Posted by: ayrshirehealth | June 15, 2012

History revisited – learning to change by @craigwhitephd

Personal Freedom

Recently I have been dipping into the social psychology literature to support my understanding of the complexities of organizational behavior and relationships, in particular work on ‘restrictions to personal freedom’.    I have been pondering this notion and how it can be applied to users of health services, students, researchers and staff of healthcare and academic institutions.  Here are three recent examples noted from my personal and professional life:

  • As a relative – freedom to be with someone when they are in hospital because ‘’the system” says visiting is only at 7pm (will the NHS ever take the brave step of open visiting ?)
  • As an Assistant Director, freedom to express concerns about professional ‘silos’
  • As a Professor, freedom to change my mind about an academic collaboration decision that could be inconsistent with my personal values

I recently read an interesting article on this topic by North American researchers (Laurin, Kay and Fitzsimons, 2012) The study concluded that when a restriction (or change) is absolutely certain to come into effect people tended to consider the situation in a positive  light (to rationalize it).   When participants viewed the restrictions as having a small chance of being implemented then these were viewed less favourably and the status quo position was valued   even more (participants displayed ‘reactance’ to it).

Collective Commitment to Change 

In my career so far, I have had the privilege of working with many inspirational nurses, medical staff, pharmacists, managers, academics, civil servants and support staff. This has often been on change initiatives to introduce new approaches or identify new knowledge. The most rewarding of these roles has been when I have been working as part of a team where the changes required are absolutely certain to come into effect (usually due to strong, consistent and authentic leadership); when the team has been open to developing and discussing collective insights and where there is a strong sense of valuing the diversity of ideas that are focused around an absolute clear commitment that change must occur – we have all understood what the right thing to do is.


The least rewarding and most demoralising times in my career to date have been, when there have been ambiguous or contradictory directions from leadership or when colleagues have not believed in the change message. Laurin and her colleagues note that “…. when there is a chance, even a slim one that the restriction will not come into effect, people respond negatively to it and exaggerate the importance they attach to the restricted freedom’ (p. 209).   It can be tough going when the climate for change (Kotter, 1996)  is not present, particularly when culture and climate in organizations and teams is so closely associated with clinical outcomes, morale, staff turnover, innovation and productivity.

  Self Study as a Habit

Bohmer (2011) has stated that one of the four habits of high performing healthcare organizations is          “self-study,…….these organizations examine positive and negative deviance in their own care and outcomes, seeking new insights and better outcomes for their patients” (p.2046).     Self-study can be challenging though. What if examining “negative deviance” (to use Bohmer’s term) creates strong emotions ?   Florence Nightingale once said “How little can be done under the spirit of fear”. Most of us will be able to identify with how the fear of an inspection, test, exam or not having the answer to a challenging question stifles confidence, creativity and learning.

Is it the self-study, the inspection, test or question that is driving the fear or inhibiting positive response to change – could it be that it is the wider culture, the ‘climate’ that is playing a greater part in the generation of fear or negative reaction ?   If an organisation does not encourage self-study , or ‘allows’ perceptions to be held that change and new behaviours are ‘optional extras’ or apply to some staff and not others then, according to Laurin’s research, the status quo will become valued even more – behaviours will resonate towards this position and change will not happen.      If there is not a clear commitment or desire to stand up for the right thing (Bennis, 2003) then changes will not be embraced and energies will tend to be devoted to the maintenance of the status quo, and not to understanding, studying or standing up for what is right.

Ask yourself

Changes can be difficult when they threaten personal freedoms, particularly when this happens without a collective and absolute commitment to a climate that supports change and self-study.  Change is exciting and empowering when visions are clear, culture is supportive and self-study is encouraged.     Change is inevitable across our health and social care organisations and within academic institutions.

If you are part of this change – ask yourself

  • Which of your personal freedoms does this change threaten most ?
  • Do you think you will ‘rationalize’ or ‘react’ ?
  • Is this because this is your pattern or your organisation’s culture or both ?
  • Could an approach based on Bohmer’s notion of self-study help you embrace and be part of creating the sort of absolute commitment to change in your organisation that energises and empowers people ?


Bennis ,W (2003) ‘On Becoming a Leader’, Cambridge, Perseus Publishing

Bohmer, R.M.J. (2011). ‘The Four Habits of High-Value Health Care Organisations’, New England Journal of Medicine, 365:22, 2045-2047.

Kotter, John. P (1996). Leading Change. Harvard Business School Press

Laurin, K, Kay, A.C. and Fitzsimons, G.J. (2012). ‘Reactance Versus Rationalisation: Divergent Responses to Policies That Constrain Freedom’, Psychological Science, 23(2), 205-209.

Craig A. White (@craigwhitephd) is Assistant Director in the Executive Medical Directorate of NHS Ayrshire and Arran (@nhsaaa) and Professor in the Faculty of Education, Health and Social Sciences at the University of the West of Scotland (@uwshealth).

Next week’s blog is by @suzi_hannah and will consider the benefits of a collaborative approach to influence clinical improvement.



  1. Nice blog, nice picture and you are right about visiting times completely ridiculous

    • Thanks for the feedback, much appreciated.

  2. Enjoyed reading your insight & thoughts about change. I find change a fascinating subject and the reactions of those it affects…. Within the bigger wheel of the change process there has to be smaller cogs to react to the resistance that is inevitable, ( sub units of change) I think. Love Kotter, find him just so sensible
    Elaine Headley

    • Thank you Elaine. Kotter’s book I tend to re-visit regularly as so much of his work has applicability with the challenges we all face daily in relation to delivering safe, effective, efficient and person centred care.

      • i agree, he is current, original and fluid in his thoughts and opinions. I would love one day to hear him speak, he;s such an inspiring character

  3. oh yes, change is so complex and throw in incentives, motivations and ‘interest’ or ability of others to have the desire or energy for change, then times can be tough. There’s something about ‘chunking’ and making individuals see that they can impact. If you’re free on wednesday morning, be good to come along to lecture theatre at Ayr hospital, 9.30 to observe and comment on this process in action. Good for you for airing

    • Thanks Lesley for the comment. Being able to present the change vision clearly in ways that people can engage with is, as you say, so important. Unfortunately, I am not free on Wednesday for whatever is planned, though perhaps you and others could share your thoughts and how it relates to the concepts in my blog entry ? Craig

  4. Thanks for sharing, this is an area I am hugely interested in, your points resonate. Engaging leadership and organisational culture so crucial across the system to empower individuals to commit to change.

    • Dear Lynne, thank you for your comments. I have been pleased with the response since Friday from people who have said that the content has triggered some helpful reflection – this was what I had hoped for. Best wishes, Craig

  5. Can I ask, interference ( negative freedom) and the freedom to act( positive freedom) , when does one, encroach on the other, if indeed they do? Is this a fundamental schism that lies between them and how does that influence the change process within self or organisation?
    Surely the decision of which path we take when meet a fork in the road will be determined, or is determined by the quality of our human experience?

    • I’ve asked Craig to also respond. My view, for what its worth, is that the positive empowerment is limited by belief, the lack of self reflection and therefore growth – I won’t be allowed to do it, ergo there is no point in taking empowerment (positive freedom). From the blog, it suggests to me that where there is scope ‘not to believe’ or where the sat-nav (leader) gives unclear or contradictory directions that followers opt to stay where they are i.e. status quo. It’s a place they know, even a negative place, but they know what to expect. Grasping hold of positive freedom, the ability to affect change is measured against their belief it ‘might’ fail – rather than a belief it ‘might’ succeed. I’m not sure the fork in the road, or the road less travelled, is always determined by past human engagement – that would suggest an inability to change as the past would always rule the future – it plays a role in decision making, but so also does vision, self belief, knowledge, skill etc. Just a few thoughts – thanks for the question: lets see Craig’s thoughts on it. Derek

      • hi, thanks for this, i see craig has replied too– i need to digest what you have both said, i’m not quite getting my head round this concept, but i will!

  6. Thanks for the question. The actions of a person could be perceived as ‘interference’ by one person, while another perceives the same actions as providing ‘freedom to act’. If someone is familiar with a particular approach to their work and a decision is made that this needs to change, some will experience this decision as interfering with their freedom to unconditionally determine how and when changes to their work environment occurs; other people who believe that they should engage positively and constructively with change won’t experience the changed working practice as ‘interference’ but will take this as a sign of freedom to influence a changing environment. My points for reflection in the blog were the extent to which our reactions to change are linked with – our perception of the way in which personally salient issues are being influenced, the extent to which this is hard-wired as a ‘trait’ that always manifests itself and the extent to which this is influenced by the culture and climate of the organisation within which the changes are happening (and of course the implication that there are complex inter-relationships between all of this and all of those involved with the change). This may pose more questions than answers, though if it does then I have achieved the goal of the blog – to provide a frame of reference against which to think about the issues in relation to ourselves and the organisations that we work in/with. Organisations that do not promote the exploration of negative and positives, seeking insights to continuously improve are, in my view, less likely to foster a climate where change proposals are viewed as threats to valued personal freedoms – people will be clear about the collective aims and focus on devoting time and energy on how to collectively deliver using the range of experiences and skills available; not ‘reacting’ to the change by questioning the need for it, ‘playing out’ or managing the emotional reactance that is being experienced. Does this help ? Craig

  7. thanks for this craig, i’ll need to digest what you’ve said & yip knowing what i’m like i will come back with more questions

    • Hi Craig,
      Now I’m off the vampire/graveyard shift, I’ve got s few more questions!
      Am I right in thinking that perception of another’s actions will provide a polarisation of concepts? Can interference be compared with the feelings of restriction, enforcement of change resulting in loss of control creating a negative experience? Conversely the freedom to act facilitates opportunity, openness, participation, control /empowerment creating a positive experience?
      Thinking on personal salient issues being influenced, does this subliminally change our perception? If a trait is inherent then those restrictors/passives or one’s with negative experience are unlikely to change themselves? Kotter suggests that those who are passive in a team will be destructful to the change process and should be removed, do you think this is right. Are the inhibitors wrong, are the receptors right?
      I believe lack of reflection only acts as a inhibitor to move forward, it prevents learning, it prevents progress. If organisations, or self are to survive then change must be embraced? Darwin identified with this when he stated that it wasn’t really the survival of the fittest that would survive, but those most adaptable to change.
      Sorry if this doesn’t make much sense, I think I have a strange way in processing thought… hope it make a molecule of sense

  8. […] on the ability of the organization to ‘self-study’ as described by @Craigwhitephd June15 #ayrshirehealth […]

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