METHODOLOGICAL ISSUES IN NURSING RESEARCH

Action research from the inside: issues and challenges in doing action research in your own hospital
David Coghlan MSc PhD SM
Lecturer in Business Studies, School of Business Studies, University of Dublin, Trinity College, Dublin, Ireland

and Mary Casey MMedSc BNS RGN RM

College Lecturer, School of Nursing and Midwifery, University College, Dublin, National University of Ireland, Dublin, Ireland

Submitted for publication 4 December 2000 Accepted for publication 9 May 2001

Correspondence: David Coghlan, School of Business Studies, University of Dublin, Trinity College, Dublin 2, Ireland. E-mail: david.coghlan@tcd.ie

COGHLAN D. & CASEY M. (2001)

Journal of Advanced Nursing 35(5), 674682 Action research from the inside: issues and challenges in doing action research in your own hospital Background and rationale. Nurses are increasingly engaging in action research projects to improve aspects of nursing practice, education and management and contribute to the development of the profession. Action research involves opportunistic planned interventions in real time situations and a study of those interventions as they occur, which in turn informs further interventions. Insider action research has its own dynamics which distinguish it from an external action researcher approach. The nurse-researchers are normally already immersed in the organization and have a pre-understanding from being an actor in the processes being studied. There is a paucity of literature on the challenges that face nurse action researchers on doing action research in their own hospital. Aim. The aim of this article is to address this paucity by exploring the nature of the challenges which face nurse action researchers. Challenges facing such nurseresearchers are that they frequently need to combine their action research role with their regular organizational roles and this role duality can create the potential for role ambiguity and conict. They need to manage the political dynamics which involve balancing the hospital's formal justication of what it wants in the project with their own tactical personal justication for the project. Main issues. Nurse-researchers' pre-understanding, organizational role and ability to manage hospital politics play an important role in the political process of framing and selecting their action research project. In order that the action research project contribute to the organization's learning, nurse action researchers engages in interlevel processes engaging individuals, teams, the interdepartmental group and the organization in processes of learning and change. Conclusions. Consideration of these challenges enables nurse-action researchers to grasp the opportunities such research projects afford for personal learning, organizational learning and contribution to knowledge. Keywords: action research, insider action research, nursing research, methodology

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Issues and challenges in action research

Introduction
Nurses are increasingly engaging in action research projects to improve aspects of nursing practice, education and management and contribute to the development of the profession (Towell & Harries 1979, Webb 1989, Holter & Schwartz-Barcott 1993, Meyer 1993, Greenwood 1994, Stark 1994, Hart & Bond 1995, Hart 1996, Morton-Cooper 1999, Webb et al. 1999). Issues of organizational concern, such as quality patient care, systems improvement, organizational learning and the management of change are suitable subjects for action research, as (a) they are real events, which must be managed in real time, (b) they provide opportunities for both effective action and learning and (c) can contribute to the development of theory of what really goes on in hospitals and to the development of nursing knowledge. Sometimes these projects have had a dual purpose to full academic requirements in addition to changing some aspect of nursing care (Meyer 1993, Waterman et al. 1995). Armitage et al. (1991) used action research to implement primary nursing and to investigate the effects of the intervention on the quality of nursing care provision, as have Titchen and Binnie (1993a). Action research projects have also been undertaken in nursing education programmes (Coates & Chambers 1990, McCaugherty 1991) and to develop clinical teaching (Hyrkas 1997). Hunt (1987) used action research to encourage nurses to use research ndings in their work and evaluated the outcome of the project. Towell and Harries (1979) acted as facilitators of change in a psychiatric hospital, giving advice and emotional support for nurses trying to change their work practices, while Webb et al. (1990) used action research to introduce a self-medication programme for older inpatients. Gibbon and Little (1995) explored ways of improving stroke care and rehabilitation using action research. More recently, Kilgour and Fleming (2000) conducted an action research inquiry into a health visitor parenting programmes for parents of pre-school children with behavioural problems. Heslop et al. (2000) used a participatory action research design to enhance a collaborative commitment to improving continuity of care across psychiatric and emergency services. Barrett (2001) also conducted a participatory action research approach toward improving midwifery practice, enhancing women's satisfaction with their early mothering experiences and facilitating women's access to informed choices. Action research is particularly powerful for the researcher because it provides direct access to the area of investigation, which is of great importance for a researcher in a practical discipline (Holter & Schwartz-Barcott 1993). According to Rolfe (1996) action research promotes a nonelitist approach,

in which the practitioners themselves carry out small-scale research projects. They also retain control and direction over the implementation of research knowledge (Rolfe 1994). Riemer (1977) argues that rather than neglecting `at hand' knowledge or expertise, researchers should turn familiar situations, timely events or special expertise into objects of study. Riemer's proposal for opportunistic research is appropriate for those engaging in action research. The action research literature tends to take the perspective of the action researcher as an external agent, or what Greenwood and Levin (1998) call `the friendly outsider'. Rarely is there much consideration of action research by the permanent insider (Coghlan & Brannick 2001). There are some explicit discussions of situations in which nurse action researchers were insiders, but these typically are sections in broader explorations of action research and are not directed at any extensive reection on the dynamics of insider action research itself (Meyer 1993, Titchen & Binnie 1993a, Webb et al. 1999). `Insider' has been contextualized differently in different action research accounts (Webb et al. 1999). Meyer (1993) returned to the same hospital in which she formerly worked. Titchen and Binnie (1993a, 1993b) created a `double-act' team relationship between them to cover both change agent and researcher roles. In East and Robinson's (1994) study the research assistant worked on the wards as part of the nursing team. In this article, we are focusing on the action researcher as the permanent insider and will explore some of the key issues which arise when nurses grasp organizational opportunities to engage in action research projects in their own hospitals. This exploration of insider action research provides an important contribution to the consideration of action research and practice based learning by nurses (Coghlan & Brannick 2001).

Action research
Action research is an approach to research which aims at both taking action and creating knowledge or theory about that action (Susman & Evered 1978, Holter & SchwartzBarcott 1993, Hart & Bond 1995, Eden & Huxham 1996, Greenwood & Levin 1998, Gummesson 2000, Coghlan & Brannick 2001, Reason & Bradbury 2001). It works through a cyclical process of consciously and deliberately: (a) planning, (b) taking action, (c) evaluating that action and (d) leading to further planning and so on. According to Hyrkas (1997, p. 802) `the most characteristic feature of action research is considered to be the spiral-like progress with alternating phases and cycles that evolve over a period of time'. Its central tenets can be expressed as follows (Argyris et al. 1985):
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it involves change experiments on real problems in social systems. It focuses on a particular problem and seeks to provide assistance to the client system; it, like social management more generally, involves iterative cycles of identifying a problem, planning, acting and evaluating; the intended change in an action research project typically involves re-education, a term that refers to changing patterns of thinking and action that are presently well-established in individuals and groups. Effective re-education depends on participation by clients in diagnosis, fact-nding and free choice to engage in new kinds of action; it challenges the status quo from a participative perspective, which is congruent with the requirements of effective re-education; and it is intended to contribute simultaneously to basic knowledge in social science and to social action in everyday life. High standards for developing theory and empirically testing propositions organized by theory are not be to be sacriced nor the relation to practice be lost. Nurses who undertake an action research project in and on their own hospital normally do so because they want to improve aspects of nursing care practice, education and management and intend to remain a member within their desired career path when the research is completed. This is in contrast to many traditional research approaches where the researcher joins the organization temporarily specically for the purposes of the research. Insider action research has its own dynamics which distinguish it from an external researcher approach (Webb et al. 1999, Coghlan & Brannick 2001). The researchers are already immersed in the organization and have built up knowledge of the organization from being an actor in the processes being studied (Evered & Louis 1981). This knowledge comes from the researcher engaging in the experiential learning cycles of experiencing, reecting, conceptualizing and experimenting in real situations (Kolb 1984, Raelin 2000). There are a number of signicant challenges for nurses considering action research in their own hospital which we will explore under the following headings: pre-understanding, role duality and organizational politics.

hospital (Titchen & Binnie 1993b, Koch & Harrington 1998, Webb et al. 1999). Nurses have a knowledge of their hospital's everyday life. They know the everyday jargon. They know the legitimate and taboo phenomena of what can be talked about and what cannot. They know what occupies colleagues' minds. They know how the informal organization works and to whom to turn for information and gossip. They know the critical events and what they mean within the organization. They are able to see beyond objectives that are merely window dressing. When they are inquiring they can use the internal jargon and draw on their own experience in asking questions and interviewing, and are able to follow up on replies and so obtain richer data. They are able to participate in discussions or merely observe what is going on without others being necessarily aware of their presence. They can participate freely, without drawing attention to themselves and creating suspicion. East and Robinson (1994, p. 59) felt it was important to explore both inner and outer context of the change process story. For this reason the research assistant worked as part of the nursing team in an attempt to `understand the nature of the inner context of the change process through the culture, beliefs and values expressed by the ward nursing staff'. There are also some disadvantages to being close to the data. When action research nurse-researchers are interviewing they may assume too much and so not probe as much as if they were outsiders or ignorant of the situation. They may think that they know the answer and not expose their current thinking to reframing. They may nd it difcult to obtain relevant data, because as a member they have to cross departmental, functional or hierarchical boundaries or because as an insider they may be denied deeper access, which might not be denied an outsider. These pose considerable challenges to nurse-researchers and require rigorous introspection and reection on experience in order to expose underlying assumptions and unreected action to continuous testing (Argyris et al. 1985). Role duality: organizational and researcher roles Nurses work in an environment complicated by the presence of many interest groups; they are not autonomous and structurally they are subordinate to medical staff (Hart 1996). When nurses augment their normal hospital membership role with the research enterprise, the research process can become more difcult and awkward. In trying to sustain a full organizational membership role and the research perspective simultaneously, nurse action researchers are likely to encounter role conict and nd themselves caught in loyalty tugs, behavioural claims and identication dilemmas (Coghlan & Brannick 2001). Waterman et al.

Challenges of inside action research

Pre-understanding `Pre-understanding refers to such things as people's knowledge, insights and experience before they engage in a research programme' (Gummesson 2000, p. 57). The knowledge, insights and experience of the nurse-researchers apply, not only to theoretical understanding of organizational dynamics, but also to the lived experience of their own
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(1995) highlight tensions between the two reasons for carrying out their study, rst the purely altruistic reason and second, the intention of gaining an academic qualication. Similarly, East and Robinson (1994, p. 61) identify the conicts they experienced when feeding back their research to the staff and at times `it appeared that the sensitive nature of the conicting perspectives (they) identied would prevent (them) proceeding with the research'. In an attempt to resolve the tension, Titchen and Binnie (1993a, 1993b) created a `double-act' whereby they split the change agent and researcher roles between them. Action researchers' involvement in the two roles affect their relationships with fellow organizational members (Webb 1989, Meyer 1993, Titchen & Binnie 1993a, 1993b). The new dimensions of their relationship to fellow organizational members set them apart from ordinary members. Their organizational relationships are typically lodged and enmeshed in a network of membership afliations. These friendships and research ties can vary in character from openness to restrictiveness. Nurse action researchers are likely to nd that their associations with various individuals and groups in the setting will inuence their relationships with others whom they encounter, affecting the data that can be generated in working with them. Probably the most important issue for nurse action researchers, particularly when they want to remain and progress in the hospital, is managing organizational politics. Managing organizational politics `Action research has the potential to bring reective practice and emancipatory action together in a way which may challenge the status quo' (Hart 1996, p. 459). Undertaking an action research project in one's own hospital is political and might even be considered subversive. In many respects action research is subversive: it examines everything, stresses listening, emphasizes questioning, fosters courage, incites action, abets reection and endorses democratic participation. Any or all of these characteristics may be threatening to existing organizational norms. While nurse action research researchers may see themselves as attempting to generate valid and useful information in order to facilitate free and informed choice so that there will be commitment to those choices in accordance with the theory and practice of action research (Argyris et al. 1985), they may nd that what constitutes valid information is intensely political. Accordingly, nurse action researchers need to be politically astute in deciding to engage in action research, becoming what Buchanan and Badham (1999) call a `political entrepreneur'. In their view, this role implies a behaviour repertoire of political strategies and tactics and a reective

self-critical perspective on how those political behaviours may be deployed. Buchanan and Boddy (1992) describe the management of the political role in terms of two activities: performing and backstaging. Performing involves the public performance role of being active in the change process, building participation for change and pursuing the change agenda rationally and logically, while backstage activity involves the recruitment and maintenance of support and reduction of resistance. Backstaging comprises skills at intervening in political and cultural systems, through justifying, inuencing, negotiating, defeating opposition and so on. As we have seen, nurse action researchers have a preunderstanding of the hospital's power structures and politics, and are able to work in ways that are in keeping with the political conditions without compromising the project or their own career. Hart (Hart & Bond 1995) narrates how, when she presented a report to senior managers and directorate mangers, its ndings were denied by the senior managers, and on being told to cancel future plans, she felt that she did not expect to see the hospital again. Titchen and Binnie (1993a) report how the `double-act' structure they had adopted enabled a reduction in role uncertainty and resistance to change. As nurse action researchers engage in their project, they need to be prepared to work the political system, which involves balancing the hospital's formal justication of what it wants from the project with their own tacit personal justication for political activity. Throughout the project they have to maintain their credibility as effective drivers of change and as astute political players. The key to success lies in assessing the power and interests of relevant stakeholders in relation to aspects of the project.

Framing and selecting the action research project

The interconnectedness of pre-understanding, role duality and organizational politics becomes evident in the process of framing and selecting an action research project in one's own hospital. The complexity of issue identication and selection illustrates that the search for an appropriate issue to study is difcult (Coghlan & Brannick 2001). How do nurse action researchers get a sense of the range of possible issues that may be addressed? Not every issue will volunteer itself automatically for attention. While acknowledging the existence of a wide and diverse range of issues, it is important to understand that any issue, once selected for attention, may be embedded in a set of related issues (Beckhard & Harris 1987). Nurse action researchers are then confronted with choices concerning boundaries and are obliged to choose what can be achieved within the time and resources available.
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Thinking in terms of issues, rather than problems or opportunities, which warrant attention is vital as language and labels are of the utmost importance at the outset (Cooperrider & Srivastva 1987). For example, framing proposed research initiatives in the context of addressing problems or opportunities carries some inherent risks. Framing an issue as a problem may inuence who gets involved in problem resolution. It may be that hospital members embrace problems with a sense of loss, wondering about the hospital's ability to reach a satisfactory resolution and often preferring to remain somewhat detached and uncommitted. Using the word `problem' as distinct from `opportunity' may also lead to convergent thinking. The mental effort expended on problem resolution may restrict the range of alternatives considered by blinding hospital members to possible novel solutions. In a similar vein use of the label `opportunity' may lead to divergent thinking, as this has a greater associated sense of gain. Members of a nursing team may feel a sense of excitement about tackling a signicant opportunity that may have the potential for creativity. Webb et al. (1990) describe the impetus for an action research study on self-medication for older patients as originating from a group of students doing a project, and subsequently this idea was pursued by the course tutor and the unit manager. What becomes important, then, is to uncover the issues that are viewed by hospital members as key issues warranting attention at any point in time. In those issues involving complex organizational change, many of them may initially fall in the category of rst-order change (Bartunek & Moch 1987). As already noted, not all issues are blatantly obvious and it is therefore important for the researcher to get a sense of both the obvious and less obvious. It may be that the obvious is but an outward manifestation of a deeper issue which hospital members are not so willing to embrace publicly. Identication of these deeper issues may point to the need for second-order change. What if the obvious only seems that way because of people being ill-informed on the nature of the issue at hand? Could it be that the obvious has become so because it embraces the language of dissent and reects the pre-occupations of hospital members without ever reecting on root causes? Nurse action researchers need to go with the story as it evolves. They are continually testing whether consensus exists concerning the array of issues that could be addressed. Such an array may be constructed following consideration of hospital members' perceptions of key issues. It may embrace a healthy diversity of thinking among members, or alternatively it may point to signicant pockets of conict in certain issue domains (Eden & Huxham 1996). Change triggers
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discussion, debate and arguments between people who champion competing ideas and proposals. Such discussion provides useful data and is desirable in order to expose different ideas to public scrutiny and examination (Buchanan & Badham 1999). No issue in a hospital is context-free. Uncovering issues necessitates establishing not only multiple versions of `the real facts' but also understanding the role that history and experience have to play in hospital members' perceptions of these facts. In a similar manner any given issue may be embedded in a system of political behaviour, which is crucial to understand if issue resolution is ever to be negotiated. Of immediate importance, then, to nurse action researchers is the need to gather and organize these data, stimuli and perceptions of themselves and others. The subsequent sensemaking process points to the need for them to have good organizational and analytical capabilities. Finally, it is important when categorizing issues that each one is framed in the context of its implicit and explicit assumptions, any known causal relationships, and any predictive judgements concerning the speed of issue resolution. Making assumptions explicit aids the resolution process as hospital members develop a shared understanding of the issue being addressed in terms of its history, scope and possible outcomes. Establishing causal relationships helps to place an issue in context by grounding it in the reality of hospital life, while simultaneously establishing how hospital members attribute certain outcomes to root causes. Outlining predictive judgements attaches a sense of urgency or otherwise to the issue at hand.

Contributing to organizational learning

The question then arises: How do the action research projects of individual nurses contribute both to the ongoing learning of the hospitals in which these nurse-researchers work and to the academic community? To answer this question we need (a) an inclusive notion of research and (b) an organizational framework that integrates individual and organizational learning. Traditionally, research addresses the audience of the community of scholars, and applied practical research addresses an outside audience in reports and recommendations. In contrast, Torbert (1999, 2001) elaborates a framework of rst, second and third person research. First person research addresses how individual researchers engage in inquiry and learning about their own life and how they act. Stark (1994) provides an account of this type of research in relation to a nurse tutor's experience of personal and professional growth through action research. Second person

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research addresses how researchers engage in inquiry with others and create a community of inquiry. Titchen and Binnie (1993a, 1993b) explicitly address how their action research project involved a team process between the two of them and a nursing team in the ward. Third person research addresses how researchers move beyond their immediate rst and second person audiences to the impersonal wider community and make a contribution to the body of knowledge. How, then, does an action research project in a nursing context contribute to all three forms of research? Clearly rst person research is benecial to the individual nurse in terms of personal learning and skill development, although it may not always promote the individual's career prospects in the organization (Coghlan & Brannick 2001). In terms of second person research, the project is useful to the hospital, through introducing some forms of rst or second order change, while the third person aspects provide valuable experience and a rigorous contribution to nursing which can contribute to the knowledge base of the profession. The integration of rst and second person research and individual and organizational learning occurs through attention to the levels of aggregation that exist in hospitals. These levels describe not only levels of analysis such as individual, team, interdepartmental group and organization, but interlevel dynamics such as the impact the individual has on the team and vice versa, the team on other teams, and the organization on individuals, teams and on the interdepartmental group and vice versa. Such interlevel dynamics are integral to the nature of hospitals as recursive systems (McCaughan & Palmer 1994), and attention to them is critical to the processes of organizational change and learning (Rashford & Coghlan 1994, Coghlan 1996, 1997). First, there is the individual learning and change level for nurse-researchers, whereby they attend to their own learningin-action through their action research project. According to Koch and Harrington (1998, p. 882) attending to what is going on while researching `requires that a reective journal be maintained throughout the research process'. Yet individual nurse-researchers' own personal learning and change is not sufcient if they aim to effect change in larger and more complex systems than themselves. Typically, the most immediate experience individual nurses have of a hospital is as a staff nurse and member of a ward-based nursing team. It is through that membership that individuals exercise their role and inuence. Hence, the second level of attention is to the dynamics of this team in which they work and use in their projects. Such attention involves attending to content and process issues. For a ward-based nursing team to learn, its members need to attend and to engage in dialogue on such

issues as establishing a shared and explicit set of values which underpin care (Nolan & Grant 1993). They also need to focus on how its members communicate among themselves, solve problems, make decisions and so on (Schein 1999, Wheelan 1999). Yet the research and change process cannot be restricted to learning and change by individuals and teams alone. The learning and change which takes place in individuals and teams needs to be generalized across the interdepartmental group, so that other teams and units engage in dialogue and negotiation. A critical focus for attention in this regard is the impact that cultural perspectives from different functions have on the change process (Schein 1992). Interdepartmental group dialogue needs to take account of how staff in functional areas in hospitals hold different assumptions from and about one another. Finally, the research project does not stop within the hospital. Hospitals as open systems have a dynamic two-way relationship with their external environment. The research process needs to include how the hospital is affecting and being affected by its patients or clients, stakeholders, local community, competitors, other organizations and wider society. Viewing hospitals through levels of analysis is only one part of the picture. The other part refers to how each of the levels is related to each of the others. There is an essential interlevel element in that each level has a dynamic relationship with each of the others. This relationship is grounded in systems dynamics, in which the relationship each of the four levels has with the other three is systemic, with feedback loops forming a complex pattern of relationships (Senge 1990, McCaughan & Palmer 1994). Dysfunctions at any of the four levels can cause dysfunctions at any of the other three levels. An individual nurse's disaffection may be expressed in dysfunctional behaviour in the ward-based nursing team and affect that team's ability to function effectively, which in turn reinforces the individual nurse's disaffection. If a ward-based nursing team is not functioning effectively, it can limit the interdepartmental group's effectiveness, which may depend on the quality and timeliness of information, resources and partially completed work from that team. If the interdepartmental group's multiple activities are not co-ordinated, the hospital's ability to function effectively may be affected. In systemic terms, each of the four levels affects each of the other three. In order that individual learning is aggregated into organizational learning, nurse action researchers need to work effectively at all four levels (Coghlan 1997). Managing the political dynamics of framing and selecting an action research project involves working with individuals, teams, across the
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interdepartmental group and the organization. Similarly, using their pre-understanding and the action research process to assess the scope of the issue and the degree of political support and/or opposition also involves working with individuals, teams, across the interdepartmental group and the organization. Such dynamics are critical to bridging the wide gap that exists between individual and organizational learning and the theorypractice gap in nursing, which results in the production of research ndings that are perceived as irrelevant to clinical practice.

The value of insider action research for practice-based learning

In many respects most of the elements discussed above pertain to any practice-based project. All nurses need to be able to engage in experiential learning or action research, to use their pre-understanding in their nursing role and be able to manage organizational politics. What then, does insider action research contribute to practice-based learning? There are two elements to an answer to this question. The rst element is that practice-based learning demands rigour and an action research approach can bring this. Rigour in action research refers to how data are generated, gathered, explored and evaluated and to how events are questioned and interpreted through multiple action research cycles (Greenwood 1994, Eden & Huxham 1996). Credibility of the research ndings should be judged on the usefulness of the research project (Avis 1995). In other words, nurse action researchers need to show: how they engaged in the steps of multiple and repetitious action research cycles (how diagnosing, planning, taking action and evaluating were carried out), and how these were recorded to constitute a true representation of what was studied; how they challenged and tested their own assumptions and interpretations of what was happening continuously through the project by means of public reection, so that their familiarity with and closeness to the issues are exposed to critique; how they accessed different views of what was happening which probably produced both conrming and contradictory interpretations; and how their interpretations and diagnoses were grounded in theory, rigorously applied, and how project outcomes were challenged, supported or disconrmed in terms of the theories underpinning those interpretations and diagnoses. The second element of insider action research which contributes to practice-based learning is the generation of a supportive environment (Stark 1994). Clinical nurse
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managers can play an important role in ensuring that action research projects generate individual and organizational learning. Through a range of interventions that focus on enabling nurse-researchers to engage in inquiry, reection and theorizing about their project, they can facilitate the enactment of action research cycles in the research project itself. For those nurse-researchers who are undertaking action research as part of an academic requirement, their academic supervisors focus on the individual's inquiry into the action research project (Coghlan & Brannick 2001). In the academic context the focus is not so much on whether the project was successful as on the exploration of the data, how a particular project was managed, provides useful and interesting theory which may contribute to learning on the subject of practicebased research (Waterman 1998).

Conclusions
In this article, we have reected on the opportunities and challenges for nurses doing action research projects in their own hospital, which in this context means both having insider pre-understanding and access, and wanting to remain a member on a desired career path when the research is completed. This view of action research is rarely afforded much attention (Coghlan & Brannick 2001). In considering insider action research projects, potential nurse action researchers need to be aware of the strengths and limits of their pre-understanding, so that they can use their experiential knowledge to reframe their understanding of situations to which they are close. They need to consider the impact of hospital politics on the process of inquiry, who the major players are, and how they can be engaged in the process. Pre-understanding of hospital politics plays an important role in framing and selecting an insider action research project. What appears clear at the outset may lose its apparent clarity as the project unfolds. How the project is framed and subsequently reframed may be a source of important learning. Finally, the ability of individual action research projects to have an impact on what and how a hospital learns depends on strategies of aggregating individual learning to team and interdepartmental group and organizational learning. Consideration of issues such as these enables nurses to meet the challenges of doing action research in their own hospitals, and so provides interesting and exciting research for the development of their hospitals and the profession.

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