Do a quick internet search and you will uncover an abundance of quotes on the constancy of change. A view, held that widely, from ancient philosophers (Heraclitus) to twentieth century politicians (John F Kennedy), speaks to the pervasiveness of change across the human experience.
Given that change is such a fact of life, should we be more surprised when we hear colleagues invoke the term 'change resistance' when describing why some initiative didn't go as well as intended?
While I can't speak to others' experiences, I've rarely found good reasons to label anyone as 'change resistant' or worse, a 'resistor'. Most of the time, there are perfectly sensible reasons why people resist, and it is never for pure intransigence. More often it might be things I overlooked, insights that weren't available to me at the time, poorly articulated explanations, clashing perspectives and simple differences.
Back in 2007, I had just been appointed to lead a newly created inpatient fall prevention program at a large hospital in south-east Queensland. I was optimistic, enthusiastic and driven - as were many at that early, promise-laden phase of the patient safety movement. One of the first things I set about implementing was a series of action planning meetings with nurse managers from wards with the highest rates of fall-related injury. It was an initiative right out of the IHI playbook (at least in my mind) - every ward would find itself on a a rigorous cycle of continuous improvement, and with my informed encouragement, improvements would inevitably follow. About six weeks into my safety drive, an email arrived with an invitation to meet with the Director of Nursing in charge of a service line to which I had been particularly attentive. I don't think I was expecting praise, it was too early for that. Still, it was plausible that my dedication to our common cause (of advancing safety) might have piqued the curiosity of our organisational leaders? I was dead wrong.
What followed was an agonising conversation with three members of their leadership team. Agonising not because of how the material was delivered (they were polite, concise and professional), but because of how badly I had misread the situation. Not only had I broken protocol by not apprising and seeking endorsements from the leadership team, but I had undermined a program of ward-based safety management that had been months in the making and potentially created a lot of parallel work. I hadn't even stopped to check what those busy nurse managers already had on their plate. I will not lie, that particular dressing-down was one of the times I questioned my career choices. I persevered though. It took months, considerable listening and understanding, lots of patience and a bucketfuls of humility. I regained lost ground slowly. Fast forward five or so years, and I needed an executive sponsor to back a grant proposal we were putting together. This time, to redesign night lighting in the same hospital (to reduce the risk of falls). I found myself pitching to a legitimately skeptical group of hospital leaders. At the end of the presentation, silence. A voice finally broke out from the back of room: "Well its certainly novel! I think we are all just a little concerned that this is going to be difficult to implement without disrupting care. That aside, I have no doubt that you will work out all the difficult details with my team - so you have my support. Let me know what else you need". Five years after 'resisting' my initial change initiative, I had a senior ally who was willing to go out on a limb for me. I had leant in to the feedback and done the work. Many years and experiences later, the core lesson still stands.
In this piece, I attempt to unpick the concept of 'change resistance', explore why it continues to find traction in healthcare improvement, the problems I think it creates, and whether there are better ways to dialogue meaningfully with resistance.
A quick word about resistance in complex systems
In a large number of cases, what we we experience as people resisting ideas or initiatives, is really a case of any given system's normal drive to defend homeostasis.
Complex systems (a clinical team or three, a ward, a hospital, or an entire health service) will often maintain islands of stabilised performance in the areas that matter - most often in frontline care. These are held in place through cross dependencies, shared resources, co-evolved values and norms. If an initiative challenges that stability, then complex systems will activate a multitude of creative responses to deflect and defend, before they will accomodate. What we have here is not mere 'inertia', rather it is a distributed but proactive mobilisation to keep things functioning. This is why 'brute force' initiatives fail. By the time you've applied enough pressure on the system to overcome resistance, you risk potentially destroying all the delicate synchronisations that make complex work possible in the first place. Equally, when change initiatives offer answers for existing pain points they can be sucked into operations as fast as can be rolled out. So there is an upside to complexity, but I digress. The message here is that system resistance is almost always a clue why a particular initiative doesn't fit the existing reality (the system as it is found, not as we would wish it to be). Unfortunately, many projects don't hang around long enough build an understanding of the systemic context within which the change is being introduced. If a sense-making strategy comprises solely of deciphering the emotional responses of people at the pointy end of the change, then "change resistance" is a most convenient label to place over any contentious situation.
Moral judgements with a thin veneer of objectivity
There are also other reasons why 'change resistance' is an appealing stereotype when a range of alternative explanations are available. First, I believe it is a remnant of an outdated logic model that still entraps organisational thinking today - most often in hierarchical settings where there are clear divisions (and specifically, disconnects) between management functions and service delivery. It is a logic that presupposes two things: 1) that operational resistance to organisational priorities for change must stem from superficial motivations and 2) that such resistance is best overcome by implementing incentives and disincentives.
This logic is classic Taylorism with shades of 'radical' behaviourism (see the work of early behavioural psychologists like B.F Skinner and John Watson).
Taylor (and Henry Ford for that matter) vigorously pursued their goals of industrial efficiency but at least they based it on a high (if misguided) ideal that it was truly for the greater good - everyone playing their part in creating organisational prosperity that benefited everyone. But unlike the typical model of management today, Taylor and Ford spent vast amounts of time on the shop-floor. They invested time and effort in studying frontline work, building technical knowledge, verifying, testing and trialing before implementing even the most basic changes. While Taylor's most useful innovations in work redesign and improvement may have been forgotten, his more belligerent views of workers seem to have found haven in innocuous-sounding phrases like 'change resistance'. When we apply these ideas without acquiring a thorough understanding of work, it shows we are willing to make reductive judgments about the motivations of operational workers (bit like the quote above) but calling it 'change resistance' makes the sentiment more palatable to a 21st century audience. Regardless, such a viewpoint can only 'stick' if we (on some level) hold ourselves to be more moral, or more committed to the greater good, than those that resist.
Deeper still, the idea is misaligned with current thinking about 'motivation' itself.
In his best selling book "Drive," author Daniel Pink presents a compelling case for rethinking popular notions of 'motivation'. Pink's core idea is simple enough. Its that individuals are fundamentally driven by autonomy, mastery, and purpose rather than a reward-punishment drive (*for a deeper examination of the problematic legacy of behaviourism in the workplace, Alfie Kohn's "Punished by Rewards" is still a brilliant starting text). Pink develops his argument with a series of case studies (likely hand-selected to bolster his narrative), but his core interpretations are close enough to the science that they can be taken at face value. For the purpose of this piece, they do offer easy insights into why organisational changes sometimes experience headwinds.
People have an innate desire to have control (autonomy) over their work lives. When change is imposed from the top-down or outside-in, it is natural for resistance to emerge at a human level if the change creates (or creates a perception of) a loss in autonomy.
Humans are also motivated by opportunities to learn, grow, and develop their skills. Change can be a positive avenue for such personal and professional growth, allowing individuals to acquire new competencies and tackle novel challenges. However, when change is perceived as disruptive, poorly implemented, or antagonistic to the natural rhythms and trajectories of growth, it can hinder that very sense of mastery that people desire and fuel avoidable resistance. Individuals also seek meaning and purpose in their work. We can spend a lot of time aligning strategies to the declared 'values' of organisations but easily overlook alignment with the individual's sense of purpose. This can become yet another source of profound resistance.
Resistance as a generative force
Pink's take on what drives us is refreshing and insightful but does not necessarily break new ground. In fact, we have known some of these things for a hundred years. Exactly a century earlier, American sociologist and visionary management thinker, Mary Parker Follett was becoming deeply interested in the tensions, frictions and conflicts that seem to arise in modern hierarchical organisations (themselves a byproduct of Western industrialisation). Follett came to some profoundly different conclusions to her contemporaries. While Taylor and other purveyors of the 'scientific management' movement were content to frame 'coal-face' workers as lazy and dull, while elevating 'management' as the act of exercising control over workers by those of superior intellect and capabilities, Follett's view on management went against totally the grain. It centred on three principles:
'Integration': of diversity and conflict (as opposed to 'domination' or compromise)
'Power-with': which described a 'co-existing', participative and distributed form of power rather than coercive 'power over' and third,
'Group power': which points to a type of cohesive social-mindedness as an alternative to personal authority.
More to the essence of this post, Follett saw resistance as something 'generative', a source of vital creative energy.
To Follett, there was no 'change resistance', just a diversity of identities, experiences and ideas to be synergised and integrated (not annihilated or absorbed) - in Follett's own words "All polishing is done by friction." What makes Follett's work even more staggering (beyond its continuing relevance a century later) is that her management theories were formulated at a time when Western society was incredibly classist, patriarchal and workers had few rights, if any. Perhaps a little too radical for the time, Follett's ideas have thankfully been reintroduced to us via later movements that channeled similar notions - the human relations school of management, Douglas McGregor's Theory X and Y, and growing interests in genuine collaboration and humanistic philosophies of management.
Reflections on managing resistance in healthcare
When we think about managing resistance in healthcare, it is necessary to first abandon the illusory premise that meticulous desktop work and careful execution can somehow guarantee a resistance-free path to adoption. Unfortunately, in the complexity of healthcare, the process of incorporating new features within systems is full of tentative explorations, timeouts for sense-making, sedate phases and surging phases. Through the lens of typical structured project management frameworks this might look chaotic - a series of mis-steps, setbacks, work arounds and inelegant lunges forward. Regardless, this is the reality of change-making - resistance is natural. In fact, cutting edge transformation programs are beginning to look a lot less like traditional change management (what with their Gantt charts, weekly milestones and success metrics). They are all about grassroots activation & discovery, co-evolution, co-creation and emergent structures (for instance: https://oecd-opsi.org/innovations/co-created-mental-health/). The work of 'program leads' begins to look more like permaculture and social innovation than project management. That aside, even in more traditionally formulated change projects, there is much that can be done to avoid unnecessarily escalating resistance; and when it is encountered, to productively redirect it into forward movement.
We should acknowledge that some change initiatives are never destined to succeed and no amount of implementation magic and practitioner artistry can save them. Sometimes these programs are merely 'théâtre politique' and not serious attempts to redress real-world issues. In these situations, once the spotlight is turned away or the project concludes, practices will reorganise into the most efficient configuration again - which can mean non-compliance with activities that are seen to be without value. Yet, most of the time, early and extensive efforts to develop an empathetic understanding of the operational context can help mitigate some of the usual issues that crop up. This level of engagement goes beyond typical consultative phases of projects. It's not about surveying what a population of recipients think about initiative 'X', rather it is about doing the deep work to understand what gets done and how, and invariably, working out how the intervention must be adapted before it can be adopted.
Invariably, you will experience some resistance. In those situations it's vitally important to legitimise the voicing of dissent. Differences of opinion are natural and healthy, and speaking up is a participatory act (its considerably worse when no one feels like speaking up). Encourage your teams to lean in to the dissent rather than trivialising or labelling it. Certainly don't assume dissent is a function of poor planning or execution. Prioritise the exploration of inquisitive and responsive questions. For example: What doesn't fit? How does the change impact everyday work (autonomy and purpose)? What should we be doing differently? What does meaningful integration of their feedback look like? Who else should we be speaking to? Would they like to contribute in some expanded way (redistribute power)? What will be the residual pain points (acknowledge post-project sacrifices)?
While it may not be feasible to take everything on board - nothing amplifies credibility and trust than when an organisational initiative rapidly and visibly iterates on a concept when they are given meaningful feedback.
Hope you find these observations helpful and motivating. Join in the conversation on our social pages.
If you are experiencing implementation challenges for a complex change piece we can help. We can also design bespoke programs in managing resistance and navigating complexity for your teams - reach out to us using the link below. We would love to hear from you.
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