You cannot plan transformation like a project (Bushe 2013) ….some thinking on grounded change


Over the past year I have been working on how the field of OD can help us with the challenges we face in health and care. This blog was actually written as a paper (so it is rather longer than normal), however a number of people have asked me to share it via my blog so here goes ….

This paper aims to help us consider new era approaches to the way we lead and nudge change in the 21st century health and care system. It focuses upon the ideas presented within the field of Organisation Development. I hope it will help practitioners consider how we focus on improving the 70% failure rate for change programmes

I have worked with change in our health service for over 30 years. Starting my career as a Nursing Assistant I found that ‘tricky’ change became a theme for me.

In the mid 1990’s I undertook a postgraduate degree in Change and Organisation Development which transformed forever my view of what ‘good change’ looked like . The classic text of Cummings and Worley ( 2001 ) clearly identified the behavioural scientist’s perspective on why change is all about people. The eclectic field of Organisation Development (OD) emerged in the 50’s and 60’s with its roots in the emancipatory movements in the USA (for a brief and readable account of the origins of the field I refer you to Chung- Judge and Holbeche , 2011). I personally define OD as “business improvement through people”, this definition seems to cut through the arguments about what is and what is not OD. For me OD is about action and improvement and its founding principles include :

  • The seeking of social justice
  • Ensuring equality of voice
  • Enabling diverse views to be considered and used
  • Action research as a primary methodology
  • Improvement driven by data

All of the above are vitally important for our current agenda. We see in Simon Steven’s “ Forward View” a focus on the NHS and care system as a “a more activist agent of health-related social change” (NHS England, 2014 , pg 10). The vision requires us to work differently , differently with others in the system and differently within ourselves. This is an exciting and big ask and it is one which needs us to significantly change our approach to the stewardship of change and the field of OD can help us.

In the early 90’s most change and improvement work was viewed via the scientific lens by people searching for the ‘single truth’ that would solve all the issues we faced. This view is rooted in the industrial and mechanical view of organisational life. It is a view which, if taken in isolation, can ignore the social and human reality of the world of work. I am of the opinion that this view of organisational life is outdated in the social era and that we need to develop our mind-sets and our change practices to include the human reality of working in ‘the care business’.

The challenge in the 21st Century is that the world has changed and the problems we face are multi-dimensional and may not lend themselves solely (or at all) to reductionist, mechanistic solutions. Such issues present as ‘challenging problems’ which Rittel and Webber (1973) define as socially complex and often, but not always, technically complex too. By focusing upon applying only diagnostic approaches to such problems it is likely that we will continue to contribute to the seemly unchanging 70% failure rate.


We cannot afford to continue to invest our efforts in approaches which are likely to deliver 70% failure. If we are to improve on this rate then we must focus upon changing our mind-sets as well as the processes of health and care delivery. Socially complex change requires adaption, not just better technical solutions (Linsky and Heifetz 2002)

Since the summer of 2014 I have been focusing upon how we compliment the dominant diagnostic approaches to change management with new era thinking. A small group of us have been working with models of change based on Dialogic OD. We have concluded that the term dialogic is in itself problematic and is not meaningful in the NHS. We have begun to translate the work of dialogic as ‘grounded change’. Grounded because it emerges from the field of practice (from the ground) and front line.

Grounded change requires us to use both our left and right brain and to engage our emotional energy to find approaches that move us forward. Change is never just about the logic of a situation and is most often about how people feel. The current context of our health and care system demands that we move beyond the reductionist approaches of the industrial era and think about how we bring mind, body and spirit together to mobilise people to action. The table below provides a simple view of both diagnostic and grounded approaches to change:

A Diagnostic theory of change A Grounded theory of  change
Reductionist Expansive
Seeking a single solution or truth of a situation Seeking meaning and sense making   within a situation
Based on compliance Building commitment

The grounded approach is about the reality of situations. It is not about reducing problems to A+B must = C, but accepting that socially and technically complex problems, those with many stakeholders require a different approach if improvement is to be achieved. Grounded change is built upon the premise that sense-making and co-creation of meaning in a community comes BEFORE the creation of solutions. This approach builds emotional and personal commitment. It mobilizes people to action.

Over the last 12 years I have been working on approaches to change which combine working on presenting issues (which some may call diagnosis) with approaches which require people to sit together and create new ways of working together (grounded change). Such co-creation is about using the power and resources of all the people involved in a situation or community, to change things for the better. Over the last decade in my work I have led a team to develop and test how such approaches can help us to work with ‘teams in difficulty’ (Conner and Stabler 2009) and how to design new ways of supporting teams which seem to be stuck in a unhelpful and unhealthy team dynamic (Craig and Moore 2015 , publication pending). All of this work has been developed using a framework of grounded or dialogic OD.

Designing change interventions based upon shared understanding can result in change and movement. Such models are founded upon the assumption that:

“change occurs when the day-to-day thinking of the community members have altered their  decisions and actions, which leads to a change in culture” (Bushe 2013).

The intent of such an approach is to create the conditions within a community which support people to stimulate and emerge practice which acts as the basis for experimentation and moving the issue forward. As this co creation takes place the whole community is changed, in that it moves towards what it aspires to be and do. Key here is the idea of motion and the collective movement towards something of value.

We can see when we are working in the arena of complex social issues we are not in the arena of project management. Bushe (2013 ) advises “You cannot plan transformation like a project” as the motivating forces for such work are usually connected to a big concern or challenge from which the leaders and the community bring all their energy and resources. This is not to say that projects, tasks and improvement work will not be done, they absolutely will be. However they will arise from the dialogue and sense-making of the whole community, rather than a single sponsor, a project manager and small group of representatives.

Grounded approaches are based on meaning-making, the creation of collective wisdom and action, they are not about problem solving per se they are about solution finding. Key in the philosophical origins of this work is the idea of the triad of logic, action, and spirit (mind / body / spirit) ( Turullois- Bonilla 2012).


It is about bringing our whole selves to the work of change, not denying emotional reactions or separating them off as something less important than the processing power of our brains. We need both. This is one of the reasons why the social movement approach to large-scale change has been so successful, it taps into our emotional responses and gets us active about things we care about, if you doubt this consider the impact Stephen Sutton had in the last months of his life ( and check out the impact Tommy Whitelaw is having as a social activist for better dementia care ( These people exemplify grounded approaches to change, they are transformative. Their work and legacies are inspirational as they reach out to us emotionally as well as logically.

So what is the DOING of grounded change?

Like most people in the field of change management and OD I am a pragmatist, I like to be in the thick of things.


I am a nurse by vocation and my reason for being is to make things better. So as ever I am interested, as are most people, in the ‘do’ of this grounded approach. Bushe (2013 ) lists over 20 tools and techniques, things change agents need to learn about and practice to apply grounded approaches. I recently spoke about this work to a colleague @mikechitty who reminded me we have been doing grounded or dialogic work for over 20 years and he shared with me his curation of dialogic tools and techniques. We must make use of what we already know.

The practices of grounded change are many and varied and are -known to us all. They centre on human connection through purposeful conversation and dialogue with the intent of finding solutions to challenging and often historic issues. Earlier this year NHSIQ published its white paper (NHSIQ 2014) which details change in the new era and sets out a vision for approaches to achieve change. At an organisation or system level moving towards using a grounded theory of change requires the leaders to enable the 5 key practices cited in the white paper:

  • Find, develop and enable your activists and radicals
  • Build relationship which support change from the edge
  • Build the story telling capability of the people , to connect people around their purpose and passion
  • Move toward the curation of knowledge and know-how ( rather than the storage of knowledge)
  • Building bridges which create new possibilities and new opportunities

Summary :

So as we work our way forward trying to improve our success rate with change in health and care we must address the issues raised in this paper. Both the heart and the head of change are vitally important if we are to rise to the challenges before us. We must never lose sight of the importance of the work we do for the people we serve and I leave the final thought to be offered by Sokoloff (2006)…..

“People come to healthcare providers to be healed and comforted.

They come willing to entrust their well-being or that of their family members to us, to strangers.

This is a unique and sacred relationship, far different than what we experience in other day to day business transactions.

Healthcare is not contrary to what some may think, just another business”

References :

  1. Bushe G. R, 2013 , Dialogic OD : A Theory of Practice, OD Practitioner, Vol 45 No 1, pp 11 – 17
  2. Chung- Judge M. and L. Holbeche, 2011 , Organization Development : A practitioner’s guide for OD and HR, London, Kogan Page
  3. Conner M., Stabler A., 2009, “Sharing our learning : Dealing with the hidden side of organisational life supporting teams and clinicians in difficulty”, A practitioner report prepared by South Tees Hospitals NHS Foundation Trust (this a practitioner paper , which was published locally under my former name Conner. Please contact me if you would like a copy)
  4. Cummings and Worley G. T., C. G., 2001, ( 7th Edition ) Organization Development and Change, UK, South-Western College Publishing ( 9th edition available)
  5. Linsky M., Heifetz R. A, 2002, Leadership on the Line: Staying Alive Through the Dangers of Leading ,Boston , Harvard Business School Press
  6. NHS England 2014 , Five Year Forward View ,
  7. NHSIQ ( Firman and Bevan ), 2014 , White Paper: The new era of thinking and practice in change and transformation A call to action for leaders of health and care
  8. Rittel J., Webber M>, 1973, Dliemmas in a General Theory of Causal Factors, Planning and Policy Science, Vol 4, No 2, June , pp 55 – 69
  9. Turullois-Bonilla R, 2012, Dialogics : Fixing the world with the triad of body, mind and spirit, Published by Dialogics , ISBN 978-0-9761653-4-7.

*images sourced via RF123

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