For the past few weeks I have been helping co-ordinate our COVID-19 response in our NHS organisation which has been a huge task and a real emotional rollercoaster. The pace and scale of change in our organisation over the past weeks has been astounding.

The pace and scale of change in our organisation over the past weeks has been astounding

In my organisation, a mental health trust, we are behaving and working differently with respect to change. Our services have been re-designed to face the challenge of staffing shortages, new physical health needs and mental health effects of the COVID-19 pandemic. It took us 10 days from conception to opening a 24 hour Mental Health Emergency Department, we reduced bed occupancy from over 100% to less than 85% (previously a pipe-dream) and introduced virtual clinics and home working. We are far from unique and up and down the country transformation of all types of services are happening. All of this happened without a single business case.

This has made me ask the question, “What has changed to make change to happen so quickly?”

Firstly, it is important to say that none of the changes have been perfect. It is not clear whether what’s happened is offering a better experience for our communities and we do not know how safe the changes are. What is true, however, is that the resistance to change that seemed to burden those of us wanting to make change happen has all but vanished.

We have to acknowledge that much of the change is driven by fear and anxiety and it is not a sustainable situation

Often trying to get change to happen can feel like pushing against an immovable object and inertia can be a great demotivator.

Over the past weeks, I have experienced times of working with almost no resistance, like I was working in a gravity-free space, where a gentle force applied to change something accelerates quickly with the support from others. For anyone familiar with the work of Ralph Stacey and complex adaptive systems, the amplifiers of change ideas in networks have been very powerful and the inhibitory networks seem to be slumbering. I thought it was worth thinking about the shift in mind-set that has occurred.

John Kotter described the need to create a sense of urgency in order for transformation to happen. For many organisations, an existential crisis is needed. I think we can agree that we all share this sense of urgency and impending crisis. We have to acknowledge that much of the change is driven by fear and anxiety and it is not a sustainable situation. The risks of burn-out and psychological trauma are clear. Thankfully, awareness of staff wellbeing has been high on the agenda in many places.

Reflecting on some of these changes in my own work culture here are some thoughts:

1. The Burden of Assurance and Governance has reduced. Many involved in QI feel strongly that the balance between assurance and improvement is tilted heavily towards assurance which can often be a real hindrance to change and a culture heavy on assurance can stifle creativity and motivation. Over the past weeks’ performance scrutiny, attendance at assurance meeting (which most people are loathe to attend and at least in my context do little to improve our system) and commissioner demands, which can cause discord, have disappeared. Released from some of the unnecessary scrutiny and burden people feel more confident and empowered to make change happen
2. Reversal of accountability. In Crossing the Quality Chasm (2001) Don Berwick and others described four levels of healthcare – from patient/community/microsystem/organisation/environment – and I remember him expressing the view that we needed to shift the direction of accountability towards the patient rather than up-the-chain of command within the organisation. I think in some ways this has happened. I have noticed many examples of senior leadership shifting from directing/demanding, to asking “how can I help?” and working to solve problems or overcome obstacles. As in point one, this creates psychological safety, a key ingredient in the psychology of change.
3. Shared purpose. There is an undeniable sense that we are in this together and people are working hard for each other and looking out for one another. I think the narrative around what is happening is so clear and undeniable and many people have reconnected with their own sense of purpose in what they do and why they do it. It also probably makes the fear and anxiety more manageable.

I am not trying to paint an overly positive picture. The pressures on our staff at all levels are enormous. But change is happening fast and people are being creative and innovative at a level I have never seen before. We would do well to try and understand some of the psychology behind this and how we can harness this in the future, hopefully not in the shadow of a horrible pandemic.

Find out more about Psychology 4 Improvement via the Q Exchange project page. 

You can also join the Psychology 4 Improvement Special Interest Group to stay up to date on the project’s work.