This chapter describes the action research process used in this study including the rationale and appropriateness of this methodology, how threats were addressed, the role of the researcher, and the strengths and weaknesses of action research. Also included are the participant criteria for inclusion in the study and recruitment strategies, data
collection procedures, and method of data analysis. The aim of this study was to explore how acute care occupational therapists describe their role in discharge planning, what guides their discharge decisions and recommendations, how they define optimal discharge planning, and what actions or steps they can take to optimize their discharge planning skills within the current health care system.
Rationale
Action research was selected as it is a qualitative method that can be used to study the complex process of discharge planning from the perspectives of therapists who
actually engage in the process. Morrison and Lilford (2001) illustrated this when they noted, “there is no understanding a…situation without understanding how the participants see things” (Morrison & Lilford, 2001, p. 443).In contrast to a strictly controlled
research environment, action research can generate new knowledge and deeper
understandings of discharge planning within the context of a therapist’s actual practice setting. In action research, it is the intended beneficiaries of the research who determine its direction and content; thereby, increasing the likelihood that any solutions generated will meet their identified needs (Morrison & Lilford, 2011).
Even if therapists work in a rigid system like acute care and cannot change the length of shortened hospital stays, they can still improve practice by strengthening their critical reasoning skills through collaboration and reflection on professional values, assumptions, and theories that guide practice (Mattingly & Gillette, 1991). Action research is also an approach that is highly effective in narrowing the gap between theory and practice (Glasson, Chang, & Bidewell, 2008).
Specific Procedures
In action research, a group with common interests discuss an issue or issues of interest to the group. They identify a problem area and then collectively come up with a solution to the problem. They implement the agreed upon strategy and then reconvene to evaluate the effectiveness of that strategy. If the problem remains unresolved, a new strategy is proposed and the cycle continues until the problem is resolved to the satisfaction of the group (Stringer, 2014).
In this study, two groups of acute care occupational therapists gathered online to discuss issues surrounding discharge planning practices. Several strategies were
proposed, implemented at their facilities, and then the group reconvened to discuss and evaluate the efficacy of the implemented strategies. The specific data collection methods that were used are discussed below.
There is no set or natural end point to action research as during the course of action research new realities emerge that can perpetuate the study (Meyer,
1993; Stringer, 2014). However, when there is a sense that significant accomplishment has taken place, participants can choose to stand back ending the study. According to Morton-Cooper (2000), an action research study is terminated when it comes to a natural
end, when little more of value emerges (what she refers to as saturation), or when there is “co-researcher fatigue” (p. 93).
Although action research can continue into perpetuity, the researcher of the present study chose to conclude the study after a maximum of five online audio chats. This decision was made so that participation in the study did not become onerous to the participants. In actuality, the study was terminated at the conclusion of Chat 5 for Group 1 and Chat 4 for Group 2, as the data generated appeared to be sufficient in addressing the research questions of the study, and little more of value emerged so that saturation was reached.
Strengths and Weaknesses of Design
A strength of action research is that it can lead to improved outcomes, system changes, and the development of best practice guidelines. Action research also has the potential to empower participants, which may lead to increased confidence and self- esteem for occupational therapists working in a hierarchical medical model
system. Action research provides opportunities for participants to reflect on their own clinical practices, take action to address any identified problems, and then evaluate the efficacy of actions taken (Wilding, 2011). Therefore, occupational therapists working in acute care may be in a better position than an external researcher to judge if observed changes in their practices are effective.
However, there are also disadvantages to action research. For example, in action research the focus of the study can change as a consequence of the action plan. One of the tenets of action research is flexibility in which the content and direction of the research is not predetermined or known at the outset (Morrison & Lilford, 2001). In addition, there is
a subjective meaning aspect to action research where “those directly implicated in the problem being researched…must be allowed to determine the content, direction, and measures of success of a research project” (Morrison & Lilford, 2001, p. 439). Therefore, the researcher may end up relinquishing control as the path of the research can become diverted from the researcher’s original or intended goal. In addressing this issue, the researcher would occasionally pose questions that refocused participants on the research questions.
In many respects, the path the researcher hoped this study would take differed from what was originally envisioned. For example, the researcher had anticipated that the groups would come up with tools to better determine discharge recommendations. This was based on the assumption that other acute care occupational therapists had the same need for more accurate discharge planning tools and strategies. However, study
participants’ issues did not solely focus on the process of making discharge recommendations, but focused more predominantly on communicating their recommendations to other stakeholders.
Another disadvantage is that reflection and reflexivity are strong components of action research and are highly subjective, so that research results are situational and context specific (Morrison & Lilford, 2001).As a result, there is no generalizability to other populations as the outcomes of action research or its study results can only be applied to those involved in the particular study or the specific setting (Stringer, 2014). Furthermore, no matter how promising the outcome, the findings from action research may not translate to meaningful or sustained change.
Participants
The initial goal was to recruit eight to 12 participants for this study, so in the event of attrition, the chances would be increased that at least six participants
would remain for the duration of the study. Nine participants signed and returned the informed consent form (see Appendix A) and participated in the initial online audio chat. However, by the end of the study only five participants remained in the first group. A second group was later recruited which consisted of five participants, making the total number of participants for this study 10 people. There is no ideal or accepted number of participants for action research listed in the literature (Herr & Anderson, 2005; Hughes, 2008; Pitney & Parker, 2009; Stringer, 2014). In the various articles reviewed, the number of participants ranged widely from a few participants to several hundred (Du Toit, Wilkinson, & Adam, 2010; Glasson et al., 2006; Paterson et al., 2007; Petersson et al., 2009;Soh et al., 2011). According to Kemmis (1997), action research can even involve a single person trying to enact small changes.
Although there is no typical number of participants, action research does have some components similar to a focus group, and the ideal number for focus groups is six to 12 participants (American Statistical Association, 1997; Crabtree & Miller,
1999; Grbich, 1999; Morgan, 1997). There is precedent for smaller groups in
occupational therapy action research literature. Wilding and Whiteford (2008) conducted an action research study that consisted of two smaller groups of five to six participants, which they felt was preferable to a larger group of 11 participants as it afforded greater opportunity for all participants to engage in the discussion.
Inclusion Criteria
Inclusion criteria for this study were as follows:
Full and part time licensed occupational therapists.
Currently working in adult acute care within the United States. At least 3 years of adult acute care experience.
Experienced therapists were desirable as they are more likely to have a comprehensive and holistic approach to discharge planning (Crennan & MacRae, 2010; Holm & Mu, 2012).
Exclusion Criteria
The exclusion criteria were:
Pro re nata (PRN) and contract therapists as they would have had difficulty
implementing an action plan and observing outcomes, because they frequently move between different hospitals or different work settings.
Occupational therapy assistants and aides (COTA, OTA, and aides) were also
excluded as they are not licensed to perform certain functions (e.g., evaluations) that can influence discharge recommendations.
Characteristics
Initial recruitment included two males and 12 females; however, by the end of the study only females remained. There was one respondent from Alaska who seemed very interested in participating in this study and contacted the researcher several times, but never returned the informed consent; therefore, was not included in the study. The majority of participants were located in the state of Georgia, with the following states also represented: Massachusetts, Ohio, Tennessee, Arizona, Washington State, and
California. Table 3.1 displays the characteristics of each participant as well as the group each participated in.
The highest frequency of occupational therapy educational level for the majority of participants was an undergraduate degree (57%), followed by a master’s degree (28.5% - 7.14% entry level, 21.43% post entry). The average number of years practicing occupational therapy was approximately four years, with a range of 3.5 to 37 years of experience, and the average number of years practicing in the acute care setting was approximately 13 years, ranging from 3 to 32 years of experience. Approximately 85% of participants were employed full time in acute care, and 15% part time at the time of the study. One participant dropped out of the study midway, as she changed her employment status from full time to PRN, and no longer met the inclusion criteria.
Table 3.1
Participant Information
Group Participant Pseudonym State Gender Highest level of occupational therapy education Number of years as an occupational therapist Number of years practicing as an occupational therapist in acute care Employment status Remained through study conclusion Completed exit survey Member check 1 1 Janet OH F BA 30 12 currently + 3 in the 1980s
Full time Yes Yes Yes
1 2 Mary TN F Other
(participant did not elaborate)
13 12 Full time Yes Yes Yes
1 3 Dougie Hamilton MA M MA/MS post entry 3.5 3.5 Full time No – repeatedly stated would attend next scheduled online chats but did not. No reason provided. No No-did not receive response to email request for member check
1 4 Felix GA F BA 14 11 Full time Yes Yes Yes
1 5 ICU AZ F BA 27 14 Full time Yes Yes Yes
1 6 Bookworm GA F MA/MS entry
level 19 17 Full time No – dropped out citing work conflict. Was not included in total number of participants who completed the study, as only attended the first and last chats. The participant contacted me ahead of time stating she wanted to be an observer and would not be contributing any data to No Yes
the last chat. 1 7 Mark Smith OH M MA/MS post entry 34 24 Full time No – dropped out stating work/family conflict No No - did not receive response to email request for member check
1 8 Tesla CA F BA 13 11 Full time Yes Yes Yes
1 9 Buttercup WA F BA 37 3 Full time No – self-
selected out mid-study, as no longer met inclusion criteria (went from working FT to PRN No Yes
2 10 Marie GA F BA 36 32 Part time Yes Yes Yes
2 11 Lizzie GA F Other
(participant did not elaborate)
2 12 Bulldog mom
GA F BA 35 17 Part time Yes Yes No - two
email requests sent for member check, however did not receive response
2 13 Andy GA F MA/MS post
entry
25 15 Full time Yes Yes No - two
email requests sent for member check, however did not receive response
Recruitment Procedure
Participant recruitment initially consisted of a general invitation posted on AOTA’s OT Connections Acute Care and Research forums. The next method employed was contacting all 50 occupational therapy state associations and asking them to post an email invitation to their Listserv, or to include an ad in their state newsletter. Only 10 states were willing to publish the researcher’s invitation to participate in this study (Arizona, Georgia, Maryland, Massachusetts, Nevada, New Mexico, New York, Ohio, Texas, and Vermont). Several state organizations suggested the researcher contact them in several months as they were in the process of redoing their websites and email membership lists. The researcher did not take advantage of one state’s offer to sell her a copy of their membership list. One other state (Montana) also informed the researcher that they only support study recruitment for members of their own state.
Recruitment for the second group also included postings to AOTA’s OT Connections; however, this time the response was extremely poor. In order to improve recruitment for a second group, the researcher asked occupational therapy colleagues in other states to request their occupational therapy associations post the recruitment invitation. The researcher also posted a recruitment invitation to the Georgia
Occupational Therapy Association Listserv (the researcher’s home state), and letters were sent out to Georgia hospitals with rehabilitation departments that included occupational therapy services and included the researcher’s previous place of employment (see Appendix B). The researcher elected not to send out recruitment letters to occupational therapy departments in other states or all acute care occupational therapists due to the unwieldy volume that might have generated.
Ethical Considerations and Review
Ethical concerns were addressed through submission of an application to Nova Southeastern University’s institutional review board (IRB). No participants were recruited prior to IRB approval, and all participants were required to sign and return an informed consent form (see Appendix A). IRB application protocol #10301216Exp.was submitted and approved after successful completion of the researcher’s dissertation proposal defense by her committee. The initial IRB application was approved on January 16, 2013, and a renewal application was approved on December 4, 2013 for calendar year 2014.
The informed consent process began by dialoging with potential participants during the recruitment process through phone calls and emails. An explanation of the purpose of the study and a description of all procedures and issues related to potential risks, benefits, confidentiality, and privacy were reviewed. Participants were all informed they had the right to refuse or withdraw from the study at any point. Each participant was sent a copy of the informed consent (Appendix A), to be completed before the study was initiated. Included with the informed consent was a self-addressed stamped envelope in which participants returned to the researcher a copy of the informed consent once signed. A copy of the executed informed consent was then mailed or scanned, and then
emailed back to the participant for his or her files.
The informed consent stated that all information generated from this study would be kept confidential and anonymous. All material created during the course of this study was kept on the researcher’s private home computer, and in a secure and locked cabinet in the researcher’s private home office. All audio chats were recorded and saved
on a password protected home computer. GoToMeeting, the company used to convene the groups and make the recordings, does not archive any audio or video recordings.
In addition, to ensure confidentiality and anonymity, participants were instructed to choose a pseudonym that was used throughout the course of this study. Refer to Table 3.1 for a list of participant pseudonyms. The researcher was the only one who had access to participants’ true identities. Along with a copy of the audio recordings, transcriptions of recordings were stored electronically on the researcher’s private home password protected computer for later data analysis. All recordings and transcriptions were kept for 36 months from the end of the study. The recordings were destroyed after that time by shredding copies of any paper notes, and deleting all online files.
Potential harm and benefits.Before initiation of an action research study there is no way to determine with any certainty the risk of participation (Herr & Anderson, 2005). For example, true informed consent cannot be achieved in action research as the type of change and its effects are unknown at the beginning of any study (Morrison & Robertson, 2016). However, it is incumbent upon the primary researcher to use sound professional judgment in anticipating and minimizing all potential risks to subjects (Herr & Anderson, 2005).
Risks for this study in terms of loss of privacy, breach of confidentiality, or emotional distress were minimized, and no harm or adverse events were anticipated or reported during the course of this study. However, this study did involve a moderate time commitment in filling out the online surveys and participation in the audio chats. There was also no financial gain; however, participants may have benefited from participation
in this study through the implementation of action plans that had the potential to improve clinical practice and patient outcomes in their own practice settings.
In addition, the Occupational Therapy Code of Ethics (AOTA, 2015), and occupational therapy professional behaviors were supported throughout the study (AOTA, 2008). For example, after participants signed the informed consent, they were provided with a list of guidelines and etiquette for participation in the study (see Appendix C). As facilitator of the group, the researcher planned on addressing
unprofessional behaviors by discreetly and privately contacting any offenders. However, there was no occasion to take action as none of the participants engaged in any
unprofessional or disrespectful behavior. There was also no occasion to ask anyone to leave the group.
Another risk that can be encountered in relation to the action research change process is that it can be unpredictable and uncomfortable for some participants. The researcher notified participants that she was available to provide emotional support and would make every effort to assist participants who found participation in this study difficult or stressful. The researcher was never contacted by any of the participants in this study with any issues relating to discomfort or stress. In addition, as stated in the
informed consent and in the general guidelines for this study, participants were informed they had the right to withdraw from the study at any point and for any reason, with the researcher maintaining the participant’s privacy.
Health Insurance Portability and Accountability Act. The Health Insurance
Portability and Accountability Act (commonly known as HIPPA) compliance did not appear to be applicable to this study, because there was no involvement of participants’
personal health information. In addition, no identifiable client or institution information (i.e., through case studies or therapy narratives) was revealed during the course of this study.
Study Setting
This study was conducted predominantly online; however, on a few occasions participants participated through telephone conference calling when they were unable to access the audio chat online. Study participation also included filling out several online surveys (refer to Appendix D for initial occupational therapy questionnaire, Appendix E for exit survey, and Appendix F for evaluation of selected strategies).
Instruments and Measures
This was a qualitative study. The online instrumentation as methods of data collection and equipment used are discussed in the Data Collection Procedures section