Change and Resilience

15 Mar

How could an organisation improve its resilience? It’s safety record? Its ability to manage uncertainty and identify risks? The temptation is to head into a change programme, adopting an external model based on success elsewhere. Or by creating a plan largely defined by senior management expectations and top down in nature. Although these approaches can work, they also carry risks.

The risks lie in the general basis for change. A lot of change is based on eliminating human error, or correcting\modifying human behaviour by making structural changes backed up with training and roadshows. This approach is based on the assumption that what will change will be for the better, and what will be replaced has been responsible for holding organisational performance back. Change implemented on this basis can draw too heavily on structure- hierarchy, training, job descriptions and procedures. Drawing too heavily on structural change can fail to recognise current organisational strengths, particularly those which are experienced based and tacit. The result; when the structural changes are introduced, they wipe out the tacit skills built up over years of effective trial and error.

Unless an organisation is aware of the tacit skills, sense making, and rules of thumb which already work consistently to create resilience, hasten recovery from unexpected events, and produce success, then there is a risk of wiping out the products of experience and expertise. The risk is heightened as tacit skills are the product of experience, transformed into wisdom. And this nature can leave the skills uncaptured by procedures and processes. They are an organisations “secret strengths”.  The irony is that efforts to reduce risk, increase organisational resilience, strengthen safety actually reduce organisational performance and stability.

Woods et al (2006) in their book on Resilience Engineering, produce a list of key findings in safety, resilience, change and risk research, highlighting the weaknesses in organisational approaches. I’ve reproduced some of the points below, but they highlight the need for continual adaption (as oppose to sweeping change), never placing too much weight on assumption, and achieving the above through a consistent collection and analysis of how frontline workers actually get things done. This is followed by a sharing of the analysis throughout an organisation. Dissemination enables the distance between plans and actions to be monitored, measured and adapted; more focused placed on continuous improvement, and brings a transparency to an organisation’s “secret strengths”. A selection from the list appears below-

“How missing the side effects of change is the most common form of failure for organisations and individuals”

“How a culture of safety depends on remaining dynamically engaged in new assessments and avoiding stale, narrow, or static representations of the changing paths (revising or reframing the understanding of paths toward failure over time)”

“How overconfident people can be that they have already anticipated the types and mechanisms of failure, and that the strategies they have devised are effective and will remain so”

“How continual effort after success in a world of changing pressures and hazards is fundamental to creating safety”

“Progress on safety therefore ultimately depends on providing workers and managers with information about changing vulnerabilities and the ability to develop new means for meeting these”

As previously stated, the list focuses on the weaknesses of assuming too much, losing touch with action, and assuming procedures which have delivered today, will definitely have things covered tomorrow. Many of the weaknesses are based on the critical difference between how plans and procedures are being implemented versus how they are assumed to being implemented. Wood et al then address the broad measures which can be taken by an organisation to effectively change, based on improving organisational resilience and thereby improve safety, and the management of risk and uncertainty.

“The initial steps in developing a practice of Resilience Engineering have focused on methods and tools:

  • to analyse, measure and monitor the resilience of organisations in their operating environment.
  • to improve an organisation’s resilience vis-à-vis the environment.
  • to model and predict the short- and long-term effects of change and line management decisions on resilience and therefore on risk”

Our own recent research into clinical decision making, construction site management and managing change has demonstrated that implementing these measures needs to be achieved in a way which supports and enhances tacit skills. This needs to be supported by placing a focus on data collection and analysis which does not overly burden frontline workers and managers, and so makes data

Easy to collect

Easy to store

Easy to retrieve

Easy to make sense of and apply

Change needs to be directed at identifying, supporting and enhancing empirical strengths, not imposing abstract procedures. Structure and procedures have their place in effective change, but they should support, develop and enhance the empirical reality of frontline working (Crandall et al, 2006), not drown it.


Hollnagel, E., Woods, D. D. & Leveson, N. C. (2006). Resilience engineering: Concepts and precepts. Aldershot, UK: Ashgate

Crandall, B. Klein, G. Hoffman, R. (2006) Working Minds: A Practitioners Guide to Cognitive Task Analysis. The MIT Press

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