Kurt Lewin and changing practice

Imagine you’ve agreed a new way of handing over when the resus team changes. You’ve explained it at teaching, people seem to like it, and the prompt is ready. Two weeks later some colleagues are using it, some have never seen it, and one senior clinician is carrying on exactly as before.

What happened? It would be easy to organise another teaching session. Before doing that, we might want to understand why the first one hasn’t been enough. People can understand a proposal perfectly well and still find it difficult to use at work.

The framework commonly associated with Kurt Lewin describes unfreezing an established pattern, moving towards a different one, and refreezing it so the change lasts. It’s an account of change which educators have found helpful. We should be careful about treating it as a literal description of knowledge sitting frozen in someone’s head.

A proposed change sits above two questions: what supports the change, and what holds it back? — A sketch based on force-field thinking. Before asking people to change what they do, find out what currently makes that difficult.

Why would anyone change?

If the current approach has worked reasonably well for someone, abandoning it may seem an odd thing to do. In our handover example, perhaps it feels quick and familiar. Perhaps team members change at different times, so a single handover seems difficult to arrange. There may be a perfectly sensible explanation for what looks, from outside, like unwillingness.

This is where unfreezing directs our attention. Before asking people to adopt your solution, find out how they see the problem. Listen to several people, including those who receive the handover. If they don’t recognise the problem you’re describing, that difference needs exploring.

The original article emphasised the part that narratives and experiences can play. A case can make an issue much easier to discuss than a general instruction to improve communication. Use it alongside the available evidence and what you can observe locally. One memorable story may open a conversation, but it cannot answer every question about the proposed change.

Nor do we need to make someone uncomfortable simply to make them receptive. If a colleague questions the plan, they may have noticed a difficulty that the enthusiasts have missed. It would be unfortunate to teach everyone an unworkable process because we had mistaken that concern for a bad attitude.

Teaching is part of the change

Once the problem is understood, we can explain and demonstrate the proposed handover. Let people try it, hear what feels awkward and revise it where necessary. Include the colleagues who will be listening as well as those doing the talking. A process designed entirely from one side of a conversation may be less helpful to the other.

But what if everyone knows how to do it and it still doesn’t happen? This is where looking beyond knowledge becomes essential. Michie, van Stralen and West’s COM-B framework describes behaviour in terms of interacting capability, opportunity and motivation. It’s a separate framework, though it can help us examine the difficulties that Lewin’s broad headings leave open.

For this team, capability might include knowing how to give the handover. Opportunity might depend on finding a workable moment to pause and being able to reach the prompt. Motivation might involve believing it helps and expecting colleagues to take part. We would need to investigate those possibilities rather than assume which one explains the problem.

If the prompt lives in a folder nobody can access, another explanation of its benefits is unlikely to help very much. Equally, if senior clinicians routinely ignore the process, a new colleague may reasonably wonder what the department actually expects them to do.

Keeping it going

Refreezing is an awkward word in emergency medicine. We hope practice will continue to develop as circumstances and evidence change. Think of it here as giving an agreed approach enough support to survive an ordinary shift.

That might mean putting it into induction, making the materials easy to find and asking senior staff to use it themselves. Someone also needs to come back and see what is happening. Are handovers giving the incoming team the information they need? Has the process introduced duplication or delays? Attendance at the launch session won’t answer those questions.

Consider what happens when the enthusiastic registrar rotates. If they are the only person reminding everyone, finding the materials and solving problems, the change may leave with them. Involve others while they are still around, and make it clear how colleagues can raise difficulties or suggest an improvement.

The original article was right to draw attention to this often neglected part of education. Challenging an old idea and explaining a new one can take considerable effort. It’s still worth asking what will support the learner when they return to a workplace where the old approach remains familiar.

A note on the history

You’ll usually see the three stages attributed to Lewin, with his 1947 work on group dynamics and social change cited. The history of the familiar diagram is debated. Cummings, Bridgman and Brown argue that the version now taught developed after his death. Burnes places the approach within Lewin’s wider work on field theory. We shouldn’t present the tidy three-stage version as an uncontested, complete explanation of change.

For the educator wondering what happened to that handover teaching, it still provides somewhere to look. Go back to the team and watch what happens. You may find a gap in understanding, but you may also find that they need something quite different from another lecture.