Participatory action research: A strategy for improving self-care management in chronic obstructive pulmonary disease patients

Abstract

Participatory action research (PAR) facilitates the change process in clinical practice and promotes knowledge development. This paper highlights the potential of PAR to implement changes in healthcare oriented for the development of self-care management skills in patients with chronic obstructive pulmonary disease (COPD). In COPD patients, the preservation of self-care autonomy and quality of life depends on the patients’ ability to adopt pharmacological treatments and behavioural changes. In a Portuguese central hospital nurses (n = 52) have identified a gap between the nursing care and the perceived needs of the patients, and developed a healthcare solution based on a PAR methodology supported by an overlapping cycle of action and research. The PAR took place during 14 months. The PAR allowed the change in the care model in use, in the organization and the nursing care documentation. This change was focused on the development of self-care management skills, responding to the needs and expectations of those involved. The PAR proved to be an appropriate methodology to identify and implement changes that contribute to the safety, quality and access to healthcare.

Keywords

Action research participation chronic obstructive pulmonary disease self-care management participatory action research

Introduction

The aging of the world populations combined with the increase of life expectancy and the accompanying rise in chronic health conditions (World Health Organization (WHO), 2008, 2013) are creating new challenges for health systems (Dent, 2003). Demand for health services is rising, as are their costs. Simultaneously, the economic crisis is challenging politicians, health service providers and citizens to optimize the management of available resources.

The implementation of guidelines that guide the decision making process of health professionals contributes to improving quality and safety of healthcare. The current guidelines on the diagnosis and treatment of chronic diseases point to the need of helping patients becoming active participants in managing their own health (European Society of Cardiology (ESC), 2012; Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2015; Global Initiative for Asthma (GINA), 2014; International Diabetes Federation (IDF), 2013). These guidelines encourage the empowerment of patients and the development of self-care skills, in order to improve quality and safety and to ensure access to healthcare. The implementation of guidelines in the clinical field pose complex issues, essentially because of the lack of participation and involvement by the health professionals in drawing up the guidelines or in adapting them to the clinical contexts (Johnston, Young, Grimmer-Somers, Ral, & Frith, 2011; Lodewijckx et al. 2009; Ward et al., 2005). The challenge for health professionals and health systems is to develop clinical solutions that operate in contexts based on the best evidence and to promote the rationalization of health costs by improving access and quality of health services.

This paper is organized into five parts. The first part shows the challenges to develop clinical solutions that promote self-care management skills among patients with chronic obstructive pulmonary disease (COPD), and the purpose of the paper. The second part presents the methodological issues, followed by the third part with the presentation of results, and the fourth part with the discussion. In the fifth part we highlight the main contributions of this paper for the AR discussion.

The challenge to develop clinical solutions that promote self-care management skills among COPD patients

COPD is one of the leading causes of death and morbidity in the world (WHO, 2008). It is a chronic and potentially progressive disease that makes it difficult for patients to find the energy necessary for self-care. The control of its progression demands the integration of a complex treatment regime into patients’ daily routine (Padilha, Oliveira, & Campos, 2010). So, treatment routines require from the patient to acquire the cognitive, practical and emotional skills necessary to put into practice long-term behavioural changes that make it possible to control the disease, maintain patient self-care autonomy and quality of life (GOLD, 2015; Padilha, 2013). COPD progresses throughout a patient’s life, progressively reducing their autonomy and culminating in an advanced phase characterized by great loss of self-care autonomy (Aguilaniu et al., 2011; Garrod, Bestall, Paul, Wedzicha, & Jones, 2000; Hernandes et al., 2009; Pitta et al., 2005; Polkey & Rabe, 2009). Patients’ lack of ability to control the disease often leads to the worsening of the condition and increasingly recurrent hospitalizations as they age.

COPD is different from other chronic illnesses as it progresses over time, and patients only tend to give importance to the symptoms in the more advanced stages of the illness, essentially when breathing difficulties make it difficult to engage in self-care management.

As far as the diagnosis and treatment of COPD are concerned, evidence has led to the establishment of clinical guidelines (GOLD, 2015) that encourage the optimization of health system services, quality improvement and the safety of services provided. However, challenges to the nurturing of self-care management skills continue to exist, a fact that has received little attention, partly due to the lack of data that might underpin the setting up of such clinical guidelines (Effing et al., 2007). This lacuna represents a negative influence on the quality and safety of care, with negative consequences for patient health as well as the direct and indirect costs of healthcare. The need to come up with a solution alongside nurses and patients that responds to the difficulties identified and functions within the context led us to opt for the action research (AR) approach to answer our research questions:

Within this context, what are the main aspects of clinical nursing practice that can be improved to encourage COPD patients’ self-care management skills?

Within this context, what changes in the organizational strategies should be prioritized in order to enhance nurses’ contribution to self-care management skills among COPD patients?

The participatory action research (PAR) has been presented as an appropriate strategy for the implementation of change in healthcare (Loewenson, Laurell, Hogstedt, D’Ambruoso, & Shroff, 2014; Silva, 2001; Sousa, 2005). For this reason, in this paper we intend to contribute to the clarification of the potential of PAR as a strategy for the implementation of changes in healthcare that promote quality, safety and access to healthcare services.

Based on a PAR methodology, we (main researcher and co-researchers – nurses) designed and implemented a change with the purpose of encourage the continual improvement of the quality of health services, improve self-care management skills of patients with COPD, and develop clinical guidelines valid for the context and useful for patients, nurses, healthcare services and for education.

Method

Participant action research is based on the building of solutions, a fact that in some contexts may lead to revolutionary change in the approach to and treatment of patients with chronic illnesses as well as in the know-how regarding the different disciplines (Mendenhall & Doherty, 2007; Munten, Bogaard, Cox, Garretsen, & Bongers, 2010).

We set up the PAR to be democratic, equalitarian, make sense and be useful (Koch, Selim, & Kralik, 2002), in order to make it feasible to improve the healthcare provided by the nurses. PAR can be viewed as a political tool, as it enables nurses and patients to take part in the decisions that affect them (Reason, 1998), facilitating change, the development of knowledge and healthcare improvement. Through the PAR we intended to raise awareness among health professionals, patients, caregivers and teaching institutions in the health area, with regard to the roles they play in the changes that are needed to face the current challenges.

The option for PAR is based on the fact that such an approach encourages the involvement of different actors (Reason, 2006) in any context (healthcare providers, patients and researchers) in order to design solutions for the challenges at hand, a fact that engenders commitment to the changes instituted.

The method used and complementary nature of the resources provided by the healthcare institutions and medical teaching establishments proved to be structural factors to allow the most beneficial decisions to be made in the context, in line with the principles and missions of the organizations.

In this path of PAR our ontological assumption was that reality is subjective and co-created and can only be apprehended through subjective experience and action. From the epistemological point of view, it was assumed that the researchers would be consciously, subjectively and interactively involved with the situation that they were studying. Our methodological strategy was to search out and build up knowledge to be acquired through a dialectic process of the iterative comparison of the data that primarily emerged from the perspective of nurses and patients. This led to the need to involve the nurses in the design of solutions answering patients’ needs within the specific context.

The involvement of the patients was essential to enable the health professionals to cater for their needs and expectations accordingly. The nurses, as well as taking a bigger role in defining the guidelines, listened to the patients regarding their preferences, namely in relation to the teaching-learning strategies, the didactic resources, the right moments for the nurses to intervene and what actions they should take.

In order to ensure scientific rigour, we adopted the criteria proposed by McKay and Marshall (2002). We brought together a cycle with two inter-related goals, one aimed at problem solving and the other responding to the research questions, we used a nursing theoretical framework (Meleis, Sawyer, Eun-Ok Im, DeAnne Messias, & Schumacher, 2000), and applied a procedural model to underpin the conception, design and management of the entire project (Figure 1). We developed a cycle of action in conjunction with research, bringing interests associated with responsibilities for solving problems and, at the same time, with responsibilities for research (McKay & Marshall, 1999, 2002). The approach was to focus on a problem as it occurred within a specific context and, through participative action, bring about change in order to contribute to the continual improvement of nursing services. Our approach was based on a continual interaction between action and research, reflection and evaluation (Hart, 1996), supported in five phases cycle of AR comprising diagnosis, action plan, implementation, evaluation and identification of outcomes (Susman & Evered, 1978).

Figure 1.

Participatory action research, a strategy for improving self-care management.

The researcher’s roles

The relationship between the main researcher (teacher at the nursing school) and the co-researchers (nurses) was guided by a participative perspective (Hynes, Coghlan, & McCarron, 2012; Susman & Evered, 1978; Wicks & Reason, 2009).

In the diagnosis phase the main researcher was responsible for collecting and processing the data, subsequently returning this information to the nurses to be interpreted and to draw up the diagnosis. The main researcher was a facilitator in this process and a reference point for nurses in designing the strategy for data collection and processing, focusing simultaneously on improving the COPD patients’ self-care management skills.

To define the plan of action, the main researcher was a facilitator in discussing, sharing and providing access to the information by creating communication channels (Bevan, 2013). The main researcher acted as a mediator of the common interests and goals, helping to draw on the energy of the actors involved to achieve the common goals, safeguarding the individual differences but ensuring a forum for discussion and to encourage open and constructive dialogue about the topics. In this phase, the researcher was also focused on change and the formalization of knowledge, namely in designing the guidelines that oriented the diagnosis, intervention and assessment of the patients’ conditions.

Having defined the plan of action, we moved on to its implementation in the clinical context. The main researcher was present throughout this whole phase, in the context to support the decisions made by the nurses concerning the action taken stimulating reflection in and on-action (Argyris, 2004). Reflection on the action was one of the main strategies used, making it possible to create discussion channels based on the mutual recognition of skills and a common goal. Giving nurses the chance to share their difficulties and to discuss the solutions emerging was also based on optimizing the individual traits by implementing individualised strategies. The reflection in action took place during or immediately following any act of nursing.

As described by Reason (1994), recognising the power of the relations and the value of experience was structural aspects in the development of knowledge, the creation of a safe environment and a catalyst for change.

The main researcher in the process of change served as a mediator of the common interests and goals, helping to draw on the energy of the actors involved to achieve the common goals. The main researcher was also focused on strengthening the organizational and logistical processes inherent to change, pooling the intentions and goals of all the actors involved and providing support for decision making.

In assessing the change process, the main researcher provided technical/scientific support, aiding the decision/nurses’ action and the data analysis and processing.

In the final phase of identifying the data acquired, the main researcher organized the discussion and reflection that allowed the group to identify the premises that underpinned the change and the development of the disciplinary knowledge.

Study context

The study was carried out in the internal medicine ward and outpatient clinic at a central Portuguese hospital, where nurses identified a gap between the nursing care, the perceived needs of the patients and the guidelines in effect (GOLD, 2011). To address this challenge the central Portuguese hospital proposed a partnership with a nursing school to design and implement a strategy to bring about ongoing improvement in the quality of the nursing care provided to COPD patients. This partnership was established between the main researcher and all the nurses (n = 52).

Patients in this study had the following inclusion criteria: COPD, being accompanied in hospital admission or outpatient consultation and have the cognitive skills preserved (Guerreiro et al., 2008) to develop self-care management skills. This path of PAR was carried out over a 14-month period.

Data collection and analysis

We use different data collection techniques (interviews, observation, content analysis, survey) in accordance with the objectives and the need for information found in every moment of PAR, and we adopted a data triangulation strategy for construction of reality (Denzin & Lincoln, 1994). In the treatment and analysis of the data we use qualitative and quantitative approaches.

Ethical issues

The project respected all ethical principles, with the hospital granting authorization for its participation. The design of the plan of change was orientated by the principles of solidarity and responsibility between researchers. The same principles guided the relationship and the internal commitment of the researchers as individual agents of change. The patients provided informed consent and full confidentiality and anonymity were guaranteed.

Results

The results of the PAR, as a strategy for improving self-care management described above (Figure 1), will be organized in three sections: diagnosis; action plan and implementation; and evaluation.

Diagnosis

In the first stage of the PAR, we identified the problem and the questions of interest for research in this clinical context. In order to identify the principal characteristics of the healthcare model in use by nurses, we observed clinical practice and conducted non-structured interviews with key participants (specialized nurses and COPD patients), as well as group interviews with nurses of the context. We also analysed documents regarding nursing cases as collected within the IT systems in use. We undertook an open-ended, qualitative and interpretive analysis of the key informant interviews, without any pre-established categories.

The resulting analysis of the corpus, therefore, took into account the entire content of the interviews. The interviewees were selected through a theoretical sampling process. We interviewed five patients using the following selection criteria: COPD medical diagnosis; cognitive skills preserved; different degrees of the illness; with and without self-care management skills; different education levels; different illness evolution times; with and without episodes requiring visits to the emergency department. We interviewed six nurses using the following selection criteria: nurses who were specialised in rehabilitation within this context, working as specialist and nurses in the context who in their professional activity have been involved in other COPD patient monitoring activities.

We later carried out two group interviews, where all the nurses involved took part. To the analysis of the group interviews we utilize a priori categories that had arisen from the key informant interviews and the analysis of IT documentation. The documental analysis was guided by pre-established categories, based on the Beta 2 version of the International Classification for Nursing Practice (International Council of Nurses (ICNP®), 2002) in use in the IT system.

Different data collection techniques were intended to reveal certain dimensions of the key problem to the issues from the perspective of nurses and patients. After applying the data analysis techniques, we requested the collaboration of the nurses to interpret the data and to delimit the problem.

This strategy led to the identification of three basic aspects, which in the nurses and patients’ opinion negatively influenced the nursing care: the healthcare model in use; the organization of care and the nursing records for decision-making process. The model of care was almost founded on treatment and stabilization of patients rather than introducing patients to self-care activities. There was little emphasis on developing patients’ self-care management skills that might help them to control the disease, preserve their autonomy and quality of life, as exemplified

‘… from the beginning of my training my central concern has been the administration of medication and the detection of complications of the disease … I feel that we have always less importance to the rest …’ (Field note 8 with nurse).

‘… the nurses haven’t helped me sort out the problems that I face every day …’ (Interview with patient 3).

The healthcare model in use suffered from a lack of guidelines for intervention and the evaluation of nurses in regard to the encouragement of patients’ self-care management skills. It also came to our attention that there were no information tools to encourage such skills since for the nurses ‘… it would be very important to have some books or visuals to help instruct patients’ (Field note 18).

The documentation of the decision-making process pointed out nurses’ difficulties in this area. In addition to limitations in nursing training in the area, these difficulties were also due to the lack of essential parameters within the IT system in use at the moment of hospital admission as well as the complete absence of any IT system for outpatient consultations that might have facilitated continuity in treatment and the monitoring of results.

The data also pointed out the negative impact the organization of nursing services had on the continuity of care in these patients. Contributing factors included: insufficient communication among the care providers; insufficient sharing of data between nurses, both internal and outpatient; difficulties in integrating self-care management skills into the flow of nursing services within the hospital care and consultation procedures; the lack of an information system that allows the access of data that facilitates continuity of care and monitoring of outcomes, essential to nursing care.

The results of this initial phase allowed to identify the need to implement a process of change able to provide greater structure to nursing care in the area of self-care management, centred upon the three main areas identified (the healthcare model in use; the organization of care and the nursing records for decision-making process).

Action plan and implementation

The identification of the opportunities for change allowed us to go on to plan the change in the second phase of the PAR. The second phase of the PAR was aimed at planning the problem resolution strategy (action-centred cycle) and planning and designing the project in accordance with the requirements of the research (research-centred cycle). Based on the information obtained and the group discussion, the group (researcher and co-researchers) defined the following goals:

For the healthcare model in use: Broadening the concept of healthcare and nursing intervention to include activities that transcend the treatment and stabilization of patients to encompass the development of self-care management skills; increasing the structured approach to diagnosis, intervention and monitoring of the results of nursing intervention; drawing up and making available sources of information for promoting knowledge and skills of patients in the area of self-care management.

Record-keeping goals consisted of: Optimizing the information system to ensure continuity of care and the ability to monitor the key results of nursing care; incorporating an information system in consultations that allows the access of data that facilitates continuity of care and monitoring of outcomes.

Goals for the organization of healthcare included: Improving the articulation between hospital services and outpatient consultations; reorganizing the outpatient nursing service; promoting the continuity of nursing and other healthcare services.

In order to achieve the goals set out, spaces for reflection and training on the state of the art were set up. They were intended to help nurses develop self-care management skills. The goal was to promote nurses’ participation by making valid information available to support their free and informed choice and internal commitment (Argyris & Shon, 1992).

The change process was based on the nurses’ predisposition for analysis and information management. This tendency was based on the nurses’ willingness to question the status quo from their point of view and to explain the decisions made; their willingness to test their decisions in the field of action was also required.

These aspects encouraged the defence of individuals’ aims, the clash of ideas, opinions and emotions. This strategy resulted in the drawing up of consensual guidelines by the nurses. These guidelines explained the field of action of nurses in the realm of self-care management, permitting the team to confer greater structure to the diagnosis, intervention and evaluation of results. In addition to best available knowledge, the guidelines established a conceptual structure based on the concept of self-care of Orem (1993) and the theory of nursing transitions of Meleis, Sawyer, Eun-Ok Im, DeAnne Messias, and Schumacher (2000).

In order to answer to the perceived need by the patients to have access to information that would support the development of self-care management skills (e.g. self-control of dyspnoea; use of inhalers), we analysed information needs by the patients, perceived usefulness, intention and ease of use of different technological supports to access health information. This assessment was made in a questionnaire given to COPD patients within the context (Padilha, Sousa, & Pereira, 2012). The evaluation allowed to develop access to information provided on paper, video and telephone.

We proceeded to reorganize the outpatient consultation procedures by redefining the skills of nurses, patient flow and the number of nurses available. To improve the articulation between hospital and outpatient consultations and to ensure the continuity of care, strategies of inter- and intra-professional communication were optimized. We reformulated the hospital admission IT forms in response to the newly identified needs and implemented an IT form to support outpatient consultations. This resulted in an ability to record and later evaluate the nursing care. This became one of the key tools for ensuring ongoing continuity, quality and safety of healthcare.

It was during this phase that the target strategy for evaluating COPD patients was identified based on evaluation of outcomes in key areas of nursing (developing self-awareness for change; hope development; involvement in the management of health status and development of knowledge and skills to effectively manage the treatment regimen). The evaluation of the results in patient’s condition was performed by evaluating the changes in nursing diagnoses documented in the information system six months after initiating change in follow-up patients.

Evaluation

In order to evaluate the impact of change on the identified opportunities (action cycle) and the effect of the intervention on the research questions (research cycle) (McKay & Marshall, 2002), we focused on evaluating the effects of the change on the three principle aspects that shaped the identified problem and the strategies of intervention planned. We also evaluated the impact of the change on the self-care management skills of patients (n = 99).

The partnership established between the context, the researcher and the expectations created in the leadership and among the nurses served as motivating factors that allowed us to transform the creative tension into a movement by the nurses aimed at achieving the objectives that they had set. This is demonstrated by the words of the nurses, namely when one of them stated that

‘… in the beginning, I often thought that the expectations that they had about what we would be able to do were overly high, but when we really thought about what obstacles we would face, they turned into challenges that motivated us …’ (Field note 73).

The nurses realized that the resources that were granted to them and the opportunity they had to design and implement the change process were essential for meeting both individual and group objectives and for committing to the process itself. This fact is seen in the nurses’ words when one of them stated that

‘… the greatest benefit was our ability to understand and guarantee the necessary resources when we began to plan the project. That enabled us to build relationships among ourselves and with the hospital where we were to work’ (Field note 82).

Upon analysing the process of change, we identified the transformation from a healthcare model strictly focused on the treatment and stabilization of patients to one progressively centred on developing self-care management skills among COPD patients.

At the end of the change process, the healthcare model exhibited an expanded concept of nursing care and nursing activity resulting from the development of individual nursing skills. This, in turn, had been supported by their participation in the development of guidelines for the diagnosis, intervention and evaluation of nursing activity. This is demonstrated by their own words when one of them stated that

‘… now I have no difficulty understanding and deciding about what patients need in order to manage their treatment well. I feel able to better act in any of the areas that we work …’ (Field note 77), or

‘… with the conditions that we were able to put together, with the investment that we made and with the participation of everyone in defining our objectives … I think that we are now able to act within this area (self-management), both in self-care, or regarding the monitoring of patients …and I find that makes a great difference …’ (Field note 69)

and some of the patients’ own words

‘… now I feel there’s someone there who really understands my (self-care) problems, who is available to help me find the best solutions. Everything they do helps me on a day-to-day basis, and today I can prevent some complications, which gives me more confidence and helps make sure I don’t get worse …’ (Field note 102), or

‘… the nurses have helped me deal with this illness better… they helped me to stay active, to use the medicines better and showed me how to take better care of my health. There is no doubt the services provided now are of a higher quality …’ (Field note 107).

Regarding the organization of nursing care, the changes implemented allowed us to optimize the information exchange among healthcare professionals and healthcare services that resulted in an improvement in the continuity and safety of care provided. The change allowed us to reorganize the working methods of the nurses within consultations and to apply the full range of human and physical resources appropriate for the demands made upon them. The changes instituted in outpatient nursing consultations reinforced the improvement in the model of care available to COPD patients and facilitated their access to healthcare. Most of the patients described that it was very easy or easy to obtain information from nurses either by telephone or due to the ease of setting up appointments. These are important characteristics in the increase of quality regarding access to nursing by COPD patients.

The change made in the nursing care documentation allowed the identification and production of outcomes that showed the results per patient, thus enabling the individual assessment of the health condition of the patients and optimizing the management of the healthcare resources. The outcomes observed increase the level of safety and quality to the nursing care, and helps patients to preserve their autonomy and quality of life.

The alteration in the healthcare model both in the organization and in the documentation brought greater structure to the provision and monitoring of nursing as well as providing self-care management indicators in COPD patients without increasing costs. It demands intention, involvement and participation of the various actors. Research also demonstrated that a more structured approach to action with greater organization and nursing care management can positively influence healthcare use.

Evaluating the change allowed nurses and patients to identify the satisfactory results, given the opportunities that arose and the strategies that were planned and implemented. The evaluation undertaken by the nurses expressed their satisfaction with the process and with the fit between the response and the expectations as expressed by the nurses themselves.

‘… now I feel as if we are doing what we are supposed to be doing, we are prepared, we have resources, the care has a common goal and this is much better for patients …’ (Field note 97).

The evaluation of change allowed us to identify the principle areas of clinical nursing practice that were improved as a result of this study and that contributed to the development of greater self-care management skills on the part of COPD patients. At the same time, the solutions designed helped develop the COPD patients’ self-care management skills and helped them learn the specific content and strategies of the nursing task.

Discussion

In the course of the change process described, we intended to encourage the participation of the actors involved (to be democratic), creating conditions for them to have the same opportunity to influence decisions, regardless of their status (to be equalitarian) (Koch et al., 2002). We gave a voice to the people involved, including them in the design and implementation of the change, helping them find answers to their needs and expectations, steering the process towards the improvement of the ability of the nurses and the patients to manage their own health (to lend meaning to their life), and to pave the way for better nursing health provision (Koch et al., 2002). The involvement of the nurses in all the phases, from the design to the assessment, as well as the organizational support (Hart & Bond, 1995; Koch et al., 2002; LeMay, Mulhall, & Alexander, 1998), which backed up the decisions made without interference, was the essential bedrock in the process of change on healthcare model and organization, allowing improving the quality of the care and the knowledge about self-care management.

Our goal was to come up with solutions valid for the context at hand that would prove useful for patients, nurses, healthcare services and for nursing education. This project has demonstrated the potential of participative action research for contexts in which it is necessary to produce change in clinical practice. In this case, PAR bring together the quality and safety of healthcare, in particular with the intent of providing answers for the needs of COPD patients designed to increase their self-care management know-how, and creating greater systematization in nursing services and giving nurses and healthcare institutions the necessary tools to implement strategies for continuous improvement of healthcare.

The study carried out shows the potential of PAR to underpin the processes of change based on optimizing the skills of the organizations and the actors involved. In this process we witnessed the development of individual and collective learning by the nurses, which positively influenced the quality of the nursing care as described by Koch, Selim, and Kralik (2002).

In this paper we present the potential of PAR to facilitate the change process in clinical situations involving a high number of health professionals, and simultaneously in the formalization of knowledge for the health service providers and medical teaching institutions. At the same time, strategies were defined with the purpose of contributing to the development of clinical solutions which are valid and work in the contexts.

Conclusion

In this paper we present an approach based on the involvement and encouragement of participation among those affected in the design, implementation and assessment of the change. We use negotiation, consensus and collaboration strategies, aspects identified by Hart and Bond (1995) as necessary to develop a culture open to the research and which is necessary to bring about ongoing improvement in the quality of the nursing care. In this process, we noted that strengthening the organizational and logistical processes inherent to change, pooling the intentions and goals of all the actors involved and providing support for decision making were key factors in the change, whereby the resources that played a fundamental role in the organizations undergoing the change were available and open to the change.

The PAR allowed us to build solutions aimed at increasing access, quality and safety of nursing care, rationalizing the costs of healthcare and encouraging the development of self-care management skills among COPD patients. The safety of nursing care was improved by more systematic action of nurses, supported by a model of care that incorporates the best evidence and focuses on the problems of day-to-day patient. The improvement of the safety of care results from increased quality and quantity of information available in the information systems to support decision making of nurses. Our strategy also broadened the knowledge of this field of research and should significantly improve the education in this area.

Footnotes

Acknowledgement

The authors would like to thank Svante Lifvergren for leading the review process of this article. Should there be any comments/reactions you wish to share, please bring them to the interactive portion (Reader Responses column) of the website: .

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

J Miguel Padilha, RN, PhD in Nursing, is an Associate Professor in Nursing School of Porto, Portugal. Throughout his professional and academic education and training he has focused on activities of self-care management with special emphasis on COPD patients. He has been leading hospital based research projects for over 5 years.

Artur P Sousa, RN, PhD in Nursing Science, is a Professor Coordinator in Nursing School of Porto, Portugal. Throughout his professional and academic education and training he has engaged in activities encompassing the Information Systems Health Management, with special focus on various aspects of the Nursing Information Systems development. He has been leading community based collaborative research projects, for over 10 years.

Filipe M Pereira, RN, PhD in Nursing Science, is a Professor Coordinator in Nursing School of Porto, Portugal. Throughout his professional and academic education and training he has focused his activities encompassing the Information Systems Health Management. He has been leading community based collaborative research projects for over 10 years.

References

Aguilaniu, B., Gonzalez-Bermejo, J., Regnault, A., Dias, B. C., Arnould, B., Mueser, M., … Similowski, T. (2011). Disability related to COPD tool (DIRECT): Towards an assessment of COPD-related disability in routine practice. International Journal of COPD, 6, 387–398. https://dx-doi-org.web.bisu.edu.cn/10.2147/COPD.S20007.

Argyris

(2004) Reasons and rationalizations: The limits to organizational knowledge, Oxford: Oxford University Press.

Argyris

Shon

(1992) Theory in practice: Increasing professional effectiveness, San Francisco, CA: Jossey-Bass publishers.

Bevan

(2013) Creating communicative spaces in an action research study. Nurse Researcher 21(2): 14–17.

Dent

(2003) Remodelling hospitals and health professions in Europe: Medicine, nursing and the state, Basingstoke: Palgrave.

Denzin

Lincoln

(1994) Handbook of qualitative research, London: SAGE Publications, pp. 2.

Effing, T., Monninkhof, E. E. M., Van der Valk, P. P., Zielhuis, G. G. A., Walters, E. H., & Van der Palen, J. J. (2007). Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, 17(4), Art. No.: CD002990.

European Society of Cardiology. (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European Society of Cardiology.

Garrod

Bestall

J. C.

Paul

E. A.

Wedzicha

J. A.

Jones

P. W.

(2000) Development and validation of a standardized measure of activity of daily living in patients with severe COPD: The London Chest Activity of Daily Living scale (LCADL). Respiratory Medicine 94: 589–596.

10.

Global Initiative for Asthma (GINA). (2014). Global strategy for asthma management and prevention. GINA. Retrieved from http://www.ginasthma.org/documents/4.

11.

Global initiative for chronic obstructive lung disease (GOLD). (2015). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease, Inc. Retrieved from http://www.goldcopd.com/guidelines-global-strategy-for-diagnosis-management.html.

12.

Global initiative for chronic obstructive lung disease (GOLD). (2011). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease, Inc. Retrieved from http://www.goldcopd.com/guidelines-global-strategy-for-diagnosis-management.html.

13.

Guerreiro

Silva

A. P.

Botelho

M. A.

Leitão

Caldas

A. C.

Garcia

(2008) Brief assessment of mental state. In study group aging brain and dementia – Scales and tests in dementia. Study group aging brain and dementia, 2nd ed. Portugal: Novartis, pp. 33–40.

14.

Hart

(1996) Action research as a professionalizing strategy: Issues and dilemmas. Journal of Advanced Nursing 23: 454–461.

15.

Hart

Bond

(1995) Action research for health and social care. A guide to practice, Buckingham: Open University Press.

16.

Hernandes

N. A.

de Castro Teixeira

Probst

V. S.

Brunetto

A. F.

Ramos

E. M. C.

Pitta

(2009) Profile of the level of physical activity in the daily lives of patients with COPD in Brazil. The Jornal Brasileiro de Pneumologia 35(10): 949–956.

17.

Hynes

Coghlan

McCarron

(2012) Participation as a multi-voiced process: Action research in the acute hospital environment. Action Research 10(3): 293–312.

18.

International Council of Nurses (2002) International Classification for Nursing Practice. Version β2, Switzerland: International Council of Nurses.

19.

International Diabetes Federation. (2013). Managing older people with type 2 diabetes – Global guideline. International Diabetes Federation. Retrieved from http://www.idf.org/guidelines.

20.

Johnston

K. N.

Young

Grimmer-Somers

K. A.

Ral

Frith

P. A.

(2011) Why are some evidence-based care recommendations in chronic obstructive pulmonary disease better implemented than others? Perspectives of medical practitioners. International Journal of COPD 6: 659–667.

21.

Koch

Selim

Kralik

(2002) Enhancing lives through the development of a community-based participatory action research programme. Journal of Clinical Nursing 11: 109–117.

22.

LeMay

Mulhall

Alexander

(1998) Bridging the research practice gap: Exploring the research cultures of practitioners and managers. Journal of Advanced Nursing 28(2): 428–437.

23.

Loewenson, R., Laurell, A. C., Hogstedt, C., D'Ambruoso, L., & Shroff, Z. (2014). Participatory action research in health systems: A methods reader. WHO, Canada: EQUINET. ISBN: 978-0-7974-5976-2.

24.

Lodewijckx

Sermeus

Vanhaecht

Panella

Deneckere

Leigheb

Decramer

(2009) Inhospital management of COPD exacerbations: A systematic review of the literature with regard to adherence to international guidelines. Journal of Evaluation in Clinical Practice 15: 1101–1110.

25.

McKay, J., & Marshall, P. (1999). 2 x 6 = 12, or does it equal action research? Paper presented at the Australasian Conference on Information Systems (ACIS 1999), Wellington, December.

26.

McKay, J., & Marshall, P. (2002). Action research: A guide to process and procedure. Retrieved from http://www.utas.edu.au/infosys/publications/research/Qual_Research/mckay%20&%20marshall_%20Action%20Research%20process%20model.pdf.

27.

Meleis

A. I.

Sawyer

L. M.

Eun-Ok

I. M.

DeAnne Messias

K. H.

Schumacher

(2000) Experiencing transitions: Na emerging middle-range theory. Advances in Nursing Science 23(1): 12–28.

28.

Mendenhall

T. J.

Doherty

W. J.

(2007) Partners in diabetes: Action research in a primary care setting. Action Research Journal 5: 378–406.

29.

Munten

van den Bogaard

Cox

Garretsen

Bongers

(2010) Implementation of evidence-based practice in nursing using action research: A review. Worldviews on Evidence-Based Nursing 7(3): 135–157.

30.

Orem, D. E. (1993). Concepts of nursing practice. Barcelona: Masson-Salvat Enfermería.

31.

Padilha, J. M. (2013). Promotion of self-management in patients with COPD: A course of action-research. PhD Thesis, Portuguese Catholic University. Retrieved from https://hdl-handle-net.web.bisu.edu.cn/10400.14/14958 DOI: 10.13140/2.1.3864.4480.

32.

Padilha

J. M.

Oliveira

Campos

(2010) Integrative literature review on treatment management in patients with chronic obstructive pulmonary disease. A Revista da Escola de Enfermagem da USP 44(4): 1123–1128.

33.

Padilha

J. M.

Sousa

Pereira

(2012) Analysis of use of technological support and information content by patients with chronic obstructive pulmonary disease. Revista Acta Paulista 25(7): 60–66.

34.

Pitta

Troosters

Spruit

M. A.

Probst

V. S.

Decramer

Gosselink

(2005) Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. American Journal of Respiratory Critical Care Medicine 171: 972–977.

35.

Polkey

M. I.

Rabe

K. F.

(2009) Chicken or egg: Physical activity in COPD revisited. European Respiratory Journal 33(2): 227–229.

36.

Reason

(1994) Three approaches to participative inquiry. In: Denzin

Lincoln

(eds) Handbook of qualitative research, California: SAGE, pp. 324–339.

37.

Reason

(1998) Political, epistemological, ecological and spiritual dimension of participation. Studies in Cultures, Organizations and Societies 4: 147–167.

38.

Reason

(2006) Choice and quality in action research practice. Journal of Management Inquiry 15(2): 187–203.

39.

Silva, A. (2001). Nursing information systems: An explanatory theory of change. PhD Thesis, Institute of Biomedical Sciences Abel Salazar, Porto.

40.

Sousa, P. (2005). The System Information sharing between contexts of nursing care: An explanatory model. PhD Thesis, Institute of Biomedical Sciences Abel Salazar, Porto.

41.

Susman

G. I.

Evered

R. D.

(1978) An assessment of the scientific merits of action research. Administrative Science Quarterly 23: 582–603.

42.

Ward

M. M.

Yankey

J. W.

Vaughn

T. E.

Boots Miller

B. J.

Flach

S. D.

Watrin

Doebbeling

B. N.

(2005) Provider adherence to COPD guidelines: Relationship to organizational factors. Journal of Evaluation in Clinical Practice 11(4): 379–387.

43.

Wicks

P. G.

Reason

(2009) Initiating action research: Challenges and paradoxes of opening communicative space. Action Research 7(3): 243–262.

44.

World Health Organization (2008) World Health Statistics, Switzerland: World Health Organization.

45.

World Health Organization (2013) World Health Statistics, Switzerland: World Health Organization.