enhancing lives through the development of a community-based participatory action research programme

Enhancing lives through the development of a community-based

participatory action research programme

TTINAINA KOCHKOCH BA, PhD, RN

Professor of Nursing, RDNS Chair in Domiciliary Nursing, Flinders University, Adelaide, PO Box

247, Glenside SA 5965, Adelaide, South Australia

PAMPAM SSELIMELIM BA, RN

Research Associate, RDNS Research Unit, Royal District Nursing Service (RDNS),

31 Flemington Street, Glenside, South Australia 5065

DDEBBIEEBBIE KKRALIKRALIK MN PhD, RN, MRCNA

Research Associate, RDNS Research Unit, Royal District Nursing Service (RDNS),

31 Flemington Street, Glenside, South Australia 5065

Accepted for publication 26 June 2001

Summary

· A community-based participatory action research (PAR) programme that has

spanned 5 years is discussed in this article. A primary healthcare philosophy

requires research in this practice setting and supports the way healthcare is

ideally organized within an integrated team and supported by a community

network that includes not only the healthcare workers and service providers but

also the community as partners.

· The principles driving three PAR inquiries are described: the development of

a model for prevention of workplace violence; working with clinicians towards

improving wound management practice; and management of continence for

community-dwelling women living with multiple sclerosis.

· Participatory action research is a potentially democratic process that is

equitable and liberating as participants construct meaning in the process of group

discussions.

· We conclude that the cyclical processes inherent in PAR promote re¯ection

and reconstruction of experiences that can lead to the enhancement of people's

lives, either at an individual or community level, or both.

Keywords: chronic illness, community health, participatory action research, work-

place violence, wound care.

Introduction

In collaboration with district nursing clinicians, we have

established a community-based research programme that

has spanned 5 years. The district nursing organization is

Correspondence to: Tina Koch, RDNS Chair in Domiciliary Nursing,Flinders University, Adelaide, PO Box 247, Glenside SA 5965,Adelaide, South Australia (e-mail: [email protected]).

Journal of Clinical Nursing 2002; 11: 109±117

Ó 2002 Blackwell Science Ltd 109

comprised of approximately 400 staff and has a designated

research unit, where nurse researchers aim to advance

nursing and management practices within the organiza-

tion. In addition, as part of a wider primary healthcare

mandate, the unit's researchers seek ways in which district

nurses can contribute to community development. The

organization's mandate is driven by the International

Declaration of Primary Health Care (signed in Alma Ata

in the USSR in 1978), which established the rights of

people to participate individually and collectively in the

planning and implementation of their healthcare. The

philosophy of the research unit advocates the organization

of primary health care in an integrated team supported by

a network that includes the community as partner to the

health care workers and service providers. In the effort to

embrace both internal (organizational) and external (com-

munity) aims, the unit's researchers have been guided by

the principles of participatory action research (PAR). We

have found this approach an appropriate and meaningful

way to engage nurses, clients and the wider community in

research projects.

In this paper we describe three research projects that

have been framed by the principles of PAR. The ®rst

project led to the development of a model for the

prevention of violence in the workplace, the second

demonstrates working with clinicians to improve wound

management practice, and the third introduces our main

research programme, which involves working with people

who live with chronic illness. Each project discussed in

this paper was granted ethical approval and pseudonyms

have been used to preserve participant anonymity.

There are many PAR approaches and in this paper we

will link the methodological rationale of our work to

several PAR theorists such as Kemmis & McTaggart

(1988), Reason (1994), Street (1995) and Stringer (1996).

We aim to show that PAR approaches have the potential to

enhance the lives of all involved in the process.

Participatory action research

Participatory action research has some commonalities with

a range of other traditions; however, the intellectual roots

are generally acknowledged as emerging from the work of

Freire (1974) and Habermas (1979). We have found that

there are some commonly agreed upon principles across

the different approaches to PAR. It is a disciplined inquiry

that seeks a focused effort to create the knowledge that is

necessary for people to take action to improve the quality

of their lives. PAR is collective, self-re¯ective inquiry that

is undertaken to improve a situation. The spiral nature of

PAR, with a planning, action and evaluation phase

(Kemmis & McTaggart, 1988; Street, 1995), goes beyond

the mere fact ®nding expedition that is the hallmark of

much conventional research. We have taken on board the

principles raised by Stringer (1996) who proposes that

PAR can be:

· democratic, enabling participation of all people;

· equitable, acknowledging people's equality of worth;

· liberating, providing freedom from oppressive, debili-

tating conditions; and

· life enhancing, enabling the expression of people's full

human potential.

Reason (1994) has also been in¯uential in guiding our

research, in particular his pragmatic assumption that the

production of knowledge and action of the PAR process

will be useful to groups of people. The second point made

by Reason is that there exists potential for the empow-

erment of people through the re¯ective processes of

constructing and reconstructing meaning through retelling

of participants' experiences and knowledge. This notion

ties in with Stringer's (1996) work. Stringer, whose ideas

are promulgated by Guba & Lincoln's (1989) construc-

tivist paradigm (which has a relativist ontology), assumes

that people invent their reality. Although each person is

able to present their construction of reality, this can be

challenged by other realities in a world of multiple

realities. Methodologically, there is a continuing dialectic

as people strive to make meaning and collectively create

knowledge. When a PAR group works well, we have

observed evidence of this ongoing dialectic as group

members shift their understandings to make sense of their

situations or experiences. Understandings gained in this

way have the potential to enhance the lives of all

participants. In summary, the principles adapted for the

PAR processes are: democratic, equitable, liberating,

meaningful (making meaning), useful and, ultimately, life

enhancing. In the section to follow we will demonstrate

the way in which these principles have been applied in

three of our research projects.

Developing a model for the prevention

of workplace violence in the community

The aim of the ®rst project was to work with nurses to

develop, implement and evaluate a best practice model for

the prevention of community workplace violence. We

applied the PAR approach advocated by Street (1995)

because her work is based on informing nursing practice

through the processes of re¯ection and deconstruction.

The process of engaging in practices that are informed by

re¯ection is called praxis, which is achieved by critically

identifying issues and collaborating to re¯ect politically

110 T. Koch et al.

Ó 2002 Blackwell Science Ltd, Journal of Clinical Nursing, 11, 109±117

upon practice to systematically deconstruct it. Participants

replay the action through the process of reconstruction.

Praxis research owes a theoretical debt to critical theorists

such as Lather (1991), Fay (1977) and Habermas (1979).

We were guided by Street (1995), who considers

participants to be co-researchers in the enterprise of

knowledge construction, and in this project also in model

construction. In addition, Street (1995) contends that PAR

facilitates people towards understanding issues of concern

and then planning action to make improvements. Her

methodology is based on Kemmis & McTaggart's (1988)

action research spiral, and the cyclical nature requires

continual re¯ection and revision of the research plan,

while maintaining a forward action. For these reasons, it

was deemed an appropriate methodology for exploring

issues of community nurse safety and developing new

strategies for security.

Once a theoretical framework had been selected, a ¯yer

was distributed throughout the organization inviting

community nurses to volunteer to be involved in the

project. Nine of them joined the PAR group, which was

facilitated by the ®rst author. The PAR group met

fortnightly for 90 min from February 1999 to December

1999. A literature review on workplace violence con®rmed

that a model for violence prevention applicable to

community practice had not previously been published.

Hence, the ®rst phase of the project was to discover the

nature of violence that community nurses experience in

practice.

Street (1995 p. 61) describes a process of raising

consciousness though story telling that involves asking

each person `to give a thumbnail sketch of their own

professional life, making links between their current

attitudes and experiences'. Consciousness-raising practices

from the early days of the women's movement in the 1960s

involved women sharing their experiences, or the actual-

ities of people's lives as they experience them, and in this

way knowledge of the social world was created that was

grounded in people's experience of their own lives. In this

project, consciousness-raising facilitated a comprehensive

understanding of the experience of being involved in

workplace violence. Nurses who participated in the PAR

group were asked to share their experiences of violence

perpetrated by community clients:

One Sunday morning I visited an older man needing

tracheostomy care, which involved him lying on his

back, with me bending over to dress around his stoma

and give him a new bib. As I was ®nishing the care

and I had my face close to his, he grabbed my

shoulders and tried to kiss me. I overbalanced and fell

on to the bed partly on top of him. He held me down

and kept kissing me. I was outraged and yelled: `Stop!

Stop! Let me go. How dare you?'. He paid no

attention and started to grope me. I struggled and he

laughed. I pushed hard against him and managed to

get free and get away. I ran to the door and out to my

car. I was very shaken up. Thinking about it later I

wished I'd blocked his trachy off with my hand, but I

doubt whether I'd really do that. I didn't report it.

Street wrote about reconnaissance as `a speci®c fact

®nding process that involves a systematic exploration of a

speci®c situation in order to provide an informed basis for

development of the ®rst action plan' (Street, 1995 p. 67).

This process involves gathering descriptive data and

information from participants' own experiences as well as

the experiences of other people. We asked participants to

write down stories and to gather accounts of situations told

to them by others. We gathered a total of 68 stories from

nurses who had experienced violent behaviours in their

workplace and in this way, identi®ed the complexity of the

issue from the participants themselves. Here the research

focus was on the identi®cation of issues, thereby enabling

participants to examine workplace violence from several

different angles.

The world is a place of multiple and contradictory views

and decision-making processes (Street, 1995), so the PAR

group participants heard each story of `violence' and were

asked to verbalize their re¯ections and critique the events

captured in the nurses' stories. The process of re¯ection is

used to understand the power relationships and imbal-

ances in the experiences of the participants. Street (1995)

describes this process of knowledge generation as `power

sensitive conversations' and during the group's conversa-

tions it became clear that the individual constructions of

violence varied within the group. Even after considerable

discussion, the group was unable to reach a consensus on

the de®nition of violence and acknowledged that conclu-

sions are multiple, contradictory and partial rather than

de®nitive. These interpretive challenges were re®ned in a

later group session, when it was agreed that violence was

in the perception of the nurse who was telling the story.

To guide analysis of storied accounts, a de®nition of

workplace violence was accepted: `Workplace violence is

de®ned as any incident where an employer or employee is

abused, threatened or assaulted in situations relating to

their work' (WorkCover, 1998 p. 5).

Analysis of the 68 stories contributed by participants

revealed that abuse and or aggression accounted for 43%

of incidents, threats 25% and assault or physical violence

32%. Many experiences of violence had not been of®cially

reported, which reinforced the view that under-reporting

is common, particularly when violence is experienced as


Issues in primary healthcare Participatory action research programme 111

abuse or threat. We found that abuse and threats in the

community nurses' workplace were common and under-

reported. However, we found that all episodes of physical

violence were reported, except where the event took place

before reporting processes of violence were established.

Hence, issues were identi®ed and nurses collaborated to

re¯ect politically upon their practice.

In June 1999, the PAR group participants made a video

on prevention of workplace violence, using the stories

generated in the group to give shape and interest to the

content. Arrangements were made for all staff in the

community organization to view the video, during which a

staff development education package was distributed.

Incorporating feedback from the educational activities, in

consultation with organizational management and in

collaboration with PAR team members, a model for best

practice in the community was developed. Hence, nurses

who were participants of this PAR group were instru-

mental in both the development and implementation of

this model.

Improving wound care management

in community nursing practice

The second project began with a wound management

survey, undertaken in 1997 in the same nursing organiza-

tion. More than 1000 clients with wounds were surveyed

(response rate � 1046/1086� 96%) and ®ndings sug-

gested that a review of wound management practices was

needed. Hence, a PAR project was developed that aimed

to collaborate with nurses to review organizational wound

management practices, explore research evidence to

support wound management practice and develop strat-

egies to resolve the identi®ed problems. Nurses were

recruited from the organization to participate in three

PAR groups (®ve±six nurses in each group) that were

convened fortnightly for 6 months.

To begin, aspects of PAR methodology were discussed

within the groups. A commitment to improvement of

clinical wound management practice was a major theme

for discussion. From these discussions the broad aim of

the groups emerged, which was to develop wound

management practices that were based on evidence.

One appealing aspect of using PAR for this project was

the knowledge that change evolves from those most

affected by it (Kemmis & McTaggart, 1988). Encouraging

participants to set the agenda facilitates empowerment

(Carr & Kemmis, 1986; Hart & Bond, 1995; Street, 1995;

Cruikshank, 1996; Stringer, 1996); hence, we speculated

that it was important for nurses to collaborate in the

research process to enable them to experience empower-

ment over the potential changes to practice. Framing the

project on the principles of PAR provided nurse clinicians

with the opportunity to be involved in a decision-making

process that might necessitate changes to their practice

(Robinson, 1995; Street, 1995; Street & Robinson, 1995).

Guba & Lincoln (1985 p. 41) recommend that

researchers should `allow the research design to emerge¼because it is inconceivable that enough could be known

ahead of time about the many multiple realities to devise

the design adequately'. Guided by these authors we used

the cyclical dynamic of the PAR process as described by

Street (1995):

· reconnaissance or preliminary investigation;

· research question or problem formulation;

· plan for action;

· take action and collect data on action;

· analyse data;

· re¯ect;

· re-plan, re¯ect, etc.

Reason's (1994) PAR principles also appealed to nurses

who participated in this project. They were: a recognition

of power relationships; recognition of the value of `the

lived experience' of people; and the empowerment of

people through the process of constructing and using their

own knowledge. These principles appealed to participants

because a sense of unity would be promoted, and a `safe'

environment created where their individual constructions

and interpretations could be compared and contrasted,

thus facilitating negotiated action.

Congruent with Street's (1995) reconnaissance phase,

we explored the literature to assist with the development

of plans of action. Current wound management literature

was collated and reviewed collaboratively, with the aim of

the review seeking evidence to support practice. The

review of the literature focused on answering the question:

What are the criteria for best practice regarding wound

assessment? One PAR group then identi®ed two clinical

issues for speci®c review: (i) cleansing of chronic leg

ulcers; and (ii) Doppler assessment of leg ulcers. The

other two PAR groups focused on issues surrounding

wound assessment and documentation.

As the review progressed, a collaborative learning

strategy was advanced as group members re¯ected on

their own wound assessment practice as well as sharing

new knowledge gained from the literature. Kemmis &

McTaggart (1988) suggest that this process of sharing

knowledge makes explicit the relationship between the

actions of individuals and the culture of the group. The

discussions with other group members encouraged the

collaborative development of the rationale for wound

management practice and upheld the democratic principle


112 T. Koch et al.

driving the PAR groups. One participant noted in her

journal her experiences of the PAR process:

I have accessed research information through peers,

wound care journals and in service lectures that has

enabled me to examine my practice in a more

re¯ective manner because I have developed a `global'

view of general wound care techniques. The PAR

group has enabled me to broaden my thinking and

increase my knowledge with rationalization of my

practice.

Whilst each group developed, implemented and eval-

uated action plans designed to improve wound manage-

ment practice, it was obvious that participatory group

relationships fostered enhancement of both clinical prac-

tice and work satisfaction. This was particularly evident

when participants from each of the three PAR groups

expressed a desire for the groups to continue after

completion of the project. One nurse said:

The group meetings were stimulating, with many

lively discussions. It was thought-provoking and I

came to question my own practices and changed

some aspects of care. It was challenging and fun. I

feel like the effort I put in has actually gone to

something worthwhile.

Since the strategies and recommendations developed in

the PAR groups for changes to wound management

practices have been implemented, a repeat of the wound

management survey has been conducted. It has revealed

there has been signi®cant improvement in the manage-

ment of chronic leg ulcers.

We concur with Hart & Bond (1995), who maintain that

action research can facilitate praxis. In addition, both

nurses and management have embraced the implementa-

tion of a research methodology guided by the principles of

PAR and, as a consequence, a research culture has

developed within this community organization based on

negotiation, consensus, commitment and collaboration of

all involved. It is because participatory action research is a

democratic process that is equitable and liberating that it

also has the potential to be life-enhancing.

Chronic illness research programme

Congruent with the research unit's primary care philos-

ophy that regards the community as a partner, we have

applied the principles of PAR to research with groups of

community clients. A signi®cant role of our community

nursing organization is the provision of nursing care that

assists people to manage illness while living in the

community. Seventy-®ve per cent of our clients live with

chronic illness and hence our research focus has been on

understanding the experience of living with chronic illness

and the ways that interactions with community nurses

support or fail to support a client's self-management

process.

Our extensive chronic illness research programme

began 5 years ago with the formation of a PAR group in

which eight women living with multiple sclerosis (MS),

four nurse consultants and the ®rst author participated.

We met at a centrally located venue and most women

mobilized in wheelchairs. Whilst the focus of the PAR

group was to generate discussion about self-management

of incontinence, we asked the participants to decide on the

issues to be discussed. The group met for 10 sessions over

6 months for a total of 40 hours of contact time. In this

project, we were guided by Stringer's (1996) principles of

PAR that are described as look, think and act. We will

show the way we applied these principles.

Looking means gathering information, de®ning and

describing the situation, and involves constructing a

preliminary understanding of the context. The ®rst author

facilitated the group discussions and, with the women's

consent, data were generated as nurse consultants wrote

comprehensive notes. Despite our initial concern that the

women might feel uncomfortable in a group discussing

incontinence, the conversations evolved to be open and

frank.

The PAR process promotes the sharing of experiences

and expertise and so the ®rst meeting began with nurse

consultants providing information to the women on

bladder function and how this may be affected by multiple

sclerosis. The women then set the agenda for discussion in

the sessions to follow.

Thinking refers to exploring, analysing, interpreting

and explaining. Here it is accepted that each person brings

her construction (as created realities) to the situation

(Guba & Lincoln, 1989). Notes generated by consultants

recording the events and conversations of the group were

analysed in detail following each session. Data generation

and analysis were concurrent, which enabled identi®cation

of emerging themes and issues to guide subsequent group

discussions. Feedback to the women participating was a

continuous process and, to validate the emerging themes,

the issues from the previous PAR session were presented

and con®rmed at the beginning of the next session.

Continence-related themes were raised in response to

the main aim of the project, which was to identify

strategies for self-managing incontinence. Containment of

urine, clean intermittent catheterization, urinary tract

infections and bowel management were some issues

identi®ed. Although the group was formed to discuss

issues of living with incontinence, other issues deemed



important by the women were raised. These included:

their experiences with community services; problems of

accessing toilets for the disabled; concern with health

professionals' lack of knowledge about multiple sclerosis;

their sometimes appalling experiences of hospitalization

and respite care admissions; their individual efforts at

living well in the context of chronic illness; and the effect

of multiple sclerosis on sexual relationships (Koch &

Kelly, 1999a, 1999b).

The role of the facilitator involved exploring the

different constructions or interpretive accounts held by

the women. Thinking was stimulated as the facilitator

asked participants to re¯ect on `What is happening in the

group?'. The women claimed they had previously been

silent on issues such as incontinence and the ways in

which they could express sexuality, but having a group of

women participants allowed free expression of sex talk and

related issues. The facilitator assisted participants to

engage in dialogue that enabled the development of

mutually acceptable accounts offering explanations of the

issues they were experiencing. Guba & Lincoln (1989)

refer to this as the hermeneutic dialectic process.

Acting refers to the development, implementation and

evaluation of plans devised by participants. To facilitate

the women towards taking action in their lives to address

the issues they had raised, they were asked to identify (i)

objectives, (ii) the tasks, (iii) steps to be taken for each

task, (iv) the people involved, (v) the place where the

activity will occur, (vi) the timelines, (vii) duration of the

activity, and (viii) the resources required. This process

was not as structured as suggested here, but rather the

shape of the action plan emerged in a piecemeal style, each

woman moving at a pace that was comfortable for her.

The planning and implementation of action to address

the issues raised by the women resulted in outcomes at

both individual and collective levels. Individually, women

developed strategies to improve their self-management of

incontinence and multiple sclerosis. This was particularly

evident with the management of urinary incontinence as

they tried various containment measures, experimented

with clean intermittent catheterization, developed strat-

egies to avoid urinary tract infections and considered ways

in which bowel management could be improved. Through

the actual process of sharing stories about living with

multiple sclerosis and being `heard' for the ®rst time, their

sense of self and identity was validated. In addition,

women reported a sense of empowerment that provided a

potent means for initiating self-re¯ection and conscious-

ness-raising.

At a collective level the women sought to reform the

world in which they lived. In particular they were

incensed by the lack of adequate facilities and services

for people living with disabilities, so collectively they

petitioned local governments for better and accessible

public toilets and wrote letters to suppliers of continence

products recommending improved delivery systems. They

were successful in instituting changes to building codes

and improving the distribution system for continence

supplies.

Evaluation of the PAR process involves identi®cation of

activities that have attained their purposes or objectives. In

this project the plans devised and actioned by the women

were exceptional and we have shared this participatory

action research through publications, highlighting the

resultant action (Koch & Kelly, 1999a, 1999b). The nurse

consultants, in collaboration with the third author, have

since led six more PAR groups and have co-authored

publications and conference presentations (Koch et al.

1999; Koch, Kralik & Taylor, 2000; Koch, Kralik & Kelly,

2000; Koch et al., 2001; Eastwood et al., 2001).

Construction of meaning

We will now focus attention on the process of PAR and

the way that meaning is constructed within the group. The

aim in PAR is to reveal the different constructions held by

individuals (Stringer, 1996); however, we have noted that

the literature has tended to under-emphasize the import-

ance of the construction of meaning that occurs during the

process of a PAR group. Stringer (1996 p. 40) states that

`the art and craft of community-based action research

includes the careful management of research activities so

that stakeholders can formulate jointly constructed de®-

nitions of the situation'. In each of the PAR groups,

personal meanings of life experiences have emerged as a

continuous process of negotiation. Meanings were not

®xed, but emerged during the conversations as partici-

pants made sense of their own experiences. Together

meanings were created through conversations in which we

compared and contrasted our individual interpretations.

Re¯ection created self-awareness and in the course of

the research process participants found a voice on topics

that were important to them. PAR has the potential to

improve and change nursing practice and to enhance a

sense of belonging, involvement and empowerment of

those involved. Group re¯ection leads to a reconstruction

of the meaning the situation holds for the individual and

therefore to an understanding and sense of clarity of what

might be possible.

The emergent, tentative understandings from PAR

group conversations were continuously validated with

participants through a reciprocal process. Although


114 T. Koch et al.

individual constructions may vary, we have recognized

that it is important to acknowledge that the experience is

always signi®cant for the storyteller. The ability to have a

voice or an opinion, or raise an issue and be heard, is

potentially empowering. Importantly, many participants

claim they feel validated through being heard, sometimes

for the ®rst time in their lives.

Towards enhancement

Whilst we argue for enhancement, the rhetoric of

participatory action research is that it may empower,

liberate and emancipate. Certainly the emancipatory

appeal of PAR has been the driving force for the three

research projects presented. The ideal of the PAR process

is that participants set the agenda (Armitage et al., 1991;

Titchen & Binnie, 1993; Cruikshank, 1996). We are

mindful that the three PAR projects discussed in this

paper had a predetermined topic for discussion (violence,

wound management and living with incontinence); how-

ever, participants discussed, identi®ed and acted upon

issues that were important for them. We found that

participants decided on the direction of the PAR group

and forging their own agendas meant that they could

decide on the issues to be discussed (Carr & Kemmis,

1986; Hart & Bond, 1995; Street, 1995; Stringer, 1996).

The PAR practices of recording and re¯ection have

provided valuable information about group processes and

group dynamics. The opportunity for systematic re¯ection

has enabled the PAR process to be analysed, and by

providing feedback to the group of the issues raised, action

can be planned and implemented. We have noted that the

continual validation and honouring of participants' re-

sponses promises to be emancipatory (Fay, 1977; Reason,

1994; Johnson, 1995; Robinson, 1995; Stringer, 1996;

Breda et al., 1997). Greenwood (1994) concurs that the

PAR process can have profound emancipatory outcomes.

Empowerment or enhancement for both nurses and clients

was an outcome from each of our inquiries. Self-esteem

was raised when participants were asked to think critically,

analytically and re¯ectively (Titchen & Binnie, 1993). In

our experience, people are empowered through the

process of constructing and using their own knowledge,

and this is particularly relevant if ownership of the

problem and subsequent action is desired.

We have learnt that it is important to foster ownership

of the project and encourage group members to initiate the

research agenda and subsequent action. Robinson (1995)

found the process of PAR to be ineffective if management

`hierarchy' imposes membership; hence, it is important to

ensure that all participants volunteer and are committed to

the purpose of the group. Participants in each of our

inquiries made decisions about which issues were import-

ant for them and that has facilitated their participation to

be active, supportive, co-operative and bene®cial.

We concur with Breda et al. (1997), Stringer (1996) and

Titchen & Binnie (1993) that participants will be inclined

to own the project if they have an equal share of the power

base. We strive for relationships within the group to be

equal, co-operative, sensitive and accepting (Stringer,

1996). These concepts may extend beyond the group

members because, as Street (1995) suggests, actions

produce changes for more people than only the partici-

pants because PAR is potentially life-changing for all

concerned.

Ethical considerations

We have described three different projects with a diverse

range of topics applying PAR principles. In each project,

the construction of meaning took place as participants

shared their stories with others in the group. The process

of PAR brings people's private lives into a public arena

(Stringer, 1996). The women with MS shared intimate

details of their lives with incontinence, the nurse practi-

tioners shared stories about their (sometimes less than

satisfactory) wound care practices, while nurses shared

stories of workplace violence that they had often sup-

pressed for fear of ridicule, disbelief and possible vili®-

cation. We believe that expert group facilitation is crucial

if Stringer's democratic, equitable, liberating and life-

enhancing principles are to drive the PAR process. In

order to safeguard participants, we argue that the facil-

itator's role is critical.

We believe that the facilitator is the catalyst that

stimulates people to develop their own analysis of the

issues presented, to examine possible courses of action and

then work towards action. The facilitator guides group

members to listen to the stories of others without

prejudice and seek negotiated accounts that include the

perspectives, interests and agendas of all participants

(Stringer, 1996). It is not a role for the inexperienced

researcher and so clinicians from our organization have

been partners in mentoring relationships with experienced

researchers, learning the skills of facilitation.

Some insights

Our experiences with PAR have revealed that despite

multiple theoretical in¯uences, there exist some common

PAR principles. The PAR process is participative, cyclical

and rigorous (as constructs are enhanced through constant



iteration and validation). PAR is also re¯ective in terms of

process and outcome, responsive to emerging needs and

can produce change, although there are varying levels of

change (individual and/or collective).

When researching with nurses, either towards the

advancement of practice or advancing research capabilit-

ies, organizational support for the process of PAR is

critical (Hart & Bond, 1995; LeMay et al., 1998). This

may require management, educational and information

structures to be established prior to the implementation of

an action phase. Having the PAR process sanctioned by

the organization's hierarchy may mean that resultant

recommendations are likely to be honoured. In addition,

these organizational structures can be a conduit for

promoting action and disseminating relevant material

about the PAR process, and promoting the bene®ts that

can accrue from its use. Therefore, to ensure the

continued success of PAR projects, it is necessary to

consider critical factors such as communication, facilita-

tion and timelines. Emancipation, empowerment and

sustaining change are signi®cant outcomes that cannot

be incorporated into one's life and/or an organizational

structure without long-term recognition and continued

support.

Conclusion

In this paper we have revealed how embracing the

principles of PAR has made a difference to the provision

of nursing care, created opportunities for a grassroots or

a `bottom-up' approach to organizational decision-making

and provided clients with a voice in the delivery of

community nursing care. The research team has shown

PAR to be an appropriate research approach that engages

nurses and clients in projects that have the potential to

enhance their lives. Participants in the PAR groups have

reported gaining an understanding of the complexities

inherent in their experiences and were provided with the

opportunity to make meaning of and clarify important

events in their lives. Nurses who participated in the PAR

groups took the opportunity to re¯ect on nursing

practice and take key elements and sensitivities that

emerged from the groups back to practice and, in doing

so, developed new and creative ways of providing

community nursing care. It seems that the processes of

PAR, combined with adept facilitation, can provide

participants with a sense of control over their lives and/

or workplace. In a reciprocal relationship, nurses gained

sensitive understandings which not only enhanced their

own lives and nursing practice, but also enhanced the

lives of others.

Acknowledgments

We sincerely thank the participants. The inquiries were

®nancially assisted by grants from WorkCover (SA),

RDNS Foundation and a Health Enhancement Grant,

Department of Human Resources SA.

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