Module 3 transcript - School for Change Agents

NHS IQ Webinar (UKNHSI0203A)

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HELEN BEVAN: So many people tell us that resistance to change is a big issue. We will also be touching on a big issue that is related to resistance, which is about resilience. So, resistance and resilience.

So, let's see who we have got with us. Fantastic to see so many of you joining today. This is module number three, and as the core team of change agents, a big test is how many people are taking part, because if we get a big drop-off between modules, we're not doing something right. Actually, the numbers are holding up really well, and that is fantastic to see.

We would like to welcome all of the people who will be listening to this recording later, so whether you are with us live or listening later, welcome, everybody.

My name is Helen Bevan and I am joined by the facilitator, Pip Hardy. She has an important job to support and work with all of the breakout rooms and the breakout facilitators, so welcome to all facilitators as well.

In terms of who is looking after things, looking after the chat room, keeping an eye on things are Ollie and Lewis, so welcome to them. Also, our technical crew behind-the-scenes, very important, Joe and Paul. They are there for you if you have any technical difficulties at all.

So, one of the best things about the school is that it is multimedia interactive. From the last couple of modules, the content that we had in the chat box has been absolutely fantastic.

For those of you joining for the first time, the chat box is on the right-hand side of the screen, and it is underneath participants. Anything you want to put in the chat box at all, any comments, take part in the discussion. If you have links to resources that you would like us to know about, please put links in there as well.

We would love you to tweet using the hash tag #SFCA, and our handle is @Sch4Change.

We had to make the Facebook group a closed group but it is very easy to join. Please make a request. Also, after every module, we will be doing a summary and putting it on Steller on the website, so please, please join in.

The school is running for five weeks, and each week, we are covering a different topic. Week one, we talked about being a change agent and that change begins with me. Week two, last week, it was about me to we. This week, we're talking about rolling with resistance, and the focus is resistance to change.



We talk about rolling with resistance, and that is very careful language. We hope that you will join us for the last two weeks of the school, where we will be talking about how to make change happen next week, and the final week, we talk about moving beyond the edge. One thing we say about effective change agents is that we work on the edge of organisations and systems.

Just to reiterate, taking part in the school can make a contribution towards your continuing professional development. Nurses, midwives and allied health professionals, you can use this experience as part of your reflective account for revalidation.

Doctors, we have applied for credits for continuing professional development for the school and we will let you know what is happening in our newsletter.

And everyone, whoever you are, whereever you are in the world, you can become a certificated change agent, and all you have to do is watch all five of the talks, either live or the recording, and then we wanted to demonstrate that you have applied the learning in your own work.

You can then become a certificated change agent, you would get a badge, and you can put it on your CV, on your Twitter profile, on your Facebook, and you can tell the world that you are a certificated change agent.

One more announcement. One thing people enjoy are the randomised coffee trials. Basically, you say you want to take part in the coffee trial and we will randomly match you to somebody else somewhere in the world who is also taking part in this call for change agents, and then you have a cup of tea or coffee together.

You can do this virtually, Facetime, Skype, and a phone call, and you talk about whatever you want to talk about.

The coffee trial was invented by an innovation organisation called Nesta, and they found there were lots of silos in their organisation, and in week one of the experiment, they did a random coffee trial every week for 16 weeks. In week one, people were focused on their own silos. By week 16, what you can see is that people were really connecting and learning from each other.

Their write-up was called "How to create a culture of serendipity." The same is true for the school; there are lots of opportunities for serendipity.

All you have to do is email and say that you want to join it, and in the next four weeks, you have to have that conversation with the person that we matched you too.

So, our topic is resistance, and we will make the annotation tools available shortly. We have given you three choices.



When I meet with resistance at work, or if you are a patient leader or community leader, what do I do? Do I bring people together with different ideas and encourage the diversity and challenge? Do I initiate a conversation in the hope of understanding the other point of view? Or, am I right and I just had to persuade the resistance?

Jo, are you there? Can you hear me?

JOANNA HEMMING: Yes, I can hear you.

HELEN BEVAN: Unleash the annotation tools.

You should be able to see an arrow, so point on the one that is most like what you do. Let's see how we get on. We are not going to put this in the public domain and tell anybody, so it is good.

I think the most popular is the middle one, about having a conversation with the person who is resisting. Jo, can you take the annotation tool away? Great.

When we go onto the next one, don't start annotating until I say because I want everybody to be able to see the categories. If we put arrows before other people see them, we will have a problem.

So, what is the role you identify with most closely? Some of you actually fit all six roles. It is the one you identify with most closely. Are you somebody who uses the care system? Are you a campaigner primarily? Are you somebody who gives care? Are you an inquirer, searcher, a finder outer? Are you a chief listener or a change agent? You can only choose one of the six.

Jo, let the tools loose again.

What are you?

Lots of change agents, lots of enquiries, a few campaigners. A few people that see themselves primarily as users of the care system.

Great, thanks for joining in. We are even getting some painting as well.

OK, Jo, if you can take the tool away. Let's get into the heart of the session.

So, each of the modules… We will work on capabilities that are based on these categories. We will look at this idea, this principle of resistance from lots of different perspectives. We're going to think about the relationship between intent and impact, because for many of us, thinking about intention and impact is one of the most effective



ways of overcoming resistance to change.

We will get resilience in a special way, building on what Catherine was teaching us last week about mobilising and organising, and then finally, we will use a model which I come back to time and time again called the stages of change model, just to understand resistance and help people through change.

So, resistance. Technically, resistance is any force that stops or slows down movement. Resistance is a very important concept in the world of change. I will show you some data from McKinsey, so it must be right. This is data about leaders of organisational change programs, and why they fail to achieve their objectives.

This is interesting. This is reported, why did we fail to reach our objectives? The majority reason why was related to resistance to change, so at the bottom, 39% said that the main reason was employees resisting change, and 33% were saying that actually, the behaviours of our managers to not support change, which is a form of resistance to change as well.

So actually, if we are going to achieve successful outcomes, we need to focus on this topic.

I put this one in because this is how I feel sometimes. We are trying to make really great change happen that will make a difference for our customers or colleagues, and there are so many reasons not to change.

"We changed this in the radiology department and it didn't work. It is not in the business plan. There is no money or resources available. People will never buy into it." We are living in a world of lots of resistance, lots of no's and lots of difficulties. This is my favourite one. "This is really innovative, but we can't consider it as it has never been done before."

Everything about resistance, what matters more than anything is the mindset, the way we look and think about resilience.

I was going to read to a poem, because I find this very helpful. It is from the 16th century, a Spanish quatrain, and I will read the English version of it.

"In this world of many mazes, there is nothing false or true. All depends upon the hue of the glass through which one gazes."

The 16th century poets have a lot to teach us about resistance to change.

I think how we view and act on this instance depends on the perspective we have. To illustrate this, I wanted to bring back one of the approaches we had in module one.



Hopefully, everyone remembers we talked about old versus new power. We talk about old power being position, authority helped by few people, pushing down, you have to do this, it is the quality standard. We talk about new power being held by many, it is shared.

Going back to the poem, we looked at the issue of resistance to change and an old power and new power with perspective.

One of the things I must say as a change agent, it's very easy to say old power is wrong, new power is right, or old power is not as good as new power. But actually, we have to think of the world as both. We have to think of people coming to new power and holding old power as well.

When we come to talk about resistance in old and new power terms, we can think of change in old power being planned and managed through a rigourous process, it is managed by several work streams, and so on.

Very often, in old power, resistance to change happens because we see it as a force to overcome, resistance prevents change. So change agents have to work that out, manage and overcome it.

Very often, we put labels on resistors as deniers, laggers. But a lot of resistance to change comes from this old power mindset. A lot of management is about overcoming resistance to change, but there's not a lot about how to overcome this resistance to change. You look at that image in the middle of a very grumpy person, resistant to change.

But there are structural terms around these programs about resistance to change. We have timescales that we have to keep to. I took this image from a nice website from Sewell. It is nice to have a read of that.

What is the role of the change agent in this old power mindset? The role of the change agent is to recognise causes of resistance and address each one. If this is not done then the change would be much harder to implement successfully and may not succeed at all. It's about being aware of and addressing resistance in terms of the outcomes we are seeking.

Contrast that with a new power lens here of resistance to change. In a new power world, what we see is about how we say change being inconsistent, it is often emergent and hard to predict.

Change occurs from connections and interactions between different viewpoints and it shapes how people think of the world. So actually, we have to think of that as a consequence that is going to happen. Rather than fighting, we should embrace and welcome it.



So we can think, is your change program a cathedral or a bazaar? When we are trying to make transformations happen, the change process in the old power world is like a cathedral, trying to hold everything together, whereas in the new power world, it is like a bazaar, where everyone shares things.

I have a quote here from Harold Shermer, and he talks about resistance being the behaviour due to people missing the relevance of change. And our job as a change agent is to make the change relevant to people.

So, what other kinds of things we should be doing as change agents to roll with resistance in a new power mindset? There are lots of ways we can do this.

I have picked up this quote by Peggy Holman. She is saying what we should do is to create the opportunities for talking about transformation by asking the kinds of questions that are focused on future possibilities and inviting diversity, and being welcoming.

We should be sharing people's views and building on each other's ideas. To be built into what we talked about the module one about the importance of diversity, when you bring diverse people together, they will consistently create better things than just experts.

The third way she gives to change the world is to find meaning in the change. I have a good example here of the health-care system, where we bring a whole group of diverse people together. I am aware we are arguing and discussing, but it brings better outcomes.

And the reality is that, actually, with resistance, giving people facts and data doesn't change people's minds. I will give you a link to this article that has really good evidence. It was published last week in the 'New Yorker'. It is called 'Why facts don't change our minds'.

It argues that the more we give people facts and data, the more it will often reinforce their contrary view. So just trying to overcome resistance by giving people facts and data will not really work.

One of the things that Mark Jaben argues is behind the science of resistance. He has four things that you have to do. If you go to the links and resources, about four points down, there is this resource to watch.

Mark Jaben has done some work about resistance to change. He has some points about what not to do with resistance to change. A lot of people see the outcome, this is our mission. They create a lot of options, and we involve a lot of people at the point when we are making decisions. We will get you to buy in and we will consult you about the different choices.



What Mark says is that if we do it that way, we are bound to get resistance. Actually, this is the way we do it the most.

He says what we should do is when we identify the issues, we need to be engaging people straight away. We need to make the desired outcome into a shared outcome, which means we intervene at a much earlier stage. So that people are buying in - no, not buying in. People are co-creating and creating a shared outcome, and they are part of the options and choice.

One of the things that Mark talks about what is the issue of buy-in. One of the things he talks about is that trying to shape buy-in is wrong. We actually need investors early on in this stage.

One of the models I find most helpful when it comes to thinking about resistance to change is this one. It is about understanding impact and content, because very often, I will go to talk to a colleague in my team about a change I want to bring about.

My intent is very honourable and good. But the impact it has on other person is really negative. It was not my intent to create a negative impact. That was the reality because of an awareness gap.

Here is what is written about me. "Helen is intent in the team, was to give people quick solutions, help them to do their work faster and get onto the next problem at hand." What we get to hear is that my intent was a really good intent - to help other people.

However, the impact of my behaviour that was intended was that people did not know how to solve their own problems. So my actions had a really negative impact on people in the team because my style was impeding their development.

So, all the time when you are in a situation with another person and things are not working the way you want, even though your intent is good, I think it's really important that we are stopping and checking with other people, that other people understand our intent and we understand the impact on them.

I think this is really helpful. "Stop talking at me. Start talking to me."

I'm just going to take a break here and take a breath and hear from our colleagues in the chat room.

Have we unmuted? I can see Kate has. And Kathryn is going to join in as well.

KATE POUND: It has been a great presentation and it's a great opportunity. It's great to see so many people joining in around the world.



I think it's a good point about finding out about the own person's experience. And Helen's point about getting off her high horse was a good point to have.

There is a lot of debate - and maybe we can consider it in the chatroom afterwards - around how we can change, and go on a journey with other people.

It is interesting to think about shareholders, so I really think that is something that a lot of people have been reflecting about today.

Kathryn, would you like to add to this conversation?

KATHRYN: There are lots of 'Doctor Who' references, which is fun. Lots of people making contact with their RCT partners as well, which is great to see.

There was some scepticism around the suggestion that data and facts don't change people's minds. It would be good to see some more comments on that.

Finally, intent versus impact resonated beautifully with a lot of people.

HELEN BEVAN: Thank you so much. Ollie and Louis, what is happening on Twitter?

LOUIS: We have got some really good conversations happening on Twitter. Kate Emery says that we don't need buy-in, we need investment. Lots of shares of that and similar posts.

From John Cologny, develop shared interests and outcomes. This harks back to the realistic conflict resolution theory.

HELEN BEVAN: Fantastic. Thanks, Louis.

A couple of things there. I completely take the pushback around process junkies, around management approaches. The key to this is that we need both. We need well organised, well-managed projects, but that is not enough. It is about getting the right conversations and the right combinations in meaningful ways.

With regard to data, does this shift people in terms of resistance? People are much more likely to change their mind or to be moved into action, or to be mobilised into change because we make an emotional or value-based connection, not because we show them facts.



Ideally, we want the best of both worlds. We want to be able to make a compelling story that connects to emotions, but we absolutely need both.

So, thank you for your comments and conversations. Please keep them coming.

So, I want to say something around resilience. A lot of people can talk about this much better than I can, so what I would like to do is to actually pick a framework and theme that Kathryn started last week, and if you remember, she talked about research that was being done in the USA by a researcher called Harry Han, which was understanding which kinds of activists and change agents deliver the most change.

I decided to pick this back up, because for me, when we talk about the resilience of a change agent, actually, much of our resistance comes when we are unable to connect up with other people like us, so how might we use that framework to think about organising and mobilising as a way of building resilience as a change agent?

What kinds of activists are most successful and delivering change? This was based on research with activists in the USA, but it is equally applicable to us here.

The first is lone wolves. They are very expert and they have a lot of information to give. They contribute to consultation, and very often, as change agents, we end up being lone wolves. We contribute because we have a lot of expertise around change, a lot of use experience.

I will put this quote here which comes from Annette McKinnon. When it comes to patient activists, the way that we get streamed into subcommittees is in order to tick the right box. Why is it that when we are asked to be participating is within a frame that has been predetermined by the organisation? When will we see co-design of new policies, and ultimately, co-production?

One thing I would say is that what happens to assess change agents is that we go into the role of lone wolves, really expert, valued for our contribution, but on our own, and what Kathyrn also talked about last week were different types of agents.

Mobilisers, people who can call on lots of people to contribute. The third kind of activists are the organisers. What they do is build power by growing leaders. They find people in the organisation, systems and communities, and trained them in a distributed network. They build a community and protect its strength.

What we saw was, actually, lone wolves are the least effective kind of change agent. Although they may play a key role, they are on their own. The most effective kinds of change agents are combination of mobilisers and organisers. When it comes to resilience, we have got to find ways to move ourselves from being the useful lone wolf to mobilising and organising.



I have a lot of connection with Jonkoping in Sweden, a most amazing community, and they have spent more than a decade building leaders in the community. When I get to meet people, we really see it. There is a massive investment in building leaders - not just formal leaders, but leaders of health and care right across the system.

There is a new report coming out next week in Sweden, and one of the ideas is about the future of health and care in Sweden. One idea coming out is the idea of unlicensed patient.

Sometimes, when we talk about social movements, we think it is about getting loads of people engaged, but that is not where the energy comes from. It comes from the distributed leadership, so who are the people that we can be connecting with, and how can we build our own dealership system? I think that is one of the most important ways that we can build resilience.

So, I come on now to the final topic of module three, and people often say to me, "What are some really practical ways to think about resilience and engaging people with change?"

I have worked with hundreds of different models, and an appropriate handful that, over the last 20 years, I come back to time and time again. The thing about models, the statistician George Box says this, "All models are wrong but some are useful."

This is a model that I use often in health and care, and I think many of you will notice this model already. So, this is the model, the stages of change model, or its proper title, the trans-theoretical model of behaviour change. This comes from Prochaska, Di-Clemente and Norcross.

This is used extensively in the health care system to support behaviour change, and very many colleagues in health and care have already used this, particularly around health related behaviours.

The most widely used reason for this model is around smoking cessation, but there are lots others. It is used in supporting people who are victims of domestic violence, medication compliance and so on. And the great thing about this model is it also works for organisational and service change. When we think back to that lovely 16th century Spanish poem, it gives us a perspective for thinking about resistance to change.

So, let's use an example. Smoking cessation is the most common use of this model. How it works is we have to work out what stage of change somebody is at. We then have to plan a change intervention based on the stage that they are at.

There are five stages. It starts at pre-contemplation, where somebody does not recognise the problem and is not interested. This goes right the way through to taking action and maintenance.



Let's illustrate this by using the example of smoking. When somebody is pre-contemplative, they don't care that their smoking is a problem and have no intention to quit. They are not even contemplating changing.

The next stage is contemplation. When I get to this stage, I am starting think about changing. I recognise my smoking is a problem, and I do want to stop but I have no plans yet. When somebody is contemplative, they are yoyo-ing. When they want to give up, then nextm they don't.

Next is preparation. Now they have decided to give up smoking on 1 April. They have got their nicotine patches and are going to the NHS service, and they are getting ready to give up on 1 April.

The next stage is action. When I get to stage four, I have stopped smoking. Fantastic.

The final stage is maintenance and this is continuing to not smoke. Sometimes I go to the pub and have some wine and think that I would like to smoke, but I am managing not to.

So, that is the model.

So, let's go back and think about this. Looking at those five stages, which stage do most change activities in the healthcare system actually focus on? When you think of change initiatives, what stage do they focus on? Will you put some numbers in the chat box? Do they focus on people who are pre-contemplative or do they focus on action or maintenance?

What do you think? Does anybody want to put a number in the chat box? Have we got any?

So, Kate. You seen some numbers?

KATE POUND: Yes, four it is the one that is coming up most.

HELEN BEVAN: OK. Four is coming up the most.

So, what stage are most people actually at? We are trying to get people to stop smoking. What is the stage most people are actually that?

KATE POUND: Helen, number one is coming up the most.

HELEN BEVAN:



Yes, I absolutely agree with that. Very often, with patient care, we are focusing on quitting smoking. But most people are actually at stage one, precontemplation.

When we want someone to stop smoking, what we are doing all the time in the healthcare system is trying to get people to pre-contemplating, or contemplating, at best, to try to take action.

Looking at those five stages, which is the stage that people are most likely to need help, but it is likely to be taken away?

KATE POUND: Interestingly, Helen, we get a range of options for that. Five, two and three are coming up for that.

HELEN BEVAN: Yes, I would say five. We put in a new process for system or care, and as soon as we have done that, we take the people away that have been supporting it and are leaving the people to wobble.

Yet what we see time and time again for change agents in health and care is that 90% of the tools available designed for the action stage are taken away after implementation.

This is an example of the WHO surgical safety checklist. It was designed for action. This was mandated through targets. But even though it was compelling for change, people were often not contemplating change, and it often missed the target.

I want to show you this, why checklists fail. It gives a quote here, "When surgeons weren't on-board and you were told, "Shut up and let's get on with it."" That is classic stage four. And 34% said that the checklist was inappropriate or illogical.

Another report published here by the University of Leicester, 'Optimising surgical safety checklist implementation'. What is important here is highlighted in the blue here. What we need to do.

I think the last one at the bottom is very important. In hospitals, without adequate resources and efficient systems, simply requiring the checklist to be used might not only fail to improve patient safety but might also introduce new risks for staff and patients.

This is the exact opposite of what the checklist was designed to achieve. In many hospitals in the UK, I think that they target the stage of action, stage four.

So we tend to try to get people to take action on stage four, whereas the reality is that people are only at stage one or two. We find that we tend to lower our ambitions for improvement. We focus our energies on those that are already in action stage. We put negative labels on those that are not yet ready for action.



I think this quote from George Bernard Shaw that says the single biggest problem in communication is the illusion that it has taken place really shows that we need to hear people's point of view and perspective.

What should we be doing? We need to be listening and understanding and appreciating people's starting point and evaluating interests. This whole idea of the module, let's roll with resistance. Don't argue against it. Again, the idea about facts, that arguing to people with facts will not change their views.

Be curious and accepting. Encourage elaboration of their resistance. What would make it so hard to do? And the data from this study shows that the problem is not that they don't want to change, but that they don't see what is meaningful about it. What would make it meaningful?

We see that the whole table of the five stages and what it shows in the study guide is having an understanding of where someone is in the stages, 1 to 5, is very helpful. What we should do as change agents that is very helpful when we try to make change happen is, let's understand where we are at.

And let's not try to force them to make action, stage four. If they are at stage one, we should not be focusing on trying to get them to take action. We should try to get them to contemplate change. The goal as a change agent is not to make someone as a pre-contemplater change immediately, but to help them move to contemplation.

I think the final thing to say is that most people are not resistant for the sake of being resistant. It's just that they don't understand how to go about the process of change.

But I think there are some people are so sceptical and cynical about change, that is never going to happen. I think as change agents, we need to put our energy into those people and their potential to change. Going back to what Mark was saying, actually intervening with people at the earlier stages, rather than at the very end, trying to get them to buy in.

But for those people that are never going to change, we need to walk away. I quite like this Cherokee proverb. "If your horse dies, get off it." There are some people that are just never going to engage in the change.

What I'm going to do is leave that quote by George Bernard Shaw up there. I hope this has been a good module and hope it has stimulated many ideas.

Let's get into Twitter and our chat. Kate, is there anything you would like to talk about?

KATE POUND: This has been a great session and I think it's been fantastic. There's been a lot of



content around change agents and how we think about change programs, and how we engage people.

Something that comes out of the session for me is that I think we really need to see how we listen to others and understand them, rather than jumping in.

Thanks, Helen. It's been great.

HELEN BEVAN: Thanks, Kate. And what about you, Kathryn?

KATHRYN: Thanks, Helen. It has been a really good session.

HELEN BEVAN: Thanks. What about you, Ollie or Louis?

LOUIS: There has been a lot of conversation on Twitter. There's a lot of people active. There are some from the health organisation as well.

HELEN BEVAN: Thanks.

I think when we think about this, there are a lot of people that are resistant because they don't actually understand it. Let's think about helping them.

I think at this stage, I will hand over to Ollie and head into the breakout room. I hope the next session will be great. And for those of you that are staying, if you would like to head over to the breakout room, Ollie will give an explanation.

Thanks, Ollie.

OLLIE: So, what happens next, if you have pre-registered with a breakout room, you will be given a number and you can transfer there.

If you would like to have a conversation, what we will do is offer a separate phone conference that you can join. You put the number on the screen, and our recommendation is that if you are unable to join the breakout room, you dial that number which is 0800 917 1950. Dial the number and join in the conversation.

Kate will be leading this, but it allows you to have a good discussion, and everyone else, if you have joined one of the breakout rooms by putting your number in beforehand, you can join that room.



For everyone else, we will invite to join the phone conference or lead the session, and we will see you next week.

If you are joining the breakout room, just to remind you, we had some good conversations last week, and if you get stuck, you can press the ask for help button. Your facilitator will be in the room and can be identified by the symbol next to them.

Once again, we have seen instances where screen share appears, so what we would suggest is that you close the windows before you go into the breakout room.

So, without further ado, I think we will press the button and you can join the breakout rooms.


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Healthcare

Module 3 transcript - School for Change Agents