Chapter 7: Action Research

What is action research?

The key concept in action research is change or action.

Action research (also known as ‘participatory action research’) aligns well with the practice of health and social care because researchers and practitioners in this discipline work with people and communities in holistic and relational ways to understand the history, culture and context of the setting. Action research aims to understand the setting and improve it through change or action.¹ This method has its roots in activism and advocacy and is focused on solutions. It is practical and deals with real-world problems and issues. Action research often undergoes phases in seeking to understand the problem, plan a solution, implement the solution and then reflect on or evaluate the solution, cyclically and iteratively. Action research is used in the practice of health and social care because it has two fundamental aims: to improve and to involve. This chapter outlines how this is evident, using examples from the research literature (see Table 7.1.).

Action research as involvement

Action research is a collaborative process between researchers and community members. This process is a core component of action research and represents a significant shift from typical research methods. Through action research, those who are being researched become the researchers, with close consideration given to power dynamics. The research participants become partners in the research and are involved in identifying and prioritising the research area, designing and undertaking data collection, conducting data analysis, and interpreting and disseminating the results.¹ The research partners may be provided with support and training to enable them to undertake these activities and to promote empowerment and capacity building (see examples following). Patient and public involvement in research and healthcare improvement (known in Australia as ‘consumer and community involvement’), has led to action research gaining popularity as a research design that captures the ‘living knowledge’ with, for and by people and communities throughout the research journey.

As an example, in the project Relationships Matter for Youth ‘Aging Out’ of Care,² Doucet and colleagues aimed to examine relationships that matter to young people in care and how these relationships can be nurtured and supported over time. The project is a collaborative participatory action research study incorporating photovoice (see Chapter 17 for more information on photovoice). Eight young people, formerly in care and from diverse backgrounds, were recruited to the study. The lead researcher highlighted their own lived experience of the child welfare system and a consciousness of the power dynamics at play. The lead researcher created processes within the project to ensure the youth co-researchers were empowered to share their experiences and that the research team members were working with the youth co-researchers and not for them. These processes included three months of weekly facilitated group discussions, shared meals before project commencement and group outings and community engagement during the project to encourage connection, bonding and trust. The youth co-researchers were provided with photography training and digital cameras. Data collection included the youth co-researchers submitting 6–7 photographs with responses to the following questions for photo contextualisation:

1. 1. 1. What does this photograph mean to you? Why is this photo, in particular, most significant to you?
      2. How do you see this photo as a reflection of the issue of supportive long-term relationships – and one that is relevant to you as a former youth in care in your community?
      3. What is the relationship between the content of the photo and how you perceive the community or the world around you? What recommendation for change in your community is associated with this photo?^2(para22)

The photographs were showcased at an exhibition that was open to the community; those in attendance included policymakers, advocates and community representatives. The change documented through this project was one of social transformation for the community and self-transformation and healing for the individuals.

Action research as improvement

Action research can be practitioner-led, whereby the study investigates problems identified by the practitioner with the goal of understanding and improving practice over time. Improvement can be both social improvement and healthcare improvement. Healthcare improvement, in particular quality (of healthcare) improvement, has been the focus of clinical practice, research, education and advocacy for more than 30 years. The two main frameworks guiding healthcare and quality improvement efforts are the Plan, Do, Study, Act (PDSA) cycle and Learning Health Systems.³ Both of these frameworks lend themselves to action research. For example, the PDSA cycle is guided by three overarching questions:

• • • • What are we trying to accomplish?
      • How will we know that a change is an improvement?
      • What change can we make that will result in improvement?^4(Figure1)

Learning Health Systems is another approach to quality improvement that has gained popularity over the past decade. Data collected by health services (e.g. patient data, health records, laboratory results) are used for knowledge creation in continuous and rapid cycles of study, feedback and practice change.⁵ A Learning Health Systems framework incorporates systems science, data science, research methods for real-world contexts, implementation science, participatory research and quality improvement approaches.

Van Heerden and colleagues adopted an action research study to transform the practice and environment of neonatal care in the maternity section of a district hospital in South Africa. The study Strategies to sustain a quality improvement initiative in neonatal resuscitation⁶ was conducted in three cycles. Cycle 1 was a situation analysis that explored and described the existing practices and factors influencing neonatal resuscitation and mortality in the hospital through administering questionnaires with nurses (n=69); a focus group with nine doctors; and an analysis of hospital records. A nominal group discussion (structured group discussion including prioritisation) was conducted with 10 managers and staff, followed by a reflective meeting with the project’s steering committee. Cycle 2 developed and implemented strategies to sustain a quality improvement initiative. The strategies addressed training, equipment and stock, staff attitudes, staff shortages, transport transfer for critically ill neonates, and protocols. Cycle 3 was an evaluation of change and sustainability after the implementation of strategies (Cycle 2) and involved the analysis of hospital record data, repeat questionnaire with nurses (n=40), focus group discussion with 10 doctors, steering committee and management members, followed by reflective meetings with the steering committee. Qualitative data was analysed through open coding, and quantitative data was analysed descriptively. The neonatal mortality rate declined (yet still needed to improve) and the implementation strategies facilitated change that led to improvement and practice transformation.

Action research as a methodology or an approach

There is debate as to whether action research is a methodology or an approach, since several different research methods and methodologies can be used. For example, multiple forms of data collection can be utilized, including quantitative data from surveys or medical records, to inform the identification and understanding of the problem and evaluation of the solution. Action research can also draw on descriptive qualitative research, quantitative cross-sectional studies, case studies (see Chapter 8), ethnography (Chapter 9) and grounded theory (Chapter 10). Action research can therefore take a purely qualitative approach, or can take a mixed-methods approach. See Table 7.1. for examples of action research studies.

Advantages and disadvantages of action research

Action research addresses practical problems, drawing on principles of empowerment, capacity-building and participation. The research problem to be addressed is typically identified by the community, and the solutions are for the community. The research participants are collaborators in the research process. The examples presented in this chapter demonstrate how the research collaborators and co-researchers received training and support to lead elements of the project. Another advantage of action research is that it is a continuous cycle of development. Hence, the approach is iterative and the full solution can take multiple cycles and iterations to develop and sustain.^7,8

Since action research is fundamentally about relationships and integrating research into the real world, studies can take years to result in a solution. It is important to be able to adapt and be flexible in response to community and stakeholder needs and contexts. The research can therefore be constrained by what is practical and also ethical within the setting. This may limit the scope and scale of the research and compromise its rigour. Action research can also create unanticipated work for community members and participants because they are not usually involved in research in this way, and thus training may be required, as well as remuneration for time and experience.^7,8

Table 7.1. Action research study examples

Summary

Action research is a research design in which researchers and community members work together to identify problems, design and implement solutions and evaluate the impact of these solutions. Change or action is a core component of this research design.

References

1. Baum F, MacDougall C, Smith D. Participatory action research. J Epidemiol Community Health.  2006;60(10):854-857. doi:10.1136/jech.2004.028662
2. Doucet M, Pratt H, Dzhenganin M, Read J. Nothing About Us Without Us: Using Participatory Action Research (PAR) and arts-based methods as empowerment and social justice tools in doing research with youth ‘aging out’ of care. Child Abuse Negl . 2022;130:105358. doi: 10.1016/j.chiabu.2021.105358
3. Taylor J, Coates E, Wessels B, Mountain G, Hawley MS. Implementing solutions to improve and expand telehealth adoption: participatory action research in four community healthcare settings. BMC Health Serv Res. 2015;15:529. doi:10.1186/s12913-015-1195-3
4. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf.  2014;23(4):290-298. doi:10.1136/bmjqs-2013-001862
5. Menear M, Blanchette MA, Demers-Payette O, Roy D. A framework for value-creating learning health systems. Health Res Policy Syst. 2019;17(1):79. doi:10.1186/s12961-019-0477-3
6. Van Heerden C, Maree C, Janse Van Rensburg ES. Strategies to sustain a quality improvement initiative in neonatal resuscitation. Afr J Prim Health Care Fam Med. 2016;8(2):a958. doi:10.4102/phcfm.v8i2.958
7. Liamputtong P. Qualitative Research Methods. 5th ed. Oxford University Press; 2020.
8. Liamputtong P, Ezzy D. Qualitative Research Methods: A Health Focus. Oxford University Press; 1999.
9. Middleton TRF, Schinke RJ, Lefebvre D, Habra B, Coholic D, Giffin C. Critically examining a community-based participatory action research project with forced migrant youth. Sport Soc. 2021;25(2):418-433. doi:10.1080/17430437.2022.2017619