Posts from the “Resistance to change blog series” Category

Resistance is human (part 5) – Ruth Glassborow

Posted on December 2, 2019

In the last part of this blog series, Ruth Glassborow highlights some of the specific factors that need to be taken into account when working with primary care.

In part four of my blog series on resistance to change, I started to share my findings from interviewing 11 GPs and 2 Practice Managers around what helps and hinders their engagement with change initiatives. I highlighted:

the importance of the individual initiating the change making personal contact with practices
the necessity of being able to demonstrate the benefits for patients
the reason why attention does need to be given to the financial case for change, and
that overall the benefits of the change must outweigh the costs and there is often a complex relationship between the two that can vary between practices.

This is the new bit. In addition to the above, evidence that change will lead to better outcomes was highlighted as important by a number of the GPs I interviewed. One GP went as far as saying that, for a current change initiative, he was deliberately avoiding the evidence in case it persuaded him that he needed to do something he didn’t want to do.

However, in practice, GPs consistently engage with change initiatives where there is limited evidence. Why is this? Why does evidence matter in some situations but not others?

My interviews highlighted that GPs do not need a strong evidence base when they can intuitively see the benefits of a proposed change and the change fits within current cultural/professional norms. However when either of the reverse apply then evidence becomes a key issue.

Further, the issues around evidence and finance interface with each other. So to help change initiators to think through how well their idea is likely to be received, I’ve summarised the role of finance and evidence in making the case for change in primary care in the following flow chart:

You can find more information about the findings behind this.

A very practical example of this is our current work in Scotland to develop and roll out approaches which reduce the amount of time GPs spend reviewing documentation. Following initial prototyping work with practices, we are now running a national programme to spread the work to further practices. We’ve had enormous interest from primary care as they can intuitively see the benefits of a change which reduces the amount of time they spend on paperwork (in one of the prototyping practice by on average 5 hours a week). It is a change that fits with current professional and cultural norms (who doesn’t want to do less paperwork?) and we’ve resourced the roll out alongside providing the evidence that once implemented, the change will save GP time on an ongoing basis. When you work that scenario through the above flow chart, you end up at a green box; a change that is ready for implementation. Which explains the level of interest we’ve seen in participating in the spread programme.

Where the flow chart is perhaps more useful is when a proposed change ends up at an amber or red box, as this highlights that the change may not yet be appropriately designed for successful implementation. From a practical point of view, it also provides ideas about adaptations that may be necessary to overcome the potential resistance.

Summary

In summary, this final blog in my series on resistance to change has highlighted some of the specific factors that need to be taken into account when working with primary care. I am conscious that these findings were based on a small non-random sample. Further, in Scotland the new contractual arrangements in primary care have bought a different context that may also impact on their validity. So I share them as insights to spark some further debate on how we can effectively engage primary care in the current modernisation agenda, and hopefully, to help with thinking through how to design improvement initiatives that are likely to succeed.

I would love to hear the views of those working in primary care whether any of the above resonates with your experiences and what you think about my analysis of the role of funding and evidence.

Find out more about the role of funding and evidence in making the case for change within primary care.

Resistance to Change – Blog Series Links:

Resistance to Change – Blog 1

Resistance to Change – Blog 2

Resistance to Change – Blog 3

Resistance to Change – Blog 4

Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.

Categories: Resistance to change blog series

Tagged: Resistance to change

Resistance is human (part 4) – Ruth Glassborow

Posted on November 25, 2019

In part four of this blog series, Ruth Glassborow continues to explore resistance to change, turning now to explore what enables and hinders primary care engagement with change.

Back in 2011 my job included leading work across Scotland to increase the number of people being diagnosed with dementia. In parallel, I was completing a Masters in Public Administration. As primary care had a key role to play in this work, I decided to focus my dissertation on understanding more about the factors enabling and hindering primary care engagement in this national improvement initiative.

This blog shares the insights I gained from interviewing 11 GPs and 2 Practice Managers. Although the sample size was small and non-random, I picked up some useful insights which I would like to share here.

First things first, all my interviewees highlighted the vital importance of involving primary care in the design of changes which impact on them. Whilst this may seem a statement of the blindingly obvious, in my work I still come across secondary care initiated change initiatives which impact on primary care but have not involved them in any way. And then we wonder why they resist!

Related to this, a key point raised by eight respondents was the importance of personal contact by the individual initiating the change. Why do they want personal contact? Because this recognises that primary care is not a single entity, but rather many different organisations each with their own unique histories, cultures and ways of doing things. Personal contact enables a joint exploration of why the change is considered important and how it might need to be tailored for any individual practice.

Which leads me back to another key issue highlighted in earlier blogs: the importance of change adopters being dissatisfied with the status quo and believing that there is a better way of doing things. In other words, being convinced of the case for change. My interviews identified that there are essentially three elements that make up the case for change in primary care:

Agreement that there is a problem that needs addressing which requires action within primary care
Agreement that the changes being proposed will deliver benefits to the individual practice
Belief that the benefits justify the costs.

This immediately leads to the question: what benefits matter most to primary care? The following table highlights the type of benefit mentioned in the interviews and the number of respondents who mentioned it.

Table: Classification of benefits

I think it is important not to gloss over the first: benefits to patients. Every single interviewee highlighted this as a critical factor in deciding whether to engage in a change initiative. Indeed this aligns with my own experiences over the last three decades of working in healthcare. The vast majority of clinicians are motivated to provide high quality patient care and they will resist change which they think will have a negative impact on patient care. Personally, I take comfort from this knowledge, as I would hate to work in a system where clinicians willingly implemented changes which they thought would have a negative impact on the quality of care being provided.

The other benefit mentioned by all interviewees was whether implementing the change would increase practice income. In my experience, this can get translated into an unhelpful stereotype that GPs won’t do anything unless they are paid for it. In reality it is more complicated than that.

The finances do matter, particularly for GPs who are self-employed and running their own business. If those of us working outside primary care had to pay out of our own pockets for a locum to cover our work when we were attending a meeting, I am sure we would either not attend or ask the organisers of the meeting to pay for the locum cover. This is the day-to-day reality for many of our colleagues in primary care. Furthermore, if you ask them to make a change that increases workload to the extent that they have to pay additional hours to their staff, the financial costs of that ultimately comes out of their pockets. So no wonder they want compensating for it. I think most of us would too if we were in their shoes.

However, my interviewees highlighted that it is not just about the money – overall the benefits of the change must outweigh the costs and there is often a complex relationship between the two that can vary between practices. The water is then further muddied by the role that evidence plays in the overall cost-benefit analysis. This is something we will explore further in my next and final blog in the series.

This fourth blog in the series has highlighted insights gained from interviewing GPs and Practice Managers. The next and final blog in the series on resistance to change highlights some of the specific factors that need to be taken into account when working with primary care.

Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.

Categories: Resistance to change blog series

Tagged: Resistance to change

Resistance is human (part 3) – Ruth Glassborow

Posted on November 18, 2019

In part three of this blog series, Ruth Glassborow continues to explore resistance to change by looking at what the research says about how to respond to resistance effectively.

Here goes:

Step One – Check your mental model

This goes back to my first blog. If you view resistance as something that an individual is doing because they are being awkward or in some other way demonstrating bad behaviour, then you are much less likely to take the time to openly explore their reasons. Instead you’ll make assumptions, or judge their personal motives. Yet effective responses are often, if not always, dependent on a good understanding of the reason for resistance.

This leads us nicely on to ….

Step Two – Understand the individual’s/group’s reasons for resisting

This goes back to my second blog; if you want people to choose to change they need to be

dissatisfied with the status quo and
believe the change being proposed is a better way of doing things and
have the ability to implement the change and
are supported by an effective leadership context.

When trying to understand why people are resistant, don’t make assumptions without actually talking to them. You might think you know what’s happening but nothing can beat sitting down and openly exploring the issues together. However, the research also identifies the risk that the individual may not know themselves why they are resisting because of what is called “hidden competing commitments”. You can read more about the reasons people resist change.

And remember, we often resist change for more than one reason.

For instance I might be happy with the status quo but alongside this I might also lack the ability to implement the change. You could address the former by getting me to listen to the poor experiences my patients are having or showing me data that says my colleagues are doing so much better than me. However, if you want me to implement the change you also need to tackle the issues around my ability to implement it. So the key message here is consider all possible forms of resistance in play, not just the first one you identify.

Step Three – Decide whether to intervene

I remember many years ago a team member saying to me “why are you paying so much attention to x when the vast majority of the team want this change? We can do this without him so please stop spending all your time on the one person who doesn’t want it and focus a bit more on the rest of us who do”. A very good point well made.

D’Herbemont and Cesar in their book ‘Managing Sensitive Projects’ propose that building a critical mass of allies who support the change is key to the success of any change project. It is not necessary to remove every opponent to change; just to build up enough support so that the positive forces for change are more powerful than the negative ones. They warn against a common mistake made by managers that they refer to as the ‘Magpie Syndrome’, an obsessive focus on opponents to the extent of forgetting one’s allies and their interests.

In my experience, it is all too easy to end up focusing too much energy on the opponents and not enough on the allies, so I’ve found the question “do I need to respond”, a useful one to ask.

In practice, ignoring the resistors and working with the willing is a proven strategy for responding to resistance. It is after all what sits behind concepts such as prototyping with a willing team.

Step Four – If you are intervening, choose an intervention which fits with your diagnosis of the reason/s for resistance

An effective response to resistance will tailor the interventions to the diagnosis. The literature on resistance to change identifies the following key principles which need to underpin this process.

Consider the possibility that the correct response is to amend the change proposal due to the validity of the concerns expressed.

The focus should be on reducing the resistance to change, rather than increasing the force for change. The risk attached to increasing the force for change is that it will result in an equal increase in the forces resisting change. Have you ever noticed yourself becoming more determined not to do something the harder someone tries to force it on you?

Don’t waste time on variables not receptive to change. As an example, trying to change an individual’s deeply held values is unlikely to achieve the desired result.

Remember that resistance is often related to more than one issue and hence your response may also need to be multifactorial to address the different issues.

Timing is important. For example, change can be resisted because of a lack of time to make the change, or an overload of organisational change, or because it is happening at a time when a key individual has a lot of change going on in their personal life. We are often given timescales to work to, which can feel very real and are usually important to work with. Indeed many change initiatives are strengthened by the “drumbeat of the change”. The complete absence of deadlines can be problematic. However, the point here is that timescales are rarely more important than the change itself. Meeting a deadline without effectively bringing about the desired change is rarely advantageous. A short delay and extension of deadline can prove far more valuable if it enables the change to take place. Those of you who, like me, have on occasion asked for extensions to essay deadlines will know this very well!

Specific Methods for Responding to Resistance

Kotter and Schlesinger (1979) developed a summary of methods for responding to resistance to change, providing a systematic way to select approaches. The original paper identifies when each of the approaches is commonly used and the advantage and disadvantages of it. Briefly the methods they highlight are:

Participation and Involvement
Education and Communication
Negotiation and Agreement
Facilitation and Support (Emotional) – providing support for coming to terms with change
Manipulation and co-optation
Explicit and implicit coercion.

Personally, I don’t recommend the last two. Having seen it first hand, whilst they may deliver in the short term, I think they build problems up longer term due to the breakdown in trust that results.

My literature review highlighted a number of other strategies :

Facilitation and Support (Practical) – providing practical support such as advice, coaching, project management resources
Training
Demonstrating how the change aligns with an individuals or groups values
Exposing the need through for instance the use of data, patient experience, process mapping, and/or peer review
Using Subject Matter Experts to highlight the need for the change
Using Small Scale Tests of Change
Making the desired state easier than the status quo
Ignoring it.

This led me to develop a revised version of Kotter and Schlesinger’s analysis .

Step Five – Review and Amend

Finally, when you are implementing change in health and social care it is rarely straightforward. Good change management requires leaders to continuously review progress and adjust as they go. In the words of James Yorke: “The most successful people are those who are good at plan B.” Or in my experience those who have a plan C, D, E, F and G!

This third blog in my series has considered what the literature says about responding effectively to resistance. In my next blog I move on to share some of what I found from interviewing GPs and Practice Managers for their views on resistance to change.

Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.

Categories: Resistance to change blog series

Tagged: Resistance to change

Resistance is human (part 2) – Ruth Glassborow

Posted on November 11, 2019

In part 2 of this blog series, Ruth Glassborow takes a more in-depth look at some of the many different reasons why change is resisted.

In 2011, I conducted a literature analysis which identified 63 different reasons why change was resisted. Each reason can be categorised under one of the following four headings:

lack of dissatisfaction with status quo
lack of belief that proposed change is a better way of doing things
lack of ability to action the change, or
poor leadership.

My dissertation was exploring the factors which lead to change being adopted or resisted within the Scottish Primary Care context. So I looked at what the generic management literature said about resistance to change, and considered whether there were any differences in the healthcare literature.

In my analysis I also categorised the reasons why people resist change into three areas: individual reasons, issues associated with being part of a group and issues associated with the organisational set up. You can find a summary table at the end of this blog and access the full analysis.

From this analysis, what struck me was:

There are significantly more reasons associated with a lack of ability to implement change, than with the other categories
Six of the nine reasons for resisting change due to group dynamics only appeared in the healthcare literature. Perhaps group dynamics play a larger role in healthcare due to the emphasis on team working? Maybe the multi-professional nature of teams leads to a greater complexity of group dynamics impacting on resistance to change?
Issues around tangible evidence only came up in the healthcare literature. So perhaps evidence for change plays a bigger role in healthcare change than in other industries? That certainly resonates with my own experiences. It also emerged as a key issue in my interviews with colleagues in primary care. (I will share in a future blog further insights on this issue generated from my interviews with a number of GPs)
The emphasis on senior management resistance in the healthcare literature. One of the common themes I’ve found when delivering training on this topic matter has been middle managers reporting that the problem is not with their teams resisting; it is convincing the senior leadership team to support a change idea that has come forward from their teams. That raises interesting questions for all of us leaders: we are often quick to criticise our staff for their resistance to our ideas, yet how open are we to theirs?

My literature review was limited to 46 papers so it may be that a broader, more contemporary analysis would have different findings. And as I reviewed my findings for this blog, I was reminded of a word of caution from a researcher friend: a lack of evidence of something is not the same as saying there is evidence that it doesn’t exist.

However, over the years of training on the subject of resistance to change, and applying the principles within my own practice, I have found that the key messages in my analysis strongly resonate with others and have usefully helped inform my practical experience of implementing change.

I would love to hear whether these findings resonate with your experiences and also what, if anything, stands out for you. And for anyone interested to find out more, you can find a more detailed analysis of the reasons why change is resisted.

Finally, whilst it is fascinating to consider the multitude of different factors which influence whether change is resisted, I find that often it is enough to stick with the main headings and ask myself whether the group I want to influence are:

dissatisfied with the status quo and
believe the change being proposed is a better way of doing things and
have the ability to implement the change and
are supported by an effective leadership context.

So I’ve shared some of my findings on the nature of resistance, on why people tend to resist change, and how those reasons vary across different social and organisational settings. In the next instalment in this series, I look forward to sharing with you my findings from the research on how to effectively respond to resistance to change.

Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.

Categories: Resistance to change blog series

Tagged: Resistance to change

Resistance is human (part 1) – Ruth Glassborow

Posted on November 4, 2019

In the first of a series of blogs about resistance to change, Healthcare Improvement Scotland’s Ruth Glassborow explores the very human nature of resistance. These draw from Ruth’s extensive change management experience and a dissertation she completed back in 2008 entitled ‘Understanding why change is resisted in primary care’.

In a landscape that seems to be continually changing, it is probably not surprising that so much time is spent talking about how we can “overcome resistance”. Yet in my view those two words are both overused and unhelpful.

Why?

Because they communicate a belief that those resisting the change are wrong and that we need to find a way to force them to accept the thing we want them to do. Further, all too often this is underpinned by a pressure on those with lesser power to conform to changes thought up by those with greater power.

Over the years I’ve run many training courses on resistance to change. I wish I’d had the foresight to keep and analyse the outputs of those sessions. By now they would have contained a rich source of evidence that even the phrase “resistance to change” is one that immediately conjures up negative words in the participants’ minds such as “stuck in the muds”, “vested interests” and “hard work”.

“We need individuals working in our health and care system who have the courage to challenge changes that they believe will make care worse. That kind of resistance is to be celebrated and responded to by openly exploring and discussing their concerns.”

Yet when I ask individuals in the room to reflect on the emotions they experience when they think about the resistance movement in World War 2 you can literally feel the atmosphere changing. In this scenario “resisting change” was an act of enormous courage and sacrifice and so clearly the right thing to do.

For me this makes the vital point that not all change is good. And, to individualise it for a moment, that includes some of the ideas that I’ve come up with and, dare I say, some of the ideas that you’ve come up with.

This means we need individuals working in our health and care system who have the courage to challenge changes that they believe will make care worse. That kind of resistance is to be celebrated and responded to by openly exploring and discussing their concerns. After all, if the idea is a good one then it has nothing to fear from such questioning.

Sometimes, when we explore the concerns, we find that the person is resisting because they are placing their own individual needs above the greater good of our populations. Yet, in my experience, more often you will find they have a genuine belief that the change will have negative consequences for those using their services.

They may be right or they may be wrong, but surely the onus is on all of us leading change to explore and better understand the concern. If they are right, wouldn’t you want to know and adjust your change?

Another exercise I undertake in the training is to divide the room in half, and without them knowing, get participants to discuss two different questions. One half looks at reasons why they’ve resisted change in the past and the other looks at reasons why people they’ve worked with have resisted change.

In most cases the discussions demonstrate in practice a phenomenon known as the ‘Actor-Observer Bias’. This is a tendency to overestimate the importance of personal/dispositional factors and underestimate the importance of situational/environmental factors as causes of other’s behaviour. And vice versa when it comes to our own behaviour.

This means we tend to see ourselves as resisting change for good reasons attached to the nature of the change, yet we judge others as resisting it because they are in some way “being bad people”.

What fascinates me about this is that, even though I know this and have spent nearly a decade training on it, I still regularly catch myself making the assumption that someone else is behaving in a particular way because of who they are, not because of the circumstances they find themselves in.

So why does all this matter? In my experience, when we make an assumption that resistance is attached to the person’s disposition rather than a genuine concern about the change, we are much less likely to take the time to find out why the person is resisting.

Yet effective responses are often, if not always, dependent on a good understanding of the reason for resistance. This is why I believe the key message is that we should seek to “understand and respond to resistance” rather than “overcome it”.

“In my experience, when we make an assumption that resistance is attached to the person’s disposition rather than a genuine concern about the change, we are much less likely to take the time to find out why the person is resisting.”

My fascination with resistance to change led me to write a Masters dissertation on it. Even though that was eleven years ago, the findings seem as relevant today. My analysis of the literature identified 63 different reasons why change is resisted, with the majority fitting under one of the following three headings:

lack of dissatisfaction with status quo,
lack of belief that the change proposed is a better way of doing things, and
lack of ability to action the change.

There was a residual set of items that didn’t naturally fit any of these three categories but which did have a common theme. They were all about the way the change was led. Indeed it can be argued that poor leadership is a causal factor of all of the other three factors.

When I used the framework to reflect on my own leadership practice I realised that, on more than one occasion, I had focused my action on supporting people to make change when in practice they weren’t actually dissatisfied with the status quo and/or didn’t believe the changes being proposed would make things better.

In other words I was trying to spread solutions to problems people didn’t know they had or solutions they didn’t believe in. No wonder they were resisting.

In my next blog I will pick up further on the analysis of the 63 reasons, before I then go on in my third blog to consider what the research tells us about techniques for responding effectively to resistance.

Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.

Categories: Resistance to change blog series

Tagged: Resistance to change