Commentary on Glasson J, Chang E, Chenoweth L, Hancock K, Hall T, Hill-Murray F & Collier L (2006) Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward.  Journal of Clinical Nursing 15, 588–598

Authors

  • Tracey Williamson MSc, PhD, RGN, FAETC

    1. Research Fellow (Older People/User Involvement), Salford Centre for Nursing, Midwifery and Collaborative Research, University of Salford, Salford, Manchester, England
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Tracey Williamson, Research Fellow (Older People/User Involvement), C715 Allerton Building, Salford Centre for Nursing, Midwifery and Collaborative Research, University of Salford, Frederick Road, Salford, Manchester, M6 6PU, England. E-mail: t.williamson@salford.ac.uk

This paper (Glasson et al. 2006) presents another valuable addition to examples of improved clinical practice being catalysed through participatory action research. In their study, Glasson et al. (2006) explore patient and nurses’ needs prior to selecting and evaluating a model of care aimed at addressing those needs. The involvement of patients and staff as key stakeholders in the change processes aimed at enhancing nurses’ practice to meet their needs is clearly evident. Yet I sense an opportunity to involve patients’ families and informal carers may have been missed. To focus on patients’ needs and compare these with nurses’ needs is entirely appropriate. However, further patient participation appears to be in the sense of being research subjects in receipt of practice interventions and assessment of associated outcomes. This study could have been strengthened if patients had continued to be involved in other stages of the research process (Calnan & Gabe 2001). Examples include contributing to the selection of a care model that would best meet their needs, informing the evaluation design and determining patient-focused outcomes. I would also ask the authors why those particular models were presented as options and why a choice was made from an existing model as opposed to developing one? There may be tension between having a model as a framework to follow and forcing a model to fit the practice situation so that the model has potential to be constraining or used incompletely.

Whilst many older people are fully responsible for their medication taking, others are reliant on the input of formal and informal carers following discharge. As stakeholders in the process, they too needed to have opportunity to inform the revision of medication practices as part of the study as any changes may have knock-on effects on the way medications are subsequently managed in the postdischarge environment. As the study shows, many patients may have demonstrated more knowledge of their medications following the intervention, but this is of little use if educators are not made aware that, once they go home, they will hand over control of medicines dispensing to their spouse or revert to their previous practices such as removing all packaging and storing tablets in egg cups or taking certain tablets with their favourite but incompatible fruit juice. The transfer of older patients between settings, such as when discharged from hospital to home, presents particular danger points for medication errors to be made (Banning 2005). Family and carers also need to be involved in study design processes and both input into and receive interventions such as education programmes.

To help change ward practice, a sizeable number of nursing staff were signed up to participation in the study. These were Registered Nurses only and I wonder what the role of the Un-registered Nurses is in medication giving and education? Also, what impact had those nurses who did not want to take part had? For example, were those patients included in the study cared for only by nurses who were participating or at times were they cared for by the non-participating nurses continuing with the old way of doing things?

One interesting finding was that patients in the model group were most satisfied with physical care. This is explained as being due to the post model climate being one of self-care. This is a point that may resonate with others experienced in working in rehabilitative environments. That is, that just because, as patients may recognize what would be good for them (self-care), this does not necessarily match how they would prefer things to be (have things done for them). Thus, there may be a mis-match between what the patient needs and what they want. Researchers need to be aware of these differences in studies eliciting patients’ views about their needs.

Action research is well recognized as a mechanism for learning in the workplace and promoting change (Williamson 2005). The culture of the setting within which organizational change is desired will have an effect on its success. More detail would have been beneficial from Glasson et al. as to what the environment was like from a staffing, culture, leadership style and concomitant departmental/organizational changes point of view, which may all have an impact on the staff and patient experience of nursing care. They do say that staff turnover was absent during the model group but do not say if this was the case in the pre-model group.

Evaluators need to consider carefully the grounding, reasoning and logic behind any recommendations they might make (Sadler 2005). Glasson et al. make several recommendations and rightly note the limits of generalizability of their findings to other settings. One particular recommendation, that future models should focus on multi-disciplinary approaches involving physicians and allied health professionals, is interesting and it would have been useful to have presented the evidence to support it. Why is that the case and what findings from this study have led that that view being formed? Can we realistically expect other professionals with their own agenda, language, values and beliefs to co-own a model of care delivery with nurses?

Whilst considering generalizability, these researchers are to be congratulated for their efforts in including older participants, with conditions such as dementia, who may ordinarily be excluded from a study. Whilst indicating the importance of this in terms of making the findings generalizable to the acute hospital population, there is a lesson to be learnt by other researchers. Whilst ethical concerns abound worldwide for the safe and ethical conduct of research particularly concerning participants who could be considered vulnerable, good research does not exclude people on the grounds of such a diagnosis if they have the capacity to take part (Barron et al. 2004). It is particularly important in this study as the interventions are educational and require active involvement and comprehension. Yet, the authors made significant efforts to prevent unnecessary exclusion.

Overall, this paper shows how action research can be tailored to the local situation and help integrate findings into practice. Good use of mixed methods is made enabling practice to be changed and evaluated in a substantive manner. Future participatory action research with increased involvement of patients and carers could prompt even greater success in addressing concerns from Phase 1 of this study including mechanisms to restore and maintain normal elimination.

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