Journal of Advanced Nursing, 1999, 30(5), 10571063

Methodological issues in nursing research

Placing empowerment research within

an action research typology
Jackie Sturt PhD BA(hons) RGN RMN
Primary Care Project Worker, Health Improvement Team,
Buckinghamshire Health Authority, Aylesbury, England

Accepted for publication 9 February 1999

Journal of Advanced Nursing 30(5), 10571063

Placing empowerment research within an action research typology
The focus of this paper is to use three action research typologies to consider
retrospectively, and understand, the processes of an empirical study. The
typologies are used to plot the changing emphasis of collaborative action
research with a primary health care team that addressed their health promotion
practice. The study implemented self-efcacy theory into the health promotion
practice of a primary health care team and developed a self-efcacy framework
for smoking cessation. The framework had some success in aiding practitioners
in their work despite the patients' disinterest in smoking cessation. Two action
research types can be identied within the study, a technical/experimental
approach which surrounded the use of a researcher-led theoretical agenda,
whereas the research facilitation was informed by critical theory and was
classied as an enhancement/empowering action research type. This paper
demonstrates the conicting natures of these types which, in this study,
resulted in positive outcomes associated with the experimental/technical
approach but only at the expense of professional empowerment. The ndings of
this study imply that theoretically-led empowering action research was an
incompatible combination in this instance and this potential conict needs to
be addressed by researchers engaging in collaborative research relationships
with practitioners.

STURT J. (1999)

Keywords: action research typology, empowerment, health promotion,

primary health care teams, self-efcacy theory
INTRODUCTION
In 1993, at the inception of this study, two forces were
directing health promotion practice in England. (1)
Empowering approaches to the promotion of health had
been advocated for over a decade (World Health Organization 1978, Rappaport 1981, Tones 1991) and continued
to form the basis for the health promotion ideology. These
approaches aimed to improve health through the elimination of health inequalities and placed considerable
responsibility for inequity upon socio-economic factors
Correspondence: Jackie Sturt, Magpie Cottage, The Tuer, Mill End,
Chadlington, Oxon OX7 3NZ, England.

1999 Blackwell Science Ltd

such as poverty and unemployment. (2) The political

initiative for promoting health was The Health of the
Nation (Department of Health 1992) which concentrated
its recommendations upon epidemiological and lifestyle
explanations for health differentials. Targets were set and
responsibility placed upon health professionals and
individuals for initiating lifestyle changes. Thus, the
`health promotion ideology' and the `political agenda'
were in conict in terms of their approaches to health
promotion.
This study attempted to operationalize the contrasting
aims of `health promotion ideology' and the `political
agenda' through the use of action research. The focus of
the research was on improving health promotion practice

1057

J. Sturt
by incorporating empowering health promotion theory
into patient consultations and consequently enabling
patients to recognize those areas in which they were able
to exercise personal control.

RESEARCH DESIGN
It was anticipated that a collaborative action research
relationship (Carr & Kemmis 1986) would be formed
with an identied primary health care team (PHCT).
Members of the PHCT who collaborated fully in the
research consisted of a general practitioner (GP1), three
practice nurses (PN1, 2 & 3) and two health visitors
(HV1 & 2). An outsider action research relationship was
initiated by the researcher and negotiated with the
PHCT. This form of researcher/collaborator relationship
was described by Titchin & Binnie (1993) as one in
which the researcher possesses no authority within the
research area and has a `diagnostic function', supporting
and feeding back information to the participants and
change agents but having no direct responsibility for
carrying out the changes.
The practitioners worked in a urban GP practice in
the south of England and the researcher, a postgraduate
student, had minimal patient contact. All collaborators
had equal authority and responsibility for the development of frameworks for practice. The roles were clearly
differentiated in relation to the utilization of the framework. The practitioners worked individually with
patients and offered their feedback to the whole collaborative team. The researcher's role was to facilitate this
change through the use of critically reective dialogue
with the practitioners based upon accounts of their
practice. The study was not funded formally by any
organization and the participants saw their involvement
as part of their own professional development and in
this respect the study was supported by the GP practice.
The researcher was employed as a research assistant by
a university.
Specic health promotion funds were identied and
obtained by the GP practice to support a team away day in
which 18 members of the PHCT participated. This was
initiated by GP1 to commence the action research study.
Thereafter, meetings were held every 10 days for
6090 minutes over a period of 9 months. During this
period data were collected by the researcher and participants in the form of audio-recorded meeting transcripts,
individual interviews, participant observation of practice
and reective journals. These data focused upon the
collection of critical incident data from the perspectives of
both the researcher and the PHCT collaborators.
In line with The Health of the Nation's (Department of
Health 1992) emphasis on addressing key areas and
achieving targets, the PHCT identied smoking cessation
as the health promotion priority for the research. The

1058

process of identifying an initial priority began during the

away day with a presentation of formal practice data on
disease incidence and `at risk' indicators ranging from
hypertension and body mass index ratios to postnatal
depression and breast-feeding rates. The smoking cessation priority was identied during a process when all
members, within their disciplinary groups, were asked to
present their priorities to their colleagues. Whilst a variety
of legitimate priority areas were established by each
group, smoking cessation emerged as most important to
the medical team. Whilst it was not a priority for the other
practitioners they acknowledged that they could use a
smoking cessation framework in areas of their practice.

INCORPORATION OF EMPOWERMENT
THEORY INTO PRACTICE
Critical social theory (Habermas 1972, 1974, 1979, Freire
1972) was identied by the researcher as an appropriate
methodological approach for the qualitative exploration of
health promotion practice and empowering health
promotion theory. Bandura's (1977) work on self-efcacy
perceptions theoretically underpinned the development
and organization of enabling health promotion practice
within the PHCT. Strong perceptions of efcacy are said to
be related to mastery in areas of one's life (Bandura 1977)
and mastery was suggested by Rappaport (1981) to be the
consequence of an empowering process and thus the
enhancement of efcacy expectations towards a state of
mastery is a process by which empowerment can occur.
The practitioners incorporated self-efcacy theory into
their health promotion work with the intention of determining the process features of developing a self-efcacy
framework for health promotion practice.
The frameworks that evolved relied heavily on a
number of tools for facilitating enabling practice.
Published and validated instruments were available for
the measurement of perceptions of efcacy (e.g. Nicki
et al. 1984, Hickey et al. 1992, Kasen et al. 1992) and
these were used to determine patients' efcacy expectations for given health-related behaviours.
The PHCT engaged in a number of exercises that helped
them to develop a practice framework and execute a selfefcacy informed consultation. There were three essential
features of this process for the PHCT. The rst was
developing a cognitive understanding of the consultation
format. This was facilitated by the verbal rehearsal of
possible patient scenarios within the team meetings. The
second feature of the process lay in the development of a
strategy list which became a kind of safety net for
practitioners if they ran out of spontaneous ideas during
a consultation. The third feature was the experience of an
outcome measure in the form of a patient's altered health
behaviour. These features were critical in enabling the
team to develop mastery in the use of self-efcacy theory

1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(5), 10571063

Methodological issues in nursing research

and were replicated when the team began to consider selfefcacy theory in relation to other health behaviours such
as dietary work and sexual health.
Despite the efcacy of the framework in the implementation process, other features of the study, such as the
general disinterest shown by patients in the smoking
cessation initiative, led the PHCT to consider the exercise
a failure. Nevertheless, where the health priorities of
professionals and patients coincided, the data
demonstrate the success of the self-efcacy framework in
facilitating health behaviour change. In the following
example HV2 describes a consultation with a student with
symptoms of depression:
We looked at different situations throughout the day and different
aspects of how it affected his life and tried to nd really simple
strategies for coping with that, like, one of his big problems was
that he didn't want to get up in the mornings So we talked
about, like the smoking thing, planning his day. Making appointments for rst thing in the morning so that if he had to see his
tutor he would make them for 9 am so that he had to get up to see
the tutor take out lots of short loan books so that he had to take
them back.

This example illustrates the potential of self-efcacy

theory for facilitating the understanding of behaviour for
both patient and professional. It is characteristic of
consultations where the health priorities of the practitioner and the patient coincided. The salient feature of
empowering use of the framework was associated with a
mutual belief that the health issue in question was
important.
Whilst the essence of this paper is the critique of action
research typology, those features of the study which have
been presented provide the reader with a context to the
action research study under discussion. A more comprehensive exploration of these issues can be found in Sturt
(1997, 1998).

ACTION RESEARCH TYPOLOGIES

Holter & Schwartz-Barcott's (1993) typology identied
three established action research approaches:
the technical collaborative approach in which the
researcher has a predetermined agenda which often
involves intervention or theory testing;
the mutual collaboration approach which involves
researcher and participants identifying problems together, followed by mutually agreed action cycles; and
the enhancement approach which begins by working in
a mutually collaborative way but takes the process
further to engage in critical dialogue to raise the
collective consciousness.
Holter & Schwartz-Barcott (1993) suggest that most of the
nursing action research studies reported were of the

Empowerment research
technical collaborative model with a few examples of
mutual collaboration and no reported evidence of the
enhancement approach. This observation is supported by
the ndings of Kendall & Sturt (1996).
Within the enhancement type, the authors suggested
two objectives for the researcher. One aim is to bring
together the contextually-related problems with which
practitioners are faced and the theory which can be used
to interpret and resolve these problems. The second is the
collective consciousness raising process in which practitioners engage as a means of addressing their problems. By
a process of critical reection, the researcher raises
awareness of cultural norms and conicts that circulate
to contribute to the problem as it emerges. Through this
consciousness raising experience, `praxis' will emerge to
address the practice condition in a more meaningful and
emancipated manner.
The typologies of Hart & Bond (1996) and of Boutilier
et al. (1997) have also considered the differing approaches to action research. Both typologies have similarities
with that of Holter & Schwartz-Barcott and refer to
empowering types, essentially incorporating reective
processes. Boutilier et al. (1997) suggest that researchers
ask questions of the research that will help them to
identify the nature of the approach they are taking. For
example, to ascertain from within the research where
power lies, the researcher should ask `Whose knowledge
has legitimacy in dening the research questions?'. This
would identify whether the action research was guided
by the ideas of experts from outside of the practice
area and thus be demonstrated as being a technical
approach.
Hart & Bond (1996) suggest that the action research
process is not statically attached to one approach but that
it involves progression through their typology, along a
continuum from a consensus to a conict model of society.
Experimental approaches are said to be located at the
consensus end, moving through organizational and
professionalizing approaches, towards empowering
approaches at the conict end of the continuum. Hart &
Bond (1996) used their typology to establish the research
approaches engaged in by Meyer (1993, 1995) as being `an
experimental type with strong professionalizing features',
and of Titchin & Binnie (1993), which they describe as
providing `the clearest example of the interplay of organizational and professionalizing types'.
The research design of the present study was
informed by Holter & Schwartz-Barcott's (1993) action
research typology since the works by Hart & Bond
(1996) and Boutilier et al. (1997) were published subsequent to the eldwork being completed and only
informed data analysis and interpretation. Holter &
Schwartz-Barcott's (1993) enhancement action research
type was identied as tting with the methodological
research objectives of this study.

1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(5), 10571063

1059

J. Sturt

ACTION RESEARCH INFORMED BY TYPOLOGY

Hart & Bond (1995) suggest that their action research
typology addressed the limitations of the static approaches described by Holter & Schwartz-Barcott (1993). This
criticism is well grounded as there is no discussion by
Holter & Schwartz-Barcott (1993) of the potential for
action research to engage in different approaches dependant upon the phase of the study. The present study
adopted Holter & Schwartz-Barcott's (1993) enhancement
approach to action research. This approach is compatible
with critical social theory through its emphasis on the
critical examination of practice and power through the
processes of self-reection. There were, however, a
number of features of this study which were aligned more
closely to their technical collaborative approach. These
were characterized by the existence of a researcher agenda
principally surrounding the use of self-efcacy theory
(Bandura 1977) to inform health promotion practice. The
technical collaborative approach was described by Holter
& Schwartz-Barcott (1993) as being concerned with
`test(ing) a particular intervention based on a prespecied
theoretical framework. The question is to see if the
intervention can be applied in a practical setting'. It is
possible, therefore to identify features of the research
design which made it compatible with both the enhancement and the technical-collaborative approach and both
action research approaches can be identied as methodologically relevant.
Hart & Bond's (1996) typology differs from that of Holter
& Schwartz-Barcott (1993) in its acknowledgement of the
legitimate movement of any study through the different
types. They suggest that the strength of a typology lies in
its potential use in helping the researcher to pinpoint the
changing directions of a study as it progresses. Holter &
Schwartz-Barcott (1993) and Boutilier et al. (1997) agree
on the dening characteristics of the technical approach to
action research. Many of these characteristics, such as the
research being `guided by the ideas of outside experts'
(Boutilier et al. 1997) can be identied in relation to the
theoretical component of the present study.
Whilst Hart & Bond (1996) suggest that several of the
action research approaches could feature in any one study,
the degree to which the features of the present study span
their typology are methodologically disorientating. The
practitioners were simultaneously required to (a) implement and test theory in line with experimental and
organizational action research and (b) examine their own
power in relation to both patients and other health
professionals in line with the health promotion ideology,
a feature of empowering action research.
The focus upon the enabling approach of enhancement
(Holter & Schwartz-Barcott 1993), roughly equivalent in
description to Hart & Bond's (1996) empowering approach,

1060

is characterized by conict and conict resolution. Reference to the data in the present study indicates the extent to
which the collaborating practitioners were unable to
confront many of the issues which resulted in their
continued disempowered status.

CONFLICT IN AN ACTION RESEARCH

CONTEXT
The use of Hart & Bond's (1996) typology enables retrospective explanation for some of the contradictions which
existed for the team and which became clear during the
process of analysis. Two themes emerged from the data
relating to power and control. The rst surrounds medical
dominance over nursing work. The second reveals a sense
of control and ownership amongst the nurse members in
relation to the research.

Dominance of the medical culture

Dietary education work was an area in which the practice
nurses identied a patient-led demand. The practice
nurses expressed pride in this area and they perceived
the work to be successful. However, without consulting
the practice nurses, a nancially motivated decision was
made by the GP partners to restrict this service. Fieldnotes following a meeting with GP1 recorded:
GP 1 was talking about dieters and said that their fundholding
colleagues would not allow the practice nurses to do dietary/
weight loss advise as it was too costly in time and did not make
any money for the practice.

The words of one practice nurse illustrate the extent to

which the authority of GPs was disempowering for her
and colleagues, and ultimately the patients:
You know, whatever the practice lays down you have to follow it
because you are working for the practice, you have to do what
they tell you.

However, the data are revealing in suggesting that the

nursing practitioners also supported the medical authority
held within the practice by utilizing its perceived power.
This was illustrated when I asked the practitioners if they
would consent to self-selective audio-recording of consultations with patients. The nurses were unhappy with this
idea and turned to GP1 for support in addressing the issue
with me. GP1's response was to ask the nurses not to attend
the next meeting and instead he asked his medical
colleagues, who had paid little keen interest in the research,
to be present. His rational for the organization of the meeting
in this way was recorded in research eld-notes;
He said that it was for my benet, that he thought I might be upset
and that it would be easier if there were fewer people around.

1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(5), 10571063

Methodological issues in nursing research

The organization of the meeting was established to limit
my access to those most affected by my involvement, i.e. the
nurses, and replace them with authority gures within the
practice and within my own clinical background. The
potential for a critical and conict-ridden dialogue between
myself and the nurse team members was prevented by GP1
when he acted to ensure that we were separated at this
critical moment in the research rather than allowed to
develop critical insight into the practice dynamics.
In his work on medical dominance, Illich (1977 p. 17)
suggested that the mark of a professional lay in `his
authority to dene a person as a client, to determine that
person's need and to hand the person a prescription'). This
exercising of professionalism can be identied in the
responses of the GP participants to potential team trauma.
The manner in which the nurse members adopted a passive
and dependant role in relation to the problem enabled the
medical team to dene the nurses as clients rather than
colleagues. The GPs were able to establish the clients' (i.e.
nurses) needs and deliver the required prescription in the
form of researcher and nurse participant separation.
A professional/client relationship developed in this
way keeps the client in a subservient position regarding
the professional. The professional (medical team) were in
possession of knowledge and skills to which the client
(nurse participants) required access and so the dominance
of one over the other became established. The ndings
suggest therefore that the nurse members of the PHCT held
a less powerful position in relation to the GP members and
that they felt both constrained by this and used it for their
own purposes.

Research ownership
In contrast to their PHCT experiences, the research agenda
afforded all practitioners the same status in directing the
framework development and the active medical participant was indeed challenged in relation to his practice of
self-efcacy theory. On the issue of goal setting, PN1
described her approach to the consultation in a way which
made her GP colleague reect upon his own approach:
Researcher: How do patients go about choosing the [goal] what
brings them to the conclusion that this is the one they want to
tackle?
PN2: I asked him, I said, so what do you think you might be able
to, and he wasn't very responsive, so

Empowerment research
Some individual practitioners had an understanding and
developing condence in the use of the framework beyond
that of their colleagues. These team members used their
own understanding to help other practitioners, irrespective
of their role within the practice. This is seen most clearly in
data emanating from the nurse members of the team. Selfefcacy theory is patient orientated and the nurse members
of the team felt able to challenge GP1 in his apparent
orientation away from the patient during a consultation. In
the data extract below, GP1 is engaged in rehearsing a
hypothetical consultation about smoking cessation:
GP1: What I want you to do is to see if we can get you to reduce
your smoking after meals and preferably stop [referring to
strategy list] what techniques have we got?
PN2: The rst thing we should do is ask they themselves what
they think would help.

A few moments later, HV1 describes different situations

and how one strategy might be more useful for some than
others. GP1 is, by now, able to see what his colleagues are
suggesting and rehearses the consultation again:
Okay, so he comes in and we say we are going to try and cut down
after a meal, what do you think you could do? So I would
probably have this leaet in front of me and write down here what
they are saying.

This interaction between GP1 and colleagues illustrates

what Habermas (1979) called Ideal Speech dialogue which
is said to exist when there is mutual understanding and
assumptions of trust, sincerity and legitimacy of speaker
between those engaged in the dialogue. For Habermas, this
type of communication represents an emancipatory
weapon. The data from the present study offers concrete,
albeit rare, examples of engagement in ideal speech
communication between the health professionals. These
data extracts demonstrate a sense of ownership in both the
research agenda and the collaborative processes by the
nurse participants. They were willing and able to challenge their medical colleague when his agenda diverges
from their own, within the connes of the execution of the
study.
On another occasion during a team meeting, HV1
indicated the extent to which she had internalized
research ownership, possibly at the expense of my own
involvement:

GP1: I said the same to [patient] what area do you think,

But I don't actually mention you, I say we are doing a research

project. You as Jackie Sturt are not there, it's a research project

rather than going for a number.

that we are doing in the PHCT.

PN1: Well I went for a number.

Throughout the study, the authority, control and

responsibility for the study was well spread across the
participants. Most of the practical applications of the
research framework were directed by the team and in this
respect they established their own power within the

GP1: I should have gone for a number is what you're saying.

PN1: I said, we'll tackle a high score rst, because it's going to be
easiest.

1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(5), 10571063

1061

J. Sturt
research context. In relation to the establishment and
recognition of power and control within their own
practice, however, the nurse members of the PHCT were
unable to challenge the medically dominant culture
under-pinning their clinical, as opposed to research, roles
and on occasions they appeared to support it.
Despite the research facilitation adopting an enhancement action research approach (Holter & Schwartz-Barcott
1993), the potential for conict and its resolution within
the team was consistently blocked by the GP partners
severely restricting the team's engagement in a critically
reective study of their practice and its context.
Consensus was represented both by the practitioners'
passive response to the medical authority within the team
and the extent to which the data suggest they supported it.
In contrast, the research experience afforded the practitioners the opportunity to engage in conict as can be seen
when PN1 talks of her role within the practice. There is
some evidence that research engagement in this collaborative way enabled the practitioners to describe the extent
to which the medical practitioners controlled the agenda
even if they were unable, at that point, to question or
challenge it.

CONSENSUS IN AN ACTION RESEARCH STUDY

Whilst the research experience itself was practitioner
focused, the context of their practice, placed under
scrutiny by the research content, was experimental and
thus researcher and social science focused. The facilitation of learning surrounding the theoretical framework
and the consequent development of tools and a framework
for practice was experimental and utilized a great of the
practitioners' time and energy in its execution.
There were additionally many organizational features
to the study, such as the practitioners' consensual desire
for tangible outcomes in relation to smoking cessation.
In many ways, this study was characterized by the
continual contradictory emphasis on facilitating collaborative research in a way which endeavoured to enable
practitioners to question the health care system and
their role within it, whilst simultaneously addressing
the very disabling priorities which that system advocated.

CONFLICT VERSUS CONSENT

Hart & Bond (1996) acknowledge the difculties inherent
in attempting to incorporate action research types representing polar opposites suggesting that `in particular,
there are problems in attempting to reconcile experimental and empowering types of action research'. Whilst
these orientations can be seen to exist within this study,
there was a degree of recognition of the limitations
imposed by the situation.

1062

Hart & Bond (1995) had located a number of

published action research studies within their typology
(Meyer 1993, Titchin & Binnie 1993). Meyer's (1993)
study, concerned with implementing lay participation in
care on an acute medical ward, was determined by Hart
& Bond (1995) to have the characteristics of an experimental action research type which endeavoured to
empower participants. Hart & Bond (1995) justied their
assessment with reference to the way in which Meyer's
(1993) senior management participants and academic
supervisor sought to ensure that the study continued
when faced with divisive relationships within the
collaborative team leading her to question the ethics of
her continued involvement.
When the present study was confronted with a similar
situation, and a small number of participants wanted the
research to discontinue, the participants were supported
sufciently by their colleagues to result in its termination.
Whilst I requested that I might return once more to say
goodbye in a more satisfactory way, there was no attempt
to alter their decision, aware as I was that anything other
than acceptance would have been contrary to the stated
philosophical approach. Despite my acceptance of the
participants' decision, the situation was unsatisfactory in
relation to any sense of empowerment which they might
have acknowledged in the making of the decision. It raises
ethical questions regarding the possibility that the group
might have been reacting to some sense of failure with
regards the research.
The data provided a great many examples to illustrate
the sense of disappointment and failure experienced by
the team with regard to the lack of interest shown in the
chosen smoking cessation priority:
HV I: suppose with smoking why it's so frustrating in a way is
because it's such low numbers, we are not getting a massive sense
of achievement ourselves.
PN: It gives the nurse an awful sense of failure doesn't it. Because
you think you're not getting the message across.

This sense of failure had, for one or two nurse members,

been compounded by a series of difcult one-to-one
meetings with myself. Whether the PHCT's withdrawal
from the study was an example of some members
demonstrating their own empowerment or a rather more
unsatisfactory withdrawal, motivated by a sense of failure,
is a question which is unlikely to be answered. Nonetheless, it raises ethical issues of a type identied by Meyer
(1993, 1995) concerning the notion of informed consent
and the right to withdraw. The PHCT exercised their right
to withdraw whilst, simultaneously, creating the potential
situation of having exposed wounds and throwing away
the opportunity which might have facilitated their
healing. There was, however, no alternative but to terminate my work with the team, in line with an empowering

1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(5), 10571063

Methodological issues in nursing research

approach to action research. The degree to which the team
were potentially disempowered as a result of the termination, establishes a paradox in relation to empowering
research approaches.

CONCLUSIONS
The action research typologies presented by Holter &
Schwartz-Barcott (1993), Hart & Bond (1995, 1996) and
Boutilier et al. (1997) present material which illustrates
broad consistency between their theoretical perspectives.
Hart & Bond's typology provides more specic criteria
against which to evaluate any potential, actual or completed
study. It establishes a requirement for the action researcher
to examine the compatibility of the different perspectives
and research agendas and helps to obtain some clarity in the
muddy waters of an action research study.
Despite the utilization of principles of critical social
theory in this research, the incompatibility of the action
research approaches provides some explanation for the
practitioners' reluctance to reect upon their work which
might have enabled them to challenge the medicine-led
agendas which existed within the PHCT. Involvement in
two approaches, one which drew them towards
consensus, through the technical/experimental use of
self-efcacy theory and the other towards conict, through
the critically reective nature of the research facilitation,
can only have served to confuse both the participants and
the research facilitator.
The participants developed a self-efcacy framework for
smoking cessation (Sturt 1997, 1998) which, once particular criteria were met, helped PHCT members to facilitate
their patients in smoking cessation. This represented an
outcome on the technical/experimental side of the study.
Raised PHCT consciousness surrounding the political and
organizational constraints to improving the health of the
practice population, an outcome measurement of an
empowering/enhancement approach, did not occur. This
suggests the fragile nature of the empowerment approach
which, in this study, capitulated when placed in competition with the more robust agendas of the experimental
and organizational action research approaches.

References
Bandura A. (1977) Self-efcacy theory: toward a unifying theory
of behaviour change. Psychological Review 84(2), 191215.
Boutilier M., Mason R. & Rootman I. (1997) Community action
and reective practice in health promotion research. Health
Promotion International 12(1), 6978.
Carr W. & Kemmis S. (1986) Becoming Critical: Education
Knowledge and Action Research. The Falmer Press, London.

Empowerment research
Department of Health (1992) The Health of the Nation: A
Strategy for Health in England. Her Majesty's Stationary
Ofce, London.
Freire P. (1972) Pedagogy of the Oppressed. Penguin, London.
Haberman J. (1974) Theory and Practice (transl. Viertel J.).
Heinemann, London.
Habermas J. (1972) Knowledge and Human Interests (transl.
Shapiro J.J.). Heinemann, London.
Habermas J. (1979) Communication and the Evolution of Society.
Beacon Press, Boston.
Hart E. & Bond M. (1995) Action Research for Health Social Care.
Oxford University Press, Buckingham.
Hart E. & Bond M. (1996) Making sense of research through the
use of a typology. Journal of Advanced Nursing 23, 152159.
Hickey M.L., Owen S.V. & Froman R.D. (1992) Instrument
development: cardiac diet and exercise self-efcacy. Nursing
Research 41(6), 347351.
Holter I.M. & Schwartz-Barcott D. (1993) Action research: what is
it? How has it been used and how can it be used in nursing?
Journal of Advanced Nursing 18, 298304.
Illich I. (1977) Disabling professions. In Disabling Professions
(Illich I., Zola I.K., McKnight J., Caplan J. & Shaiken H. eds),
Marion Boyars, London, pp. 1139.
Kasen S., Vaughan R.D. & Walter H.J. (1992) Self-efcacy for AIDS
preventive behaviours among tenth grade students. Health
Education Quarterly 19(2), 187202.
Kendall S.A. & Sturt J.A. (1996) Negotiating access into primary
health care: insights from critical theory. Social Sciences in
Health 2(2), 107120.
Meyer J.E. (1993) New paradigm research in practice: the trials
and tribulations of action research. Journal of Advanced
Nursing 18, 10661072.
Meyer J.E. (1995) Lay participation in care. Unpublished PhD
thesis, Kings College, University of London, London.
Nicki R.M., Remmington R.E. & MacDonald G.A. (1984)
Self-efcacy,
nicotine
fading/self
monitoring
and
cigarette-smoking behaviour. Behaviour Research and Therapy
22(5), 477485.
Rappaport J. (1981) In praise of paradox: a social policy of
empowerment over prevention. American Journal of Community Psychology 9, 125.
Sturt J.A. (1997) The implementation of self-efcacy theory into
health promotion practice in primary health care: an action
research approach. Unpublished PhD thesis, Brunel University,
Uxbridge.
Sturt J.A. (1998) Implementing theory into primary health care
practice; an empowering approach. In Health and Empowerment (Kendall S.A. ed.), Edward Arnold, London, pp. 3856.
Titchin A. & Binnie A. (1993) Research partnerships: collaborative action research in nursing. Journal of Advanced Nursing
18, 858865.
Tones K. (1991) Health promotion, empowerment and the
psychology of control. Journal of the Institute of Health
Education 29(1), 1726.
World Health Organisation. (1978) Alma Ata Declaration. WHO
Regional Ofce for Europe, Copenhagen.

1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(5), 10571063

1063