Engagement enacted: Essentials of initiating an action research project

Research setting

The action research project was designed to be conducted in a new ward, a so-called Care Innovation Unit (CIU), in a care facility for elderly people in the Netherlands. In the CIU, which was established by the care facility in collaboration with two schools of nursing, health care providers collaborate intensively with a large group of students to combine care, education, innovation and research (Frost & Snoeren, 2010). The goal was to develop a challenging workplace for practitioners and improve the quality of care using principles of practice development, which Manley, McCormack, and Wilson (2008) define as ‘a continuous process of developing person-centred cultures’ (p. 9). As the organizational structure traditionally had been more hierarchical, through the development of a CIU the management hoped to encourage practitioners not to act solely on tradition and instruction.

The first author, a lecturer at one of the faculties of nursing involved in the CIU project, was hired as a consultant for two days a week to facilitate this process by helping the team to develop their own knowledge and skills and to work towards transformation of the culture and context of care. She was used to working in a non-hierarchical organization in which learning and innovation are highly valued and hoped to operate as a free change agent in the formal structured health care facility. Since action research is known to be well suited to practice development and encourage participation, change and improvement (Manley et al., 2008), the first author set up an action research project. Having read the literature and shared ideas with colleagues involved in action research, she had built up a range of ideals. These would be useful, she thought, once the ward was in operation.

Before the ward opened in September 2007 the first author, hereafter referred to as the (initiating) action researcher, arranged a meeting with the executives and managers involved to promote commitment and partnership between the collaborating organizations. Ideas were shared to clarify the concept of a CIU and to explore the role of the stakeholders in establishing the CIU. Despite differing interests, the participants showed willingness to work together, strong enthusiasm and high expectations.

From the beginning, the action researcher had to work together with the nurse manager, a person regarded highly by the senior management and with a hierarchical position over the practitioners on the ward. Together with the student co-ordinator within the care facility and a nurse teacher from the second nursing faculty, the nurse manager and researcher had to become a team that could effectively support the staff members and the students in working and learning on the ward.

This supporting team also planned how and when to start up the unit. Qualified staff members were selected to join the team and eight half-day meetings were organized with the 12 nurses and healthcare assistants to lay the groundwork for becoming a team. During the meetings, which were facilitated by the researcher, there was time for sharing ideas, critical dialogue and reflection. All parties evaluated the meetings as useful and it seemed as if there was a shared understanding about the goals to achieve and how to work together.

The first months after the CIU had opened were very chaotic. Twenty-two residents, 15 students and the 12 nurses and healthcare assistants came together. The trained staff members were responsible for both supervising the residents and coaching the students, a combination that was new to most of them. After everyone had settled into the new unit, the situation kept changing because of a variety of circumstances. For example, the group of students changed every six months when their placement ended, some staff members left and the care needs of residents altered frequently. The research setting was very dynamic.

Data collection and analysis

To present the researchers’ experiences in setting up the action research project we used an auto-ethnographic approach; an autobiographical genre of writing and research that connects the personal with the cultural to look more deeply at self-other interactions (Ellis & Bochner, 2003; Reed-Danahay, 1997).

During the first six months of the CIU project, the researcher kept daily reflective notes about her experiences. These notes served as field notes for constructing a chronological and detailed story as close as possible to the experiences as the researcher remembered them. This chronological story was shared with four other researchers from different backgrounds, each with expertise in action or qualitative research. One of them was familiar with the research setting, another had also faced difficulties in setting up an action research project.

The peer researchers were asked to express their feelings on reading the story to judge its validity, which means to ascertain if the reader feels that the experience is authentic, believable and possible (Ellis, 1995). In addition, beliefs about crucial events and issues were shared in (one-to-one) dialogues helping the initiating researcher to develop a deeper understanding of the story and to identify key aspects and dynamics (themes). These events and issues were restructured in two short stories, each highlighting one or more identified themes. Reliability was examined by asking the peer researchers to give feedback on these stories. Also, the student-coordinator was asked to give her comments and interpretation of the stories to check their recognizability and representativeness from an insider perspective. Based on this feedback some small changes were made in the wording of the text and the degree of detail.

During the process of writing and (re)constructing the stories, the researcher engaged in reflection on her experiences, which resulted in increased awareness of her own and others’ values and the influence of ideologies. In addition to the writing process, dialogue with others and the use of theory facilitated ‘moving in and moving out to analyse the data from a cultural perspective’ (Ellis & Bochner, 2003) and to alternate between narrative and categorical knowledge in giving meaning to the experiences.

Although we are aware of the role of influencing structures and systems in the research context, our analyses are mainly focused on individual acting and interactions with others to emphasize the impact of and the individual responsibility for relationships. In the next section lived experiences and insights are presented in detail providing opportunities for the reader to have vicarious experience (Stake, 1994) and to test the generalizability of the findings by determining whether they are in line with their own practices.

A normatively laden care practice: Conflicting values

As explained earlier the first seemingly successful steps in opening up the communicative space were taken before the ward was actually established. However, soon after the CIU had started an incongruence between espoused values and theories-in-use (Argyris & Schön, 1974) became visible and frictions arose between the researcher and the nurse manager (Box 1).

Box 1. Determining positions

Three weeks after the CIU had started, the nurse manager decided to organize a meeting for qualified staff members only. Dissatisfaction among team members had grown and she wanted to give staff members the chance to air their concerns. The manager told me she did not want to have me there as the subject of the meeting would only be ‘practical things’. I felt left out and had a strong feeling that I was not taken seriously by her. Furthermore, I did not agree with the exclusion of the students. In my opinion the meeting provided an opportunity to share different perspectives on situations, which could help all concerned to improve their working together as a team. Apparently, we thought differently about my role and position on the ward and valued participation differently. I decided to use every opportunity to share my beliefs about these topics and did so during a meeting with the supporting team (consisting of the nurse manager, nurse teacher, student co-ordinator and myself) that same day. The nurse manager had decided she was too busy to join, but came in unexpectedly after half an hour. She told us that things were tense on the ward and that the different cultures of the team members, who came from different work settings, did not mix well. I had the feeling that she was taking control of the supporting team meeting without asking what was on the agenda. She focused on her own concerns and solutions. For example, the manager was not happy with how and when the daily evaluation took place and felt that the hand-over was not necessary. She wanted to change that. I had the feeling she was pushing her ideas without first asking others what they thought should be done, confirming my view that we had different ideas about decision-making and the involvement of others in these processes. Later during that same meeting I explained my idea about working on the ward and observing situations to discuss them with the team, so that they could decide what they wanted to improve. The nurse manager said that I should not tell the team members that I was observing, because this would scare them off. For me this was ethically unacceptable. I told her it was essential for me to tell the team members what I was doing and why, which provoked a reaction I had not expected. The nurse manager said that although I asked team members how they were doing, I did not do anything with that information when things were busy on the ward. She told me that she expected me to do bed-side work to help reduce the workload and increase the number of nursing hours that could be delivered. I responded in all honesty that I felt I was an outsider and that I was not sure about my role. I explained I was looking for possibilities to build effective relationships and to co-operate with her and the team. She did not respond but repeated that I should deliver care. I saw no opening for further discussion and had the strong impression that I was expected to work on the ward to meet the goals of the nurse manager.

When we analyse this situation, it becomes clear that the nurse manager as well as the researcher were trying to define their roles and positions on the ward, a situation that is similar to Wicks and Reason’s (2009) explanations of the inclusion phase. Moreover, they valued different things and had different perceptions of how knowledge is gained. The researcher promoted dynamics, heterogeneity and inclusion of all stakeholders, whereas the manager valued stability, homogeneity and exclusion of those who were not part of the regular team; the latter three being characteristics of a closed culture (Hofstede & Hofstede, 2005). As is customary in the top-down structures, bureaucratic control and hierarchy that are common in health care organizations (Jacobs, 2006), the nurse manager saw instruction and formal authority as the obvious ways to gain knowledge and insights. Where the manager supported autocracy and top down decision-making, the researcher promoted bottom-up approaches to encourage equality, partnership and democracy as well as the use of dialogue as a vehicle for knowledge production and shared understandings. In this, she differed fundamentally from the nurse manager, who focused on ‘doing’ and ‘acting’ in practice, whereas the researcher valued theoretical insights, learning and change.

Differences in values, interests and power are common and can be enriching when recognized and acknowledged by explicating and discussing them with stakeholders (Brown, Bammer, Batliwala & Kunreuther, 2003; Lavie-Ajayi et al., 2007; Mead, 2002). In this situation, however, there was no genuine dialogue and the incongruence between espoused values and theories-in-use (Argyris & Schön, 1974) were not explicated. The researcher and the manager were trying to persuade each other of the superiority of their own value and belief system. They were not really prepared to explore each other’s perspectives. They did not communicate openly and did not explore the differences and similarities between their views. By adhering to their own values, they triggered mutual stereotypical perceptions of each other. Although differences can be valuable for learning and collaboration, in this situation they created suspicion, distrust and resistance to change; bottlenecks also described by other action researchers (Brown et al., 2003; Lavie-Ajayi et al., 2007).

As a result of her strong individual (instead of joint) engagement, emotional involvement and perhaps lack of outside support, the researcher got lost in the situation and forgot to take an ‘attitude of inquiry’ (Marshall & Reason, 2007). She was unable to step back to reflect upon the situation and as a result unable to respond effectively to events. Based on her values, her theoretical ideas and the prevailing culture and habits in her own workplace, she kept using the same strategies to try and change the situation. These strategies, focusing on spoken communication (like convincing by arguments and showing one’s own vulnerability), did not match with the values of the nurse manager and the pragmatic and hierarchical culture of the CIU. Since the manager and other team members preferred not to talk but instead engaging in hands-on work and mimicking each other’s behaviour (role modelling), the researcher was not successful. In fact, she became inflexible and paid little attention to what the nurse manager and team members felt was important. She underestimated how important ‘simply’ working on the ward was in building relationships and the development of her role in this context, where people place high value on practical skills and where finishing nursing tasks before a certain time is considered of prime importance. Hence, ideals were not translated to the present context, but were glorified in an absolute way.

The nurse manager reacted in accordance with her values by using her power to lay down the law. She gave instructions and directions to clarify her expectations of the researcher. The situation continued. Paradigm differences were not bridged and similarities were not used constructively to encourage relational empowerment (VanderPlaat, 1999). Instead of encouraging open, trustworthy and reciprocal relationships, a breeding ground had been created for mutual misunderstandings, feelings of insecurity and power issues.

Temporarily crystallized enactment

Although the relationship with the nurse manager was anything but perfect, the researcher tried to set up the action research process anyway. She kept promoting her beliefs and ideas about how to start an action research project. As a result she captured the attention of the student-coordinator and the nurse teacher and managed, temporarily, to take some steps forward (Box 2).

Box 2. Reconnaissance phase

In December the nurse manager fell ill and was absent from the ward for two weeks and for another four weeks in January, which made me feel less insecure. I managed to reach consensus with the team about observing activities on the ward. These activities started after the nurse manager had returned and given her permission. She had little option as all those involved were enthusiastic. She also agreed to schedule two meetings with all team members to share feedback. It was a busy time for me. I observed situations on the ward and supported the nursing teacher and student co-ordinator in doing so. I analysed the written observations, checked those with the other observers and prepared the meetings with team members. I enjoyed the collaboration and felt more connected to team members. This was what my role should be. I was enthusiastic and full of energy again. However, as soon as the nurse manager returned from her second period of absence, I felt unhappy again. I did not feel appreciated and valued for the work I had done, especially because the nurse manager had not actually scheduled the feedback meetings with the team. She said she had simply forgotten to do so. She was laconic and said that I could talk to the team members who would be on the ward that afternoon. This meant I could only speak with two staff members and three students at the most. In the end, we agreed that I would give feedback on the observations on three different afternoon meetings with the team members present on the ward. It was not ideal, but postponing the meetings for a couple of months was even less so. The meetings themselves were great. I used creative and active work forms to support team members in expressing their beliefs about topics from the observations. We discussed different themes where improvement was needed and team members prioritized them. The nurse manager, who had promised to attend all meetings, did not show up at any of them. She sought no information at all about the workplace analyses. I told her I did not feel supported and that her presence was important to reinforce the value placed on change and innovation; she responded that she trusted me to facilitate these processes and that her presence was not required. The team members, on the other hand, evaluated the meetings as useful and were motivated to continue to participate. I felt we had made a really good start towards reaching consensus about what we wanted to improve first and in forming small groups of team members to make action plans for specific themes. We agreed to do this at the next monthly staff meeting. However, for almost six months meetings were either not scheduled or were cancelled for different reasons. I felt very frustrated. In my opinion the nurse manager was not showing any willingness to engage in action research, although she explained she had limited possibilities to create the necessary resources. Since the team members generally deferred to the manager, were used to receiving instructions from her and valued her opinion, their interest in the process we had started decreased. By the time of the next meeting, other things were given higher priority for discussion and the motivation for improving the identified themes had evaporated. The momentum was lost.

The experiences described in Box 2 illustrate how the difficulties that had arisen earlier had a lasting undesirable impact, or, in the words of Wicks and Reason (2009), ‘unfinished business may trip up the process at later stages’ (p. 254). We believe that the difficulty in escaping the reified character of the situation is rooted in the crystallization of enactment. The situation described depicts a ‘slice of working life’ that is frozen (crystallized) for uses of reflection. To enact a situation in situ (spontaneously, physically, experientially and afterwards – more indirectly – cognitively) is like being thrown into an environment that already has meaning given the history inscribed in it. Those involved act in accordance with that meaning and at the same time are influencing it by their participation.

When we reflect on the particular slice of life (the temporarily crystallized enactment) in the CIU, the researcher was trapped in a configuration that consisted of multiple heterogeneous elements (Niessen, Abma, Widdershoven, VanderVleuten & Akkerman, 2008). This configuration included real physical constraints (such as the limited time available for the research and the absences of the manager), but also the researcher’s mental images (her ideals and self-image) and those of the health care providers (hands-on mentality). The developed pattern is neither purely physical nor purely mental, but a combination of the two. It is a way of dealing and coping with the issue at hand that is inscribed in flesh, mind and context. These patterns or configurations stretch the boundaries of the mental into the entire brain/body system (Niessen et al., 2008; Varela, Thompson & Rosch, 1991), since we are enacting beings grounded in experiential and bodily knowing (Heron & Reason, 1997). We can see this in the researcher’s emotions and feelings of frustration; physical expressions of her values which she feels are under attack. There was no movement, no dynamics until the nurse manager was physically absent. Then the researcher experienced space to interact creatively with her environment.

Since this entrapment within a configuration is the result of a habitual (mindless) handling of the situation, grounded in and influenced by all the elements mentioned, it seems inevitable, according to Varela (1999), that participants slip into another enactment, or ‘microworld’, when elements change or disappear. This explains why the researcher had more (communicative) space (literally and mentally) when the manager was absent. The different configuration made it possible to enact another space. It also explains how, on the manager’s return, the previously performed micro-world ‘jumped in’, since all the previous elements fell into place once again. Although she might have been able to partially recognize what was happening in a cognitive way, the researcher was unable to develop a new, more creative response. She was trapped in a micro-world that was inscribed in her and others to be triggered again by the nurse manager’s re-appearance.

Not getting trapped in old patterns and encouraging movement requires a certain awareness and sensitivity of the researcher to identify configurations. This seems especially difficult for novice researchers, like the researcher in this situation, who initially develop their ideas and ideals of research on the basis of propositional knowledge and role taking (through role modelling). Yet literature tends to give a tidy impression of action research (Cook, 1998; McArdle, 2002) and propositional knowledge can be a barrier to flexible responses to events, which might involve creativity and looking beyond the present knowledge (Cook, 1998). According to Grant (2007), ‘being and doing’ participatory research is necessary to really see and understand what it means. Therefore, lived experiences and embodied knowledge are important to develop awareness and sensitivity to detail in situations.

(Self)-reflection seems prerequisite for learning from these kinds of knowledge (Grant, 2007; Marshall & Reason, 2007). We believe, however, that prior to reflection or perhaps instead of it, a certain openness is needed, through which people are able to perceive without prejudice what comes to their awareness. Langer (1997) calls this mindfulness. It requires patience and courage to continually observe what happens without evading unwelcome or unexpected events or responding by re-enacting habitually formed patterns. Although reflection after action seems always appropriate, we would like to add that when appropriating a mindful posture or engagement in practice, one’s way of handling (enactment) a situation will emerge spontaneously, holistically combining cognitive and more embodied ways of knowing, instantaneously on the spot and hands-on (Varela, 1999; Varela et al., 1991). Although organizational problems and power issues will not be solved immediately, it helps the researcher to deal with differences and her own feelings more constructively.

A researcher who adopts a participatory focus should therefore first and foremost (learn to) cultivate a mindful attitude. However, once a researcher has become trapped in a configuration without being mindful of the situation, it can be difficult to step back and observe it. It will be necessary to introduce new meanings by introducing other voices or exercises as was done, for instance, by Abma (2000) when exchanging roles with the individual with whom a dysfunctional conflict had arisen. This will lead to new experiences and perspectives allowing the researcher and others involved to see the fuller context again and to break with habitually formed patterns.

Siegel (2010) has explained this situation from a neuroscientific perspective, using the concept of ‘mindsight’ as a way to change from autopilot to mindful observation and (re)shaping of the internal workings of the mind and thus to become more flexible and free in ones response to situations. Siegel illustrated that mindsight can be learned through some practical steps, usually starting with focused attention (mindfulness) followed for example by narrative reflection, meditative practice or body scan, resulting in a better balancing of emotions, homeostasis of body and mind and ultimately in better relationships with oneself and others.