Using Action Research and Action Learning ( ARAL ) to develop a response to the abuse of older people in a healthcare context

Purpose – The purpose of this paper is to describe Monash Health’s development of a Policy and Procedure on the abuse of older people in metropolitan Australia. Monash Health is a public healthcare network that consists of six public hospitals and over 40 community health care sites throughout the South East of Melbourne. Design/methodology/approach – An Action Research Action Learning approach was employed to develop a comprehensive set of policy and procedure documents to ensure that Monash Health became compliant with the State Government’s expectations around responding to the abuse of older people in a consistent manner. Findings – Almost 90,000 Monash Health hospital admissions per year are older people aged over 65 years. Senior Monash Health management recognized that staff did not have adequate information, education and resources to consistently identify and respond to situations of elder abuse. What is more, the existing internal Monash Health document Supporting Older People at Risk did not meet obligations stated in the Victorian Government’s Elder Abuse Strategy (2009). Originality/value – The project’s emphasis upon participatory action research, cooperative inquiry and action learning further resulted in the identification of an opportunity to develop a strategic response to violence and abuse for all patients of Monash Health, not just older people.


Introduction and research problem
Abuse of older people has increasingly become a local, national and international concern.The World Health Organization stated that "elder abuse is a violation of Human Rights and a significant cause of injury, illness, lost productivity, isolation and despair" (cited in Victorian Government, 2009, p. x).Studies in Australia suggest that elder abuse affects between 0.5 and 5 percent of people aged 65 years and older (Lownes et al., 2009).The Victorian Government began addressing the issue with a social action plan, Fairer Victoria: Creating Opportunity and Addressing Disadvantage 2005-2007.In 2009 the Elder Abuse Prevention strategy and project released a practical guide for health services and community agencies dealing with the abuse of older people.The volume of elder abuse cases necessitating legal intervention through the Victorian Civil Administrative Tribunal has increased so much that in 2010 there were a sufficient number of applications from within Monash Heath alone to warrant on-site hearings being instituted.
Monash Health is a public healthcare network that consists of six major hospitals and over 40 community healthcare sites throughout the South East of Melbourne, Victoria.In an area covering 2,000 square kilometers, over 14,000 staff cater to the health needs of a population of close to one million people, or 17 percent of Victoria's population.With a budget of over $1 billion, approximately 2,130 beds and 250 programs, the services provided range from health promotion and prevention to complex and intensive care.As a consequence of the correlation between health and ageing, out of 193,000 admissions per year to Monash hospitals, close to 90,000 are older people aged over 65 years.That is, looking after older people is a high-volume, core activity.
The unpublished Monash Health document, Supporting Older People at Risk, written in 1999, did not facilitate a consistent organizational response to elder abuse or increase the capacity of the staff to recognize or respond appropriately.The existing Monash Health document, Supporting Older People at Risk, was written in 1999 and did not facilitate a consistent organizational response to elder abuse or increase the capacity of staff to recognize and respond to abuse appropriately.Under the Victorian Government's Elder Abuse Strategy (2009), the organization had a stated obligation to review or develop a Policy and Procedure on Elder Abuse.This paper explains Monash Health's approach to developing a Policy and Procedure on Elder Abuse using action research/action learning.

Action research and action learning
Recognition of the project as a change management process within Monash Health led to an appropriate approach that would enhance engagement with the wider organization.It was hoped that a high degree of participation across the organization would maximize the success of the change management process.Action research was identified as the most useful approach because it is a collaborative process that facilitates simultaneous action and research (Coghlan and Brannick, 2005, p. 13).Traditional definitions of action research suggest that the key elements are a collaborative relationship between the researcher and the client, and that the research aims to address a task or problem and leads to the generation of new knowledge.
Different approaches have emerged under the umbrella of traditional action research since Lewin's (1946) early work (Dick, 1993;Coghlan and Brannick, 2005).Elements of Participatory Action Research (PAR), and Action Research Action Learning (ARAL) were used for this research project (Dick, 1993;Long, 1998).The ARAL approach to change management and organizational learning is the fusing of two separate processes.Lewin's (1946) concept of Action Research was designed as a cyclical process to address problematic situations and bring about noticeable improvements, whereas Revans (1982) concept of Action Learning emphasizes the development of managers' skills and abilities to ask the right questions (Abraham, 2012, p. 6).Nevertheless, the two approaches are similar in some respects as both are "problem-focused, action-orientated and utilise group dynamics" (Abraham, 2012, p. 6).Abraham (2012) provides the following formulae to help explain how the ARAL model fuses both Action Learning and Action Research.AL + C + R ¼ AR.The key ingredients required to produce ARAL outcomes are Action Learning, plus the cyclical nature of Action Research and the role of the researcher to guide the group (Abraham, 2012, pp. 9-10).
The four phases of an ARAL project are diagnosing, planning action, taking action and evaluating action (Coghlan and Brannick, 2005, p. 22) (Coghlan and Brannick, 2005, pp. 22-23).These four phases are repeated cyclically.The cyclical nature of ARAL means that projects are composed of a number of cycles, and mini-cycles within them.Reflection occurs during and between each research cycle and is used to identify the researcher's meta learning.PAR assumes that the members of the organization system are ideally placed to have knowledge of their own organization; such as where information might be gained and how new information could improve those systems (Long, 1998).In PAR, organization members are in a position to "utilise the results of the research for implementation and action to change the system" (Long, 1998, p. 4).The three basic elements of PAR are active collaboration, an iterative cyclical process and a consultative process.This process means that the project is undertaken in a collaborative and participatory manner with active engagement from stakeholders throughout the organization.

This PAR/ARAL project
The researcher was a member of a "set" throughout the course of the project.Other "set" members included students from the Master of Business Management course at the University of Ballarat who were participating in an action learning action research project in their workplace or elsewhere, and who met on a monthly basis over a ten-month period during the project.
Cooperative inquiry is a significant element of the action research methodology employed.A representative group with a common and meaningful concern was formed and met throughout the project.The group shared information, knowledge, insights and challenges from their organization and project.This shared learning contributed to both the project's aims and the researcher's personal learning and development.
In keeping with the action research approach, several cycles of action were undertaken as part of the process.A sub-group formed to work on the development of the documents, to receive feedback, interpret the data, feedback to the larger group and refine the documents; these in turn formed the basis for further progress and development.
The experiential learning cycle within the ARAL framework, was used to understand how self-awareness and sensitivity becomes knowledge and meta learning.The cycle was used to understand the researcher's contribution to both the research outputs and their personal growth.The underlying assumption was that you are the researcher and the instrument used to generate data are not just "asking an individual a question or observing him or her at work is also generating learning data for both you, the researcher and the individual concerned (Coghlan and Brannick, 2005, p.

99)"
The experiential learning cycle is illustrated in Figure 1.
Action research is about becoming a practitioner, not learning about practice (Revans, 1982).A framework of alpha, beta and gamma outlines three different ways of using information for different means.Alpha refers to the external world and the information is used to design objectives.Beta refers to the achievement of the objectives and gamma, adapting to the experience and to the change.Alpha was the investigation and startup phase, beta was the cycles of action, working towards resolution and gamma was the learning and change that took place over the course of the project.The three levels are nonlinear, sequential or discrete, overlaps occur and they need to be understood as a whole with differing emphasis at different times.The gamma system will be used to illustrate the learning that occurred in the following section.
Method: understanding the research action Monash Health's Policy and Procedure Framework requires the support of an executive sponsor when developing a policy and procedure for the whole organization.The Framework ensures that every procedure links to a policy and that the policy must have approval from the executive.This process means that it is not permissible to develop a procedure that applies to only a single unit or department within the organization and not the others.For example, one emergency department cannot have a procedure on family violence that does not link to the whole organization's related policy.The Framework demands that each department works closely with the Policy Unit to submit a written application for a policy and/or procedure to the Monash Health steering committee for approval.The process is designed to "support effective governance and ensure a systematic and consistent approach to the commissioning, development, approval, implementation, management and review of all policies, procedures and related documents" (Monash Health Policy and Procedure Framework, 2012, p. 1).
The research methodology and actions taken during the course of this project were informed by the action research cycle.The ARAL cycles and min-cycles within them are described below.

Cycle one
In the first cycle, the researcher met with the manager of the Policy Unit to discuss the scope of the project and strategies to ensure its success.The manager suggested forming a Document Development Group with 10-12 participants and meeting two or three times over the course of the project.A stakeholder analysis tool was used to identify members from across the organization.The target was to engage with a minimum of ten departments and six different disciplines.Customized e-mails were sent to key stakeholders, inviting representatives to join the group and giving a short time frame for response.Within ten days, 100 percent membership of the group had been confirmed and a date for the first meeting was set.Representation covered all key areas and disciplines within Monash Health, as shown in Table I.
Two types of stakeholder groups were established within the Document Development Group.The first group included active participants who attended a series of meetings.The second group was established to review documents and provide a communication link to their program or discipline.These stakeholder groups are illustrated in Table II.Actions during cycle one of the project centered on information gathering, benchmarking with other health networks, presenting the project idea to various program areas and preparing for the first meeting.The agenda was finalized and distributed to the participants in advance.All documents from within the organization were reviewed, relevant government position papers were examined and the researcher attended two workshops and one conference on elder abuse.One of the main challenges during this cycle was effective time management and organization skills.Different systems and technical tools were used by the researcher to address workload challenges and improve performance.

Communication matrix
Management Team, I was effectively using the resources available to me, and I stopped acting from baseless assumptions and opened my practice to scrutiny and challenge which contributed to improvement.I realised that I did not regularly ask for the opinion of others, perhaps due to fear of appearing not to know, or being viewed as not competent.I noted the need to reflect on this further and to be honest in my reflections.Earlier I presented to the "set" that my project was not in "full swing".Reflecting on this, I was aware beforehand that others had held several meetings and have developed "sets" in their workplaces, I was comparing one dimension of action in my project to other projectsnot acknowledging to myself the significant amount of work I had completed in preparation for my first meeting and the importance of all the collective actionsnot just meetings.I needed to be vigilant not to over rate one aspect of the project and to under rate the importance of all the action.I had learned a vast amount without holding any meetings.
Background information, an overview of project aims, the principles of ARAL and the project design were presented during the first Document Development Group meeting.Participant confidentiality and security around project materials were assured.organization documents were summarized and the meeting was opened up for discussion around the needs from each program represented in the room.All participants reported that they regularly encountered cases of elder abuse and agreed that the project was necessary.The meeting concluded with the group agreeing on a preferred format for the documents and three members volunteering to assist with writing the documents.

Cycle two
Following the first Document Development Group meeting, a sub-group of four members, including the researcher, formed to commence writing the documents.Each member was allocated responsibility for particular documents and it was agreed to cross refer and collaborate during the writing process.All information and resources were shared with the sub-group, time-lines were agreed and the writing began.During mini-cycle one, the sub-group focussed upon developing a policy statement, a background document, a procedure and an implementation tool.These documents were drafted within two weeks.
Researcher's Reflective Journal Entry Divergence is occurring by other people talking about the project, this is a good thing.Feeling: Positive, people are talking about the project and making the links and connecting people together.Empowered by doing the project this way, validating for myself and others.Has anyone conceptualised a whole of organisation response to violence and abuse?Prior to applying an action research framework, I would have been frustrated and irritated that others were not following due process within the organisation and possibly taken a directive approach with a situation like this.The action research approach gave me the foundation to evaluate the challenges that emerged and the possibility of different responses.
During mini-cycle two, a project officer from a Monash Hospital Emergency Department approached the researcher with a new opportunity.The project officer had successfully obtained philanthropic funding to conduct a 12 month project to develop and implement a family violence procedure and collect related data.

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Abuse of older people in a healthcare context Existing work within the maternity unit on screening for family violence was also brought to the researcher's attention.It became apparent that there was an opportunity to link the pieces of work that existed: the elder abuse project, work in maternity on family violence screening and the planned Emergency Department project.After being discussed with the sub-group, the larger Document Development Group, project client and Policy Unit, the idea was endorsed by the Monash Health Steering Committee.
All the stakeholders were brought together to amalgamate the documents and develop one policy statement on violence and abuse covering all age groups during mini-cycle three.After the first set of revised documents was prepared, the sub-group submitted them to the Policy Unit for review and feedback, before sending them to the full Document Development Group.The rationale for this process was to use the available expertise to check the content and structure of the documents to ensure their standard was high enough to circulate within the broader representative group.The Policy Unit felt that the procedure was a duplication of the chart and they should be amalgamated into the procedure which should take the form of a flow chart: "You have done well to get 100 pages of content into nine.Now you need to get it into one" (Policy Unit Manager).
The next versions were prepared over ten days during mini-cycle four.The policy statement remained the same, the background document doubled in size and a new implementation tool was created.The updated documents were then circulated among the larger Document Development Group before re-sending the documents to the Policy Unit.Almost six weeks had elapsed since the first Document Development Group meeting, and to progress further without involving the larger group did not seem to be in keeping with the action research principle of collaborative processes and the ethical obligation of keeping everyone informed.The documents were distributed with an invitation to critique and attend the second meeting scheduled for early October.

Cycle three
Table III is a summary of the mini-cycles of action that took place in the final two months of the project.The third cycle commenced with the second Document Development Group meeting.
The main focus of mini-cycle one and the second Document Development Group meeting was to receive feedback on the suite of documents and to refine them into final drafts for submission to the Policy and Procedures steering committee for approval.The other agenda items were the idea of the strategic policy alignment with other existing procedures and those under development and the title of the documents.The group came prepared with feedback; the four people who could not attend sent feedback via e-mail or a proxy.The level of engagement remained encouragingly high in the group.The feedback received prior to the meeting was summarized and presented and then it was opened up the group to give feedback from their program and discipline perspectives.The majority of the feedback was positive with suggestions for value adding changes, statements on cultural diversity and sensitivity to sexual orientation to be included.At this point, the name of the Policy and Procedure changed from Elder Abuse to Abuse of Older People based on feedback (the term Elder Abuse could have the potential to offend to members of the Aboriginal community).A revised version of the flow chart was presented to the group but the feedback was that it was too busy.It was decided that a further sub-set meeting would be required to revise the flow chart yet again.
The sub-set met and improved the flow chart during min-cycle two.All the previous flowcharts had contained four pathways because every other chart from every other service and government document indicated a need.But it was then realised that only three were required.The documents were amended and the final set of drafts was prepared for circulation one more time.The final procedure flow chart is provided in Figure 2.
The feedback was positive in mini-cycle three and the documents were ready for submission to the Policy Unit for review before being tabled for approval at the Monash Health Policy and Procedures Steering Committee.If approved, the next steps would focus on implementation planning.

Analysis: understanding the action learning
The experiential learning cycle described earlier was used to understand the action learning that occurred throughout the project.Figures 3-5 illustrate the learning that occurred at different points during the project cycles.
First, Figure 3 illustrates the framework used to analyze material from the researcher's journal and the "set" (Dick, 1993).An example is presented below to demonstrate the researcher's meta learning: • I was feeling much calmer than I anticipated that I would be.This I could attribute to the level of preparation that I had undertaken prior to the meeting and this provided me with a level of confidence to conduct the meeting and future meetings.Preparation was the key.• I was surprised by the level of apparent interest in the project that I had not anticipated.It was encouraging to engage with others who also attributed a high-level of value to the project.It was of benefit to involve others in the process.
Next, Figure 4 reflects the action centered on the development of the original set of documents and the interaction with the Policy Unit during the cycle two.The Policy Unit gave unexpected critical feedback on the documents that the sub-group had spent many hours developing in the format agreed by the larger Document Development Group: • I experienced feelings of frustration in the first instance.I was thinking that time had been wasted, the format was agreed to and do I have to listen?When I later reflected and interpreted this, I recognized that it was my reaction to change, with elements of irritation and denial evident.My awareness of my tendency to be impatient reminded me to slow down and attend to the process and the need for collaboration to be true to the process.My immediate reaction was feeling challenged and wondering if I had to accept the feedbackcould I have it over ruled by the group?However my later and more considered interpretation was that this was expert advice and that it would not be ethical to discount it.Over the following days, in discussion with the subgroup, I accepted it as valid and part of the process and progressed to the next set of actions.
Finally, Figure 5 illustrates the learning that occurred during the second cycle.Incremental learning occurs if you evaluate your practice as you go (Whitehead and McNiff, 2006).The reflection included below demonstrates that while the researcher evaluated practice, the learning became more evident.The comments and reflection illustrate the learning that occurred following the second Document Development Group meeting when further unanticipated feedback was received toward the end of the meeting: • While receiving the feedback, I listened and processed what the group member was proposing be changed in the documents again.My thinking was that any contributions were evidence that others were engaged and invested in improving the work, they were taking ownership and the environment was open for contributions.True collaboration was occurring.
• I was anxious and excited.Excited because after each cycle of feedback, improvements had occurred and we moved closer to achieving the objectives of the project.Seven versions of the documents had been created, each an improvement on the last.I was enjoying the process and I had gone through a change process.The slight anxiety related to the external competing pressures of other work.
Researcher Reflection I felt I had progressed to the level of 'practical knowing' as while I was receiving the feedback, I was able to consciously reflect and respond competently in the moment.I had not been able to do this when I received feedback from the Policy Unit in the previous cycle.This also applied to the discussion on the title of the documents when I was able to revisit the issue and process and synthesize the contributions of the group to   From the commencement of the project, I was impressed with the level of commitment from all levels of the executive, management and staff within Monash Health.I felt this commitment went beyond the need to merely comply with the latest government requirements and illustrated a deeper level of concern and that the project facilitated an earnest endeavor to address the serious issue of abuse of older people in our community.This level of commitment was encouraging and built a foundation of confidence for me to leverage off into the developmental phase of the project.Developing pieces of work and putting them forward to a high-level diverse group of professional colleagues and actively seeking critical feedback was challenging and confronting at various stages.It caused me to experience many conflicting reactions and emotions.I took some time to process and eventually accept critical feedback.Further work, journaling, reflecting, discussing and reading, shifted my thinking.After I had recovered and developed insights into what was occurring, I was able to more fully accept the feedback and to learn and incorporate the feedback.The openness that this learning created in my thinking, led to the development and consideration of other possibilities in relation to broader and more strategic approaches to how Monash Health could structure policy and procedures in relation to all forms of violence.

Action learning action research results
The project was rigorous and followed the action research methodology as judged by the criteria in Table IV (Coghlan and Brannick, 2005).This approach enhanced the achievement of the project aim to develop a Policy and Procedure on Elder Abuse for Monash Health.Each cycle of action, collaboration and reflection improved the outcome and has been illustrated by the evolution of the documents.
In brief, there was significant development and application of actionable knowledge coupled with reflection during the course of this project.The outcome was a successful project that met its stated aims while providing a vehicle for significant professional growth and empowerment as well as divergent pathways and unanticipated learning.Through this project, gaps were identified both in the organization and governments' response to violence.Parallel service gaps were also found to exist, all of which were unintended discoveries.Utilizing an action research approach created the opportunity for engagement with the entire organization and improved the organization's response to elder abuse.In addition, the project identified a broader strategic opportunity to design a joined-up policy response to violence.Further potential now exists to influence future service development and government policy directions.The learning outcomes from this will be available to all participants and to the Policy Unit to inform future work.

Conclusion
In summary, before this project, Monash Health had a hard copy Procedure on Elder Abuse that was 12 years old as well as a series of other single department procedure documents across the organization.The organization was not meeting the Governments' stated expectation that all public health networks develop a Policy and Procedure to respond to Elder Abuse in a consistent manner at the commencement of the project.The project rectified this and made an improvement by moving the organization to a position of compliance and developing a Policy position and a comprehensively researched Procedure and Implementation Tool to guide all staff in the organization, assisting them to recognize and respond to abuse of older people.The project continued into an implementation planning phase following formal approval of the documents.A specific objective of engaging stakeholders across the organization to participate and contribute was achieved, for they were engaged and prepared to be the champions for the education and implementation phase of the project.Communication, particularly the face to face meetings of the Document Development Group, created a network of sharing and learning within the organisation.
In conclusion, this project developed a shared vision for a more strategic response to violence and abuse, not only of older people but of all patients of Monash Health.This outcome and my own learnings would not have occurred if an action research methodology had not been applied in this project.
Figure 1.The experiential learning cycle

Researcher' s
Reflection My learning through what I originally considered to be just a few preliminary actions in the preparation phase actually shifted my confidence to a new level [during the first cycle].I understood the structure of the organisation, I had confirmed my capability to effectively engage with members of the Executive Figure 2. Abuse of older people Figure 5. Action learning during cycle two make a decision.I would not have become as effective in my new role as a Director without the learning through the project and the application of action research theory.
the issues are, the planning phase focusses upon taking stock of the current situation and developing action plans, activities are implemented and interventions are made in the taking action phase and outcomes of action are examined during the evaluation phase what

Table II .
slightly overwhelmed by the volume of work in my relatively new role as a Director and had concerns as to how I might complete the work required •I was feeling• I was feeling positive at this stage by launching into the unknown with a level of excitement.I enjoy leadership roles and hoped this would challenge me.I had support and resources to draw upon.