala. He was familiar with Macropodus cupanus, the most are considerably shorter) from any source, ancient or
fish which he identified for me, as he had written a thesis on it. He modern, which have appealed to the reader.

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