Implementing new habits

A few years ago, I read the work of Everett Rogers on the Diffusion of Innovation written in 1962 describing the dissemination of novel ideas among farmers. It is the source of the taxonomy of early adopters, early majority, late majority and laggards. Analytics fosters and supports innovators and early adopters because it helps one ‘see’ connection that is not readily apparent. However, implementation of new concepts and their associated actions while a function of the social networks Rodger’s describes is more difficult and his taxonomy tells us when people may change or adopt, not why. Understanding the why makes implementation more effective.

In changing our work behavior, we argue that “it is the right thing to do” (moral), “it meets meaningful use or key performance indicators” (economic), “it is clinical best practice” (medical relevance) and in some cases “there is no alternative” (punishment). Some physicians acquiesce immediately, others question the underlying reasons both clinical and administrative, and some fight it ‘tooth and nail’.  

Gretchen Rubin in Better than Before discusses how habits are a building block of behavior and provides a taxonomy explaining the why and perhaps, providing a roadmap to implementing changes.

Rubin suggests that our response to expectations governs our behavior and assimilation of new habits. Understanding these responses facilitates change. Expectations can be external or internal, healthcare has both in abundance, and we know from other behavioral studies that internal motivators are the most persistently effective. Rubin provides a taxonomy of our responses. “Upholders readily respond to both outer and inner expectations. Questioners question all expectations, and will meet an expectation only if they believe it’s justified. Obligers respond readily to outer expectations, but struggle to meet inner expectations. Rebels resist all expectations outer and inner alike.”

It seems that most people are either Questioners or Obligers (You can take a quiz to classify yourself here) so what is the best practice for implementing and fostering change? It begins with education not fiat and it involves describing both the external and internal motivators for the change. This begins to capture the Upholders and the Obligers. By making the reasoning behind the change explicit, encouraging questions, we begin to bring the Questioners into the process. The Rebels remain a difficulty because on the surface neither the education nor opportunity to question may overtly meet their independent, contrarian approach. Rubin provides two insights to courting the Rebels. Habits and behavior defines, in part, our identity. Therefore, we need to make it clear that the changes in behavior are exemplars of being a better healthcare professional, that it represents a higher not just newer standard. This speaks to identity. Secondly, watching over the Rebels is counterproductive because “audience = expectation.” Giving Rebels the information and leaving them to their own thoughts may be far more effective than specifically targeting their behavior with rewards or punishments.

One last thought. Obligers, derive their name from their sense of obligation to others at the expense of their obligations to themselves. They will more readily comply with change but perhaps at a hidden cost of their own needs. For example, they do CPOE even while doubling their workload because it is expected of them. I think these might be the professionals most susceptible to ‘burnout”.