Introduction
This chapter draws on a range of literature to suggest that the process of individual unlearning may have particular features. The analysis of individual unlearning presented here is based on a review of the contemporary academic literature on unlearning, but to help address themes that are relatively unexamined by this literature it also draws on a wider body of work on learning and change. After the chapter unpacks and defines the concept of unlearning, it presents the details of the literature search that was conducted. Following this is a large section that differentiates between two different types of individual unlearning, and which suggests that each type of individual unlearning may have its own distinctive features and dynamics. The final two sections summarise recent changes in the UK health-care sector and present the research questions of the study.
Clarifying and developing the unlearning concept
Thus far, ‘unlearning’ has been very broadly defined as abandoning or giving up knowledge, ideas or behaviours. This is in contrast to ‘learning’, which has been defined as increasing one's capacity to take effective action through the addition of new skills or knowledge.19 However, to fully understand the concept of unlearning it is necessary to define it in greater detail. Although unlearning can be traced back to the 1950s, until recently it has been largely neglected in the literature on learning and knowledge management. Akgün et al.20 trace the origins of unlearning to literature on learning and cognitive psychology published in the 1950s and 1960s. Another perspective on unlearning emerged in the 1950s, which explored ‘unlearning . . . the inherent dominative mode’ in relation to Western thinking about the ‘other’ (p. 376).21 The ‘other’ referred to how people in the West view people or perspectives they regard as non-Western. Unlearning in this context concerned Westerners trying to think beyond their own perspective to take account of others.21 Indeed, some educational literature22 applied Williams'21 meaning to understand how trainee teachers could unlearn their attitudes to ethnic minority and working-class young people. Similarly, Mavin et al.23 utilise unlearning in the same sense and suggest that an unlearning process is necessary to challenge the unquestioned and unchallenged gender-blind and male-biased character of the academic business and management literature.
In the business and management literature unlearning tends to be linked to one or more of organisational learning, change and memory,2,8,9,20 knowledge management24,25 or human resource management.26 However, some authors draw on more than one discipline, relate unlearning to individuals and/or groups and locate the concept in the disciplines of education and learning2,22,27 or psychology.26
If unlearning involves the giving up or abandonment of knowledge, values or behaviours, it needs to be acknowledged that this can happen both unconsciously and deliberately. The unconscious or accidental giving up of something is typically referred to as forgetting, as it occurs over time through particular knowledge or behaviours becoming unused and eventually forgotten.6,17 This process of forgetting contrasts with deliberate unlearning, which involves a process of consciously choosing to abandon or give up particular knowledge, values or behaviours. As with Tsang and Zahra,2 the assumption here is that unlearning is a conscious and intentional process and, as such, is distinct from forgetting. De Holan and Phillips18 agree about the deliberate nature of unlearning, although they do not distinguish in the same way as others between forgetting and unlearning. Indeed, for them, ‘managed unlearning’ is one of four modes of forgetting old knowledge.
A second area of difference in the unlearning literature relates to whether or not the knowledge or behaviours being given up are obsolete, outdated and in some way inferior to new knowledge or behaviours that are subsequently acquired. As highlighted in , a number of articles make this assumption.24,28,29 Thus, for example, Srithika and Bhattacharyya28 define organisational unlearning as ‘the identification or removal of ineffective or obsolete knowledge’ (p. 68). However, making such a value judgement regarding the inferiority of the knowledge to be abandoned is unnecessarily restrictive and judgemental. Thus, similar to Tsang and Zahra,2 we suggest that it is more appropriate to define unlearning simply as abandoning or giving up knowledge or behaviours without making any judgement on the status of the knowledge or behaviours being unlearned.
Academic articles on unlearning (2000–12)
In considering individual unlearning, an issue that is typically neglected is what happens to the knowledge or behaviours that people unlearn. It is important to acknowledge that what is unlearned is not permanently lost by people such that they are unable to think or act in the way that they had done previously. Arguably, the only ways that particular capabilities could become permanently lost are through some type of medical or neurological intervention (drugs, surgery, etc.), through developing an illness or having an accident (such as having a stroke or a car accident that results in brain injury) or through lack of use over a long time period. Thus, the type of deliberate individual unlearning considered here does not involve the permanent loss of something, but instead involves a person putting particular values, knowledge or behaviours ‘to the side’ and consciously choosing not to continue using them. Thus, individual unlearning in this sense is not necessarily permanent because, either consciously or unconsciously, people may at some point in the future begin to reuse that which they had previously abandoned or unlearned. An example of this would be when someone changed how he or she undertook a task by returning to do it in a way that had been previously abandoned.
The final issue in developing the concept of unlearning is how it is relates to learning. Tsang and Zahra2 consider that unlearning may precede learning, occur simultaneously with learning or occur independently of learning. However, the dominant perspective regarding the relationship between the sequencing of unlearning and learning is that unlearning is a unique stage and is a prerequisite to, and a precursor of, learning.20,26,30–32 For example, Cegarra-Navarro et al.30 define unlearning as ‘the elimination of obsolete knowledge’, which is regarded as a necessary precursor to learning, or ‘the creation and absorption of new knowledge’ (p. 901). However, an alternative way to conceptualise the relationship between unlearning and learning is to consider unlearning as a distinctive type of learning.33 This is the perspective utilised by Argyris and Schön,34 who argued that ‘we may also speak of the particular kind of learning that consists of “unlearning”: acquiring information that leads to subtracting something (an obsolete strategy, for example) from an organisation’s existing store of knowledge’ (pp. 3–4).
In summary, in examining individual unlearning this section suggests that individual unlearning should be conceptualised as a distinctive type of learning. It involves a conscious process of choosing to give up knowledge, values or behaviours. No value judgement should be made regarding the value or status of what is abandoned, and that what is unlearned is not permanently lost to people and may be utilised again at some point in the future.
Reviewing the academic literature on unlearning
Although Tsang and Zahra2 conducted a partial review of the unlearning literature, their central focus was organisational-level unlearning rather than individual unlearning. Their review identified 34 separate pieces of work. However, they do not specify the boundaries of the search that was conducted to produce this list, with it including book chapters and journal articles published over a wide time frame.
Because of the multidisciplinary nature of the interest in the topics of learning and unlearning, we searched several management (Business Source Complete, Emerald), psychological (PsycINFO), health (MEDLINE) and education [Education Resources Information Center (ERIC)] electronic databases for English-language articles that were published between January 2000 and March 2012. We searched for articles that had ‘unlearning’ in the title, abstract or keywords. Additionally, we searched for articles on ‘abandoning behaviour or knowledge’ and ‘giving up behaviour or knowledge’. This search generated over 330 articles. From these sources we concentrated on those published in peer-reviewed scientific journals, leaving 261 articles. After removing duplicate search results we examined the abstracts of these articles and excluded studies that reported on animal-based, psychological or memory experiments. We also excluded personal viewpoint and unreferenced opinion articles, leaving approximately 100 articles. After a first round of reading of the collected articles, we selected those articles that investigated the topic of unlearning, either theoretically or empirically. This led to the exclusion of articles that used the term ‘unlearning’ in the abstract or title, but which were not fundamentally concerned with investigating it as a topic. Although the focus in this article is fundamentally on individual-level unlearning, our initial review included all articles on unlearning, whether they were focused on individual-, team- or organisational-level unlearning (see and ). We also searched the reference lists of all sources collected and performed citation searches, which resulted in the addition of several relevant articles.
Focus of unlearning articles
A total of 34 articles2,3,6,9,10,20,22–26,28–32,37–49 were identified for analysis (). An initial observation from the list is that < 35 relevant articles were identified in a time period of over 10 years, which highlights the extent to which the concept of unlearning is neglected and underdeveloped. This neglect is in stark contrast to the considerable level of interest in the topic of learning since the mid-1990s.5,35,36
In terms of how the literature defines unlearning (see , column 2), although many authors develop their own particular form of words, what is noticeable about the way that unlearning is defined (also found to be the case by Tsang and Zahra2) is the striking degree of homogeneity that exists. What is common to these definitions is that unlearning involves ‘abandoning’, ‘eliminating’, ‘rejecting’, ‘discarding’ or ‘giving up’ something – with that something being particular values, assumptions, knowledge or behaviour at the individual level, and knowledge, assumptions or routines at the organisational level.
In terms of the type of unlearning examined, as highlights, there has been a greater focus on organisational or group or team unlearning (21 articles2,3,20,23,24,26,28,31,37,40,42–44,46,47,50–54) than on individual-level unlearning (16 articles6,9,10,22,23,25,26,29,30,32,37–39,41,45,48). In this context, group or organisational unlearning, as with organisational learning, refers to norms, assumptions, behaviours and routines that are collectively shared and understood.20,24 Although a few articles look at multiple levels of unlearning,37 or the inter-relationship between different levels of unlearning,38 the vast majority of articles focus on one level of unlearning alone.
Another difference in the focus of the reviewed articles was whether they examined the antecedents, process or consequences of unlearning. The largest proportion of articles (n = 183,9,10,20,22,25,26,30,39,41–47,53) examined the antecedents of unlearning, with unlearning facilitated by the organisational context,9,25,30 environmental turbulence51 and organisational size.26 A total of 133,23,24,29,31,37,38,40,48–51 of the reviewed articles examined the consequences of unlearning, with unlearning argued to be related to a diverse range of processes and outcomes including knowledge transfer processes,49,50 processes of internationalisation,24 the non-academic impact of academic scholarship,33 organisational performance37,54 and health-care policies.31 Finally, only 62,6,20,28,32,52 of the 34 articles examined the character and dynamics of unlearning processes.
also reveals that of the 34 articles reviewed only two6,32 focused on individual processes of unlearning. These are the articles by Rushmer and Davies6 and MacDonald.32 Further, of these two only MacDonald32 presents any empirical evidence, which was a reflection on personal experience. Thus, to say that there is a conceptual and empirical gap in knowledge with regard to the process of individual unlearning is an understatement.
The following utilises the work of MacDonald32 and Rushmer and Davies6, as well as some other literature on learning and change, to consider the character and dynamics of the process of individual unlearning. In so doing it is suggested that distinctions can be made between different types of individual unlearning.
Types of individual unlearning and the nature of individual unlearning processes
As has been outlined thus far, distinctions can be made between individual- and organisational-level unlearning, and between the unlearning of values/assumptions, beliefs, skills, knowledge and/or behaviours. A number of authors go beyond these distinctions to construct distinctive categories of unlearning.6,51,54 For example, Akgün et al.51 develop a typology that links differences in the nature of the business environment to the character of organisational unlearning. Sinkula54 on the other hand distinguishes between the unlearning of axiomatic knowledge and the unlearning of procedural knowledge. Here, axiomatic knowledge is defined as fundamental unquestioned beliefs and values, and procedural knowledge is considered to be equivalent to Argyris and Schön's34 concept of ‘theory in use’, referring to the tacit knowledge that shapes the way that people act.
However, the categorisation proposed by Rushmer and Davies6 is the most relevant to individual unlearning as they propose a useful distinction between three possible separate and distinctive types of individual unlearning: fading, wiping and deep unlearning (). Each type of unlearning is argued to differ in respect of catalyst, intentionality, speed and impact. First, fading or routine unlearning occurs gradually over time through lack of use. It is regarded as neither significant nor challenging for people. Indeed, fading may not enter individuals' consciousness unless they are invited to identify lost skills or capabilities.
Characteristics of individual unlearning types
Wiping is the second category of individual unlearning identified by Rushmer and Davies.6 The catalyst for wiping is a change initiative external to the person. Wiping can be defined as a process of unlearning that results from a deliberate process of change that has been externally imposed, for example a change initiative or a change in job role. Wiping is deliberate, conscious and more significant than fading, and is typically focused on a relatively narrow practice or activity, with a person consciously making deliberate attempts to give up a particular way of thinking and acting as a precursor to changing his or her beliefs and practices.
Parallels between wiping and categories of unlearning developed by other authors can be discerned. For example, wiping is similar to ceasing a particular behaviour and making incremental change8 and to intentional forgetting of new or existing knowledge.18 The notion of wiping is reinforced and extended by other categories such as ‘operational level unlearning’, whereby performance routines (enacted by individuals) and ostensive routines (codified systems) are discarded as a result of evolutionary, continuous, incremental change.2 Wiping is also similar to ‘adjustive unlearning’, in which incremental changes in beliefs are accompanied by fundamental changes in routine, and to ‘operative unlearning’, which involves small-scale changes in beliefs and routines.51
The third category of individual unlearning proposed by Rushmer and Davies6 is deep unlearning. This radical form of unlearning is argued to occur rapidly as a result of an external event whose characteristics and/or outcomes are unexpected, and which bring into question some basic assumptions. Characteristically, it has a significant impact on the individuals who experience it, leading them to question their values and beliefs, and possibly their frame of reference. As a consequence, deep unlearning may be accompanied by challenging emotions such as anxiety, fear and confusion. Thus, in contrast to wiping, deep unlearning is more likely to involve the unlearning of values and assumptions.
Like wiping, the notion of deep unlearning is echoed elsewhere. Baumard and Starbuck8 talk about challenging core beliefs and Tsang and Zahra2 characterise deep unlearning as discarding values and norms as a result of episodic, discontinuous change. Deep unlearning is also similar to reinventive unlearning and formative unlearning identified by Akgün et al.20,51 Reinventive unlearning occurs when an organisation changes both beliefs and routines in response to a changing and highly unpredictable environment, whereas formative unlearning occurs when new beliefs structures are combined with incremental routine change. Finally, there are similarities between deep unlearning and what MacDonald32 defines as transformative unlearning (see Deep unlearning).
Finally, linking back to the idea that unlearning represents a distinctive type of learning, it can be suggested that, although wiping has parallels with single-loop learning (incremental learning or change in which basic assumptions remain unchallenged), deep unlearning can be equated more with double-loop learning (learning or change in which existing assumptions and values are questioned and reflected on).
The above definitions and descriptions provide only a brief overview of the general character of fading, wiping and deep unlearning processes. Thus, to develop a fuller understanding of the dynamics and character of the processes of fading, wiping and deep unlearning it is necessary to consider them in more detail. The definitions suggest that there are significant differences between the ways that people experience and understand fading, wiping and deep unlearning, and in the process dynamics of fading, wiping and deep unlearning. Therefore, it is useful to consider each separately, which is presented in the following three subsections.
Fading
Rushmer and Davies6 argue that unlearning could be considered as a process that will automatically occur when the factors that sustain the original learning are removed. Schein55 refers to unlearning as the forgetting curve, which suggests that some past learning will simply fade away over time. Rushmer and Davies6 propose that, with simple behavioural actions, this passive replacement can be seen as moving down the unlearning curve. They give an example of a health-care professional comprehending a new, altered, mandatory health form. The professional may first puzzle over the new layout and in completing the form may make errors through an erroneous habitual response. However, Rushmer and Davies argue that, as the health-care professional continues to complete the form, familiarity and confidence are gained with the new layout. The old way of completing the form recedes, discomfort and previous expectations fade and forgetting takes place.
However, as unlearning requires conscious and intentional action it is questionable whether or not fading should be conceptualised as unlearning. A lack of conscious action suggests that fading is more akin to a process of unintentional forgetting, rather than unlearning. Even authors who use the term ‘forgetting’ in their definitions of unlearning18,30 identify intentionality or purposefulness as defining characteristics of unlearning. We could not find any other studies that conceptualise passive unlearning, possibly because of the difficulty of investigating the concept. Without longitudinal study it would be very hard to gather data on learning that had been unintentionally forgotten, as by definition the participant could struggle to identify it. For this study we decided to continue to use the fading category for the purposes of empirical testing and fulfilling our original project proposal. This allowed us to examine the concept of fading and the value of this element in Rushmer and Davies'6 categorisation.
Wiping
In terms of the relationship between unlearning and change, the dominant perspective in the unlearning literature is that unlearning is a facilitator of change.2,9,10,23,31,38,50 Although this may be true in relation to wiping (see ), it also needs to be acknowledged that the relationship works in the opposite direction, with external change acting as the prime catalyst for wiping. Thus, in the context of wiping, the primary reason why people engage in unlearning is because it is perceived as being a necessary element of a specific organisational change initiative. This is articulated explicitly in a textbook on change,56 which, in talking about the importance of change for contemporary organisations, says that ‘people are being required to unlearn old ways and develop new competencies’ (p. 7).
Although much of the unlearning literature suggests that the relationship between unlearning and change is close, it has considered only unlearning as being a facilitator of change and has not examined the relationship between unlearning and change in any detail. Consequently, the literature provides limited insight into how change can be a facilitator of wiping, or how individuals experience the character and dynamics of the process of wiping.
The most useful article for considering the bidirectional relationship between unlearning/wiping and change is the conceptual article by Akgün et al.20 In talking about the relationship between unlearning and change it refers explicitly to Lewin's57 three-stage model of change. This very simplified and much criticised model of change suggests that change happens through the sequential processes of unfreezing, change and refreezing (see Akgün et al.,20 pp. 800–1; Hayes,56 p. 52). Akgün et al. assume that unlearning and learning together constitute the second stage in Lewin's model. This conceptualisation of the wiping/change relationship, with unlearning being at the centre of change, highlights the bidirectional nature of the change/wiping relationship. However, the focus of Akgün et al.'s20 article is on organisational-level unlearning/wiping and, thus, it does not provide insights into the character and dynamics of individual-level unlearning/wiping.
Tsang and Zahra2 also examine the relationship between learning, unlearning and organisational change. They distinguish between different types of change (continuous and episodic) and suggest that each type of change will involve a distinctive form of unlearning. They define continuous change as change that is incremental and gradual in character. By contrast, episodic change is typically discontinuous and infrequent and is greater in scope than continuous change. Episodic change can also be linked to a process of double-loop learning in which basic assumptions are challenged. Thus, in relation to the types of unlearning considered here, continuous change can be linked more to wiping, whereas episodic change can be linked more to deep unlearning.
As wiping is so closely inter-related with processes of organisational change, it is useful to refer to some change-related concepts. In this context, if organisational change provides the catalyst for wiping/unlearning, people's attitude to unlearning is likely to be closely linked to and virtually inseparable from their attitude to the change process that precipitated it. Thus, if people do not regard the changes being undertaken as favourable they are unlikely to have a positive attitude to any unlearning that flows from the change. Equally, if the opposite is the case and people do regard change as necessary and important, they are likely to have a more positive attitude to any unlearning it precipitates. Although Tsang50 does not explicitly use the concept of resistance to change, the reluctance to unlearn and learn that he found in relation to the knowledge transfer processes that were examined can be argued to constitute resistance to change.
The concept of resistance to change is useful when considering people's attitudes to change and unlearning. The change literature suggests that, because of the uncertainty caused by change, resistance is common. A key theme in the change literature is concerned with anticipating, managing and minimising any potential resistance to change.56 Although some of the unlearning literature touches on the topic of resistance to change,47,52 people's attitudes to unlearning are neglected. This neglect may be because of the assumption that people will embrace wiping-type unlearning relatively willingly. However, this assumption represents an important omission because people's attitude to unlearning is likely to be shaped by their attitude to change. Thus, to understand the character and dynamics of individual-level wiping-type unlearning processes it is fundamentally necessary to take account of people's attitudes to the changes that precipitated them.
Deep unlearning
In examining how individuals experience deep unlearning and the process through which it unfolds, few of the unlearning articles reviewed are relevant. Of the six articles2,6,20,28,32,52 that focus on the process of unlearning (see ), only two examined processes of deep unlearning,6,32 with the other four concerned with individual and organisational unlearning, which is more equivalent to wiping. In tentatively outlining a model for the dynamics of the process of deep unlearning this section draws on MacDonald's32 empirical and conceptual work and links it with some wider, relevant literature on learning.
MacDonald32 suggests that the process of what she labels ‘transformative unlearning’, which has much in common with deep unlearning, has three distinctive but overlapping steps. The key features of transformative unlearning that resonate with deep unlearning are that it involves questioning, reflecting on and giving up some core values, assumptions, knowledge and practices, and also that this process is deeply emotional and challenging for people to undertake. Similar to the mainstream perspective in the unlearning literature, MacDonald conceptualises unlearning as a necessary precursor to learning, and that both together are interlinked components of change. Finally, the catalyst for transformative unlearning is a process of change that brings a person's pre-existing values, assumptions knowledge and practices into question.
The first stage in MacDonald's model is receptiveness, in which a person accepts the possibility that there are perspectives and viewpoints that challenge his or her assumptions and that he or she is prepared to consider these perspectives. Following this is the second stage of recognition, which is the process through which a person acknowledges the veracity of these alternative viewpoints, and the limitations that exist in his or her own perspectives. Finally is the process of grieving, which she suggests is the emotional core of transformative unlearning, whereby a person comes to terms with ‘the loss of prior ways of seeing – the loss of fundamental assumptions which until now had brought certainty and security’ (p. 174). It is only after these three stages of the transformative unlearning process have been undertaken that a person is able to effectively change and learn new assumptions, knowledge and practices.
MacDonald's32 model can be illustrated by summarising the example she uses, which involves her own experiences as a practising nurse in relation to changes in the recommended sleeping position for infants following research on cot death, or sudden infant death syndrome (SIDS). In the 1970s and 1980s, the generally accepted and unquestioned practice was that babies were put to sleep in the prone position (lying on their front with the head to the side). This was a practice that MacDonald not only recommended to young mothers but also used with her own children. However, research in the early 1990s into the causes of SIDS suggested that putting infants to sleep in a supine position (lying on the back or side) reduced the risk of SIDS. Being aware of and reading this research represented the process of receptivity for MacDonald. However, this process was not quick or easy as it challenged ideas and practices she had taken for granted her whole working life. As more research emerged in the early to mid-1990s on the causes of SIDS, and as MacDonald read more of it, she entered the recognition phase in which she started to accept the validity of the new perspective on infant sleeping positions and began to accept the need to change her own assumptions and practices. This process was facilitated by dialogue with other nurses who were also going through the same process. However, before she was able to comfortably and fully accept the need for this change, MacDonald suggests that it was necessary to go through a process of grieving in which she came to terms with the fact that current research and advice suggested that her previous knowledge and practices had their limitations. This was argued to be the most emotional aspect of the unlearning process as it ‘touched the emotional core of my identity as a nurse’ (p. 174). As with the process of recognition, this process of grieving was facilitated by dialogue and communication with others.
Although this model of the process of transformative unlearning has resonances with Rushmer and Davies'6 concept of deep unlearning, it also differs from it in two key respects. First, the catalyst for transformative unlearning was external change rather than some specific incident or experience. Second, a more significant difference was the timescale over which transformative unlearning occurred. Although Rushmer and Davies suggest that deep unlearning involves a sudden and rapid realisation of the need for change, and an equally sudden process of change, in MacDonald's model transformative unlearning was a slow process that occurred over a period of years. As both transformative and deep unlearning involve the emotionally challenging process of unlearning fundamental assumptions and values, they represent comparable forms of unlearning. However, what MacDonald's perspective highlights is that not all deep unlearning occurs through the sort of sudden Archimedean epiphany which produces an instantaneous change in behaviour. Although particular events may lead people to question their values and assumptions, it may take more time for behavioural change to follow.
Two other process models of learning from the learning literature also have potential relevance to understanding the character of deep unlearning processes. First is Garud et al.'s58 narrative model for learning from what they call ‘unusual experiences’. Unusual experiences are defined as ‘situations that bear little or no resemblance to the types of experiences that have occurred in the past’ (p. 587). Although Garud et al. talk of learning rather than unlearning, there is the potential that, in making sense of unusual experiences, people's assumptions, values and practices may be brought into question and a process of individual unlearning may be undertaken, in which certain values and/or behaviours are abandoned and changed. However, although the narrative model that they develop for how people make sense of unusual experiences may have some relevance to understanding the dynamics of individual unlearning processes, a major limitation of their framework is the lack of consideration given to emotional issues. Despite acknowledging that making sense of unusual experiences involves reflecting on basic assumptions, and that dialogue with others in doing so may result in contrasting perspectives, issues of emotion are not considered. For this reason, Garud et al.'s model is not considered appropriate for understanding the dynamics of the process of deep unlearning.
A final very general model that is relevant for understanding the process of deep unlearning, which has some synergy with MacDonald's model, is the process of organisational inquiry outlined by Argyris and Schön,34 which takes inspiration from the work of the pragmatist philosopher John Dewey. Similar to deep unlearning, and Garud et al.'s58 unusual experiences, the catalyst for a process of inquiry is the experience of doubt, which is defined as the experience of a ‘problematic situation’, triggered by a mismatch between the expected results of action and the results actually achieved. Such experiences, they argue, inhibit continued action and encourage a process of reflection/inquiry aimed at resolving the doubt. Thus, the start of this process of inquiry can be considered equivalent to the initial stage of receptiveness in MacDonald's32 model, with the objective of resolving the sense of doubt that has been experienced, providing the primary catalyst to this receptiveness. The process of inquiry outlined by Argyris and Schön34 is relatively generic and lacking in detail but it involves combining reflection and action as well as an active process of dialogue with others. The ultimate aim of this process of inquiry is doubt resolution, whereby the mismatch that was experienced is made sense of. Arguably, this process of inquiry is equivalent to both the receptiveness and the grieving stages of MacDonald's model. Once the process of inquiry has resulted in the doubt that was experienced being resolved, this makes it possible for learning and change to occur, whereby people adapt their knowledge and actions to take account of the recently experienced mismatch.
Overall, therefore, MacDonald's three-stage model of dealing with transformative unlearning provides a useful template for understanding how people experience and make sense of what is referred to here as deep unlearning. However, as the only empirical illustration of this model is MacDonald's reflections on her own experience, further research is necessary to empirically test and evaluate this model before its validity can be established. As has been revealed by reviewing the literature on individual unlearning types, change can feature as the catalyst to individual unlearning and unlearning can trigger further change. Therefore, the following section briefly reviews the literature concerning individual-level transitions in change theory.
Reviewing the literature concerning individual-level transitions in change theory
When examining individual attitudes to and experiences of change there are two main literatures of relevance: resistance to change and emotion/attitude to change. The following reviews each of these literatures and considers how they may relate to individual unlearning.
Organisational change has been studied from many perspectives with the use of many methods.59 In their literature review, Armenakis and Bedeian60 identified five themes in the change literature: content issues, which deal with the substance and nature of a particular change; contextual issues, which deal with forces and issues that exist in an organisation's internal and external environment; process issues, which examine the actions taken to implement change; criterion issues, which focus on outcomes from organisational change efforts; and affective and behavioural reactions to change. It is the last category that is of most interest to this study.
Resistance to change is a concept that is frequently discussed in conjunction with the unfreezing stage of Lewin's57 change model. It is often presented as a negative barrier to change, defined as a restraining force acting to maintain the current state of equilibrium.61 Traditional approaches to resistance to change frame compliant behaviours as non-resistant and non-desirable behaviours as resistant. The early solution presented to overcome resistance was to increase employee participation.62 However, Lawrence63 argued that this was an oversimplified solution to resistance and that change had both technical and social characteristics. It was a lack of attention to the latter that often led to resistance to change. Lawrence's view was that attitudes were important in how managers think about resistance to change and that expecting resistance to change from employees often delivered resistance.
In his review of the literature Foster59 observes that other scholars have conceptualised resistance to change as an emotional reaction rather than a purely behavioural one. For example, Argyris and Schön64 discussed resistance in terms of defensive routines and frustration, and Kanter65 refers to feelings of uncertainty and loss of control in understanding individual responses to change. Klarner et al.66 argue that the literature concerning emotions during change can be divided into two parts. First, some studies in change management focus on employee behaviour as a result of emotions evoked during change. Second, other studies have used psychological stage models to explain the relationship between emotions and employee behaviour during change. Both of these parts are considered briefly below.
It has been argued that emotion drives the adaptive behaviour of employees in response to change.67 This adaptive behaviour involves learning new strategies and being resilient to setbacks.68 Several studies have considered the behavioural outcomes of employees who show either positive or negative emotions. It has been argued that failure to emotionally adapt to change leads to resistance among employees.69 For example, resistance can lead to withholding of participation during change events. By contrast, Avey et al.68 found that positive emotions could help individuals cope and could create support for the change. Positive emotions were found to increase the level of commitment and emotional engagement to the organisation, even in times of disruption.70 However, Piderit71 has argued that dichotomising individual responses to change as either altogether negative or altogether positive is an unhelpful oversimplification. Piderit71 proposes that conceptualising resistance to change as multidimensional would help account for the possibility of ambivalence or mixed feelings towards change, and presents a tripartite attitudinal model of resistance to change that includes three components: emotional (affective), intentional (behavioural) and cognitive. She concludes that the term ‘resistance to change’ is inaccurate and unhelpful, and does not provide the best framework for understanding organisational change implementation. Ford et al.72 add that, by assuming that resistance is necessarily bad, change agents have missed potential contributions that could help build awareness and momentum and eliminate unnecessary or counterproductive elements, increasing the likelihood of successful implementation of change. Both Piderit71 and Foster59 conclude that studies at the individual level would be better served using the term ‘response to change’. Further, Klarner et al.66 argue that studies on emotions during change treat change as a snapshot event but would be better served by characterising change as a process, with the result that emotions could evolve during change. Klarner et al.66 add that studies often focus on single change but neglect to consider the repetitive nature of change that occurs in many organisations and that emotion should also be examined as a continual construct.
Studies in human resource management and organisational behaviour have also attempted to use psychological stage models to explain the relationship between triggers for employee emotions, coping behaviours and change outcomes.66 It has been argued that the trigger for the change process can produce strong emotions as well as the change itself.73 Other studies have looked at the relationship between employee emotions and coping behaviour during change. Smith and Lazarus74 advocate psychological appraisal theory to explain this relationship, with the employee engaging with an appraisal process that considers the implications of the change for his or her personal goals and well-being. The appraisal process shapes the individual emotional response, which is translated into specific coping behaviour. These coping strategies can influence the organisational change outcome.75 Positive employee emotions towards change can increase engagement, affecting the emotions of other team members.76 By contrast, resistance to change is demonstrated by disengagement, which can hamper effective change.68 Klarner et al.66 contend that these stage models suffer from the same deficiencies as those of change management studies that have examined emotion. The studies tend to consider emotions as either positive or negative rather than considering multiple possible emotions during change. They treat change as a snapshot event and fail to consider how emotions may evolve during a change process, with different events during a change process triggering different emotions. Consequently, they call for more studies that consider the evolving character of emotions during a change process, as well as studies that consider employees' emotions during repeated change.
Reflecting on the literature presented in this section suggests synergies between individual unlearning and individual transitions from change. Several studies have proposed that a catalyst to unlearning can be an organisational change event.2,6 Therefore, individual unlearning may be part of the adaptive behaviour process that employees experience as a result of change. Employees may be required to give up or abandon some previous strategies or knowledge as well as learning new ones, and this abandonment may trigger strong emotions. MacDonald32 argues that the unlearning process can involve giving up some core values, assumptions, knowledge and practices, which can be challenging and deeply emotional for people to undertake. Similarly, studies of individual transitions during change have found that employees report feelings of uncertainty, loss of control and frustration and enact defensive routines.64,65 Positive emotions have been found to increase commitment and engagement with change, but may also demonstrate an increased willingness to engage with individual unlearning, seeing it as an opportunity to refresh old thinking and knowledge. Therefore, it is possible that employee emotions during change may also influence their engagement with unlearning processes, which may explain how employees respond and adapt to change.
Emotion has also been linked to decision-making processes, the main outcome of interest for this study, and the following section reviews the decision-making literature in relation to individual unlearning.
Reviewing the academic literature on decision-making
In reviewing the literature concerning individual decision-making and decision-making processes we examined the learning, knowledge management and organisational behaviour fields. By searching for literature published from 2005 we identified 29 articles that considered learning and decision-making in the article title, but we found none of these articles to be directly relevant to this study. Similarly, since 2005, 11 articles had been published that included knowledge management and decision-making in their titles, but these also did not provide any further insights for this study. Neither field provided any new material regarding unlearning and decision-making. However, searches in the organisational behaviour field were more successful, especially concerning work psychology, which is most relevant to this study because of its focus on the individual. Consequently, the following discussion draws heavily from this discipline.
Much of the work psychology literature on decision-making has considered how individuals deviate from strictly ‘rational’ processes, with ‘rationality’ defined as choosing the option that has the highest expected value among those options available to the individual.77 However, this definition assumes that all other things are equal, and Tetlock78 has argued that in different circumstances individuals may have different motives and goals for a decision and that the attractiveness and utility of certain decisions is subjective to individuals' perceptions of these possible outcomes. Arnold77 states that there are many different strategies for decision-making, such as evaluating options using a very limited range of important criteria, or searching for an option that an individual considers to be good enough. This latter approach has been termed ‘satisficing’ and can be contrasted to ‘maximising’ in which a thorough search is made for the best possible option. Arnold77 argues that a satisficing strategy may be suitable if a person does not have time and/or the ability to use a more thorough approach. Frisch and Clemen79 argue that, although attention to the perceived attractiveness and utility of a decision outcome is useful, attention should also be given to the early stages of the decision-making process. In particular, they argue that to understand decision-making well it is important to consider consequentialism (the expected personal consequences of making a decision), thorough structuring (considering more than one option and the likely consequences) and compensation (the trade-offs between one benefit and another from making different decisions). These three influences on decision-making highlight the key role of information processing in the decision-making process.
There are several different aspects to information processing in decision-making such as attitudes to uncertainty and risk, gains compared with losses and framing of information. Although these aspects are relevant to decision-making we identified four areas that may have particular significance for individual unlearning and process management decision-making. The first of these areas was the role of emotion, action and inaction. Isen80 provides evidence to suggest that individuals who are experiencing positive emotion are able to be more creative and are more able to process information than those who are not. However, it appears that positive emotion can also lead individuals to be unrealistically optimistic about future events and outcomes.81 Further, individuals seem likely to consider future emotions when making decisions and, in particular, the emotion of regret. It is argued that individuals regret actions more than inactions, probably because the consequences from actions are more tangible. In line with these results, Baron82 found that worries concerning future regrets encouraged inaction over action. This may suggest that managers could choose not to abandon certain behaviours or knowledge even if they feel that they are outdated or not well suited to the current environment if the alternative is a step into the unknown.
The second area was escalation of commitment. This phenomenon is now well established77 and emphasises that, if a decision is made freely and explicitly, the individual making it is committed to it and retrospectively seeks to find reasons to justify his or her rationale for making it. McCarthy et al.83 report evidence of this escalation of commitment in some managerial decisions. This phenomenon is important for managerial decision-making because laboratory experiments have shown that, when decisions are reported to individuals as unsuccessful, they will feel compelled to continue to support their decision in the belief that they will ultimately prove that their wisdom was correct. Simonson and Staw84 investigated how to counter this compulsion and found that decision-makers who set advance minimum outcome levels were less likely to pursue the course of action if the minimum outcome had not been reached than decision-makers who had not specified a minimum outcome level. Escalation of commitment was also reduced if decision-makers were told that it was the quality of the decision-making process that would be evaluated, not the outcomes achieved (which in any case may be beyond the control of the decision-maker). Such strategies may have value to managers when assessing the quality and effectiveness of their decision-making by providing indicators of when existing decision-making practices should be reviewed and potentially abandoned.
The third area was heuristics. Heuristics are rules of thumb that people use to simplify information processing and decision-making.77 In their seminal work, Tversky and Kahneman85 identified three common heuristics. The ‘representativeness’ heuristic refers to when an individual judges something purely according to how representative it appears of a particular category, regardless of the probability of it actually belonging to that category. For example, if an individual encounters three medical students who are all aggressive and demanding, the individual may conclude that all medical students are aggressive and demanding, regardless of the probability of this actually being the case. The ‘anchoring bias’ heuristic refers to a person's failure to change his or her views as much as he or she should in the light of new information, for example the difficulty an interviewer may have in dislodging the first impression of a candidate over the course of an interview. The ‘availability’ heuristic concerns a person's tendency to consider an event more probable if it can be easily imagined than if it cannot. For example, after seeing news reports about redundancies in local government, a manager in the NHS may believe that he or she is in danger of being made redundant, regardless of whether or not there is any genuine risk in their sector. Such rules can therefore skew individual decision-making processes and risk poorly founded decisions being implemented. The process of unlearning may provide opportunities for managers to become aware of the influence of heuristics on their decision-making processes, abandoning old rules in favour of more structured information-gathering procedures, enabling more objective decision-making.
Finally, the fourth and final area in which information processing can affect decision-making was evidence-based management. Evidence-based management is defined by Briner et al.86 as follows:
Evidence based-management is about making decisions through the conscientious, explicit and judicious use of four sources of information: practitioner expertise and judgement, evidence from the local context, a critical evaluation of the best available research evidence, and the perspectives of those people who might be affected by the decision.
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They argue that evidence-based management is a relatively new concept, although the use of research evidence to help make managerial decisions is well established. Reay et al.87 observe that many of the calls for the increased use of evidence-based management reference the more mature discussions in the medical and health-care literatures, which promote the use of the ‘best available evidence’ in medical decision-making.
There is still considerable debate concerning the value of evidence-based management for improved decision-making. In the review of the literature by Reay et al.,87 it was found that much of the existing research lacks strong evidence from which to draw conclusions. Reay et al.87 also concluded that research had so far failed to provide clear evidence to determine whether or not employing evidence-based management improved organisational performance. There is also debate concerning what constitutes suitable ‘evidence’ on which to base management decisions. Evidence-based medicine draws heavily on evidence gathered using rigorous methods such as systematic reviews and randomised controlled trials. However, Briner et al.86 caution against following a blind adoption of a big science perspective that privileges randomised controlled trials and meta-analyses above all other kinds of research evidence. This is partly because of a lack of systematic reviews in management or organisational studies for managers to draw on, but also, as Walshe and Rundall88 note, because the constrained, contested and political nature of many managerial decisions may make the application of research evidence difficult for managers, even when it is available.
A further dimension that has attracted growing attention in evidence-based medicine research has been investigating how to effectively translate research findings to practice settings. Reay et al.87 argue that this area of research, known as knowledge translation, has potential as a model for evidence-based management. Knowledge translation research in health care focuses on understanding how complex interventions, based on research evidence and involving multiple providers, recipients and organisations, can be implemented. What has become clear from knowledge translation research is that the existence of evidence is critical but not sufficient to guide action. Despite the existence of evidence to support a particular behaviour change, Kitson et al.89 found that changing practitioner behaviour remained difficult. Reay et al.87 believe that innovative and creative methods are required to bring evidence to managers to overcome barriers to change. Consequently, it is possible that the inability of a manager to engage with processes of unlearning may help to explain why some managers resist changing or abandoning established behaviours and practices, despite the availability of evidence to support the change.
Furthermore, the shortage of systematic management research evidence compared with medical research evidence, and the increased political and constrained aspects of management decision-making, may mean that clinicians moving into managerial roles are not able to translate established evidence-based medicine practices into effective strategies for management decision-making. Walshe and Rundall90 highlight the divide between the biomedical and the social science evidence bases that clinicians and managers are likely to draw on. One is experimental, replicable and generalisable and the other is non-replicable and contextual. As a result, clinicians who become health-care managers may feel that they have to abandon or give up their established views of what constitutes reliable evidence and learn to use new forms of evidence for their decision-making. This type of change is illustrated by recent work investigating the use of evidence in NHS commissioning processes.90 Swan et al.90 concluded that commissioners needed to view evidence as something that is coproduced rather than being purely external and independent. For example, they argue that knowledge of the local context may be just as relevant as the latest research-based findings or policy guidance. They also argue that commissioners needed to recognise the limits of medical and scientific models for effective management decision-making and that evidence-based medicine templates could not be simply transferred to management decision-making processes.
The decision-making process
Several authors have proposed various conceptualisations of decision-making processes. For example, Briner et al.86 suggest that an evidence-based management process could comprise five steps. First is the manager's attempt to define or state the problem or issue. Second, having stated the problem, internal organisational evidence is collected to check the problem relevance and validity, leading to a reformulation of the problem as necessary. Third, external evidence from published research about the problem is identified and critically appraised. Fourth, the views of stakeholders and those likely to be affected by the decision are considered along with ethical considerations. Fifth, having critically appraised all of these sources of information, a decision is made that attempts to take into account these four sources of information. Alternative conceptualisations of a decision-making process have been presented by several authors although, as Nutt91 observes, these conceptualisations differ significantly, which makes integration of the findings difficult. For example, Dean and Sharfman92 classify the decision-making process through procedural features of rationality, political behaviour and flexibility. Others focus on coalition formation and decision-maker attributes such as tolerance for ambiguity, uncertainty or risk aversion.93 However, Nutt91 argues that, although these studies are helpful, they do not explain how decisions were made.
To address this weakness, Nutt91 compared four different types of decision processes to investigate their adoption, value and duration. First, based on interpretive studies, Nutt argues that decision-makers cater to the interests of powerful stakeholders by looking for ready-made solutions that they can support. These solutions provide a clear course of action leading to an outcome that can easily be visualised, a process called ‘idea imposition’. Second, by contrast, the literature calls for decision-makers to gather intelligence about their needs, discover and evaluate options according to their benefits, and implement the chosen decision by working with relevant interest groups. This process is called ‘discovery’ because it calls for learning about possibilities. Nutt also investigates two hybrid processes to decision-making. If an idea presented in an idea imposition process seems ill advised then the decision-maker might change to a ‘redevelopment’ process to find a replacement. If a discovery process throws up an ‘emergent opportunity’ then the discovery process may be abandoned if the opportunity seems beneficial.
Nutt91 found compelling evidence to support the discovery process model of decision-making with little empirical support for the idea imposition process. He also found that the discovery process was more successful than either of the hybrid approaches. Nutt concludes that the sequencing and steps in decision-making matter. The most important steps include to investigate needs, conduct a sensitive stakeholder implementation and set a direction. Further, these steps should be conducted early in the decision-making process. There was an emphasis on logical and political rationality with expectations needing to be set and politics managed early in the process. Decision-makers who preferred idea imposition seem to be keen for action, the motivation for a quick solution being motivated by pragmatics and fear. However, Nutt argues that such quick fixes can create a trap that limits search and discourages knowledgeable people from offering ideas. In addition, the opportunity can be seen as a personal idea, raising questions about the decision-makers' motives and requiring the rapid action to be delayed while the decision-maker formulates a defence.
The attractiveness of remedy-driven solutions that seem compelling may be due, in part, to a decision-maker's desire to remove ambiguity. By following this path, sources of ambiguity are swept away, giving temporary relief but stopping the search for intelligence and alternatives. The approach also distracts decision-makers away from contemplating their needs, and draws decision-makers to document their ideas and the stakeholder response. Nutt91 concludes that accepting ambiguity is a necessary motivator to effectively address difficult and troubling issues. This transition may well be an important aspect for managers who have moved from clinical roles with established evidence-based decision-making practices into managerial roles that have a less well-defined evidence base and involve higher levels of ambiguity. Managers in these roles may initially adopt idea imposition as a process of decision-making to remove the ambiguity associated with their new positions. If, as Nutt's research suggests, this method of decision-making proves unsuccessful, this experience may act as a catalyst for unlearning this approach and adopting a more discovery-orientated approach. As a key antecedent of individual unlearning has been found to be change at an individual, an organisational or a policy level, the following section reviews recent major changes in the NHS to provide a contextual background to the study.
Recent changes in the National Health Service
Over the last 40 years, significant organisational changes have taken place in the NHS. Major reforms in, for example, general practitioner (GP) fund holding, NHS organisations moving to trust status, governance management and patient involvement have meant that staff frequently experience major structural and organisational transformations. The introduction of ‘formal’ management positions into the NHS followed the Griffith Report in 1983.94 In addition to recommending the introduction of general managers into health authorities, the report also focused on specific management training for NHS staff, particularly for those with a medical background.95 Since the Griffith Report, changes in the health service have been accompanied by the introduction of many formal management positions. Managers from both clinical and non-clinical backgrounds now occupy many of the crucial senior roles within the health service, bringing about local organisational change and reform.
The pace of change in the NHS has continued to be significant in recent years. For example, Greener7 talked about how the ‘pace and scope of change’ was ‘intense’ (p. 206). Most recently, the introduction of the health and social care reforms for the NHS in England in 2012–13 will require many NHS staff to further adapt in their roles and responsibilities. In summary, the reforms have meant that almost every GP practice across England has joined with neighbouring surgeries to form clinical commissioning groups (CCGs). The 152 local NHS primary care trusts (PCTs) that managed most of the NHS budget in England have merged at a senior managerial level to form 51 clusters. Some staff will stay on after PCTs are abolished in 2013 in organisations that will continue to advise the new GP-led groups on how to plan and buy health care. A new NHS Commissioning Board that was established in shadow form in October 2011 will undertake specialised care that needs to be planned at a national level. Below the board will be four regional hubs and then beyond that 50 local offices. From 1 April 2013, strategic health authorities and PCTs will be abolished, and the CCGs and National Board will take on their full functions.96,97
Thus, it is anticipated that, because of the amount of ongoing change in the NHS, all health-care managers are likely to have experiences of unlearning processes such as Rushmer and Davies'6 categories of wiping and fading in which they have had to adapt their work practices and routines as a result of change. Rushmer and Davies' category of deep unlearning on the other hand may be experienced by health-care managers who have undergone a significant role transition, such as would happen when a clinician moved into a managerial role. Thus, it is possible that processes of deep unlearning may be more evident in managers who have undergone such transitions. To examine these aspects in more detail we developed the following research questions for the study.
Research questions
The overall research aim of this project was to empirically investigate the extent to which health-care managers engage in processes of individual unlearning and the barriers that exist to them doing so. This is important because it will improve our understanding of how managers make decisions and will help provide relevant support and training for those involved in running the health service. An addition was made to the second research question from the outset of the project to investigate enablers as well as barriers to unlearning. This change was made to ensure that the study captured a full understanding of the factors influencing health-care managers' unlearning processes.
The specific research questions investigated were:
To what extent do health-care managers engage with the process of unlearning and what impact does the engagement with this process have on health-care managers' decision-making?
What are the barriers and enablers that influence the engagement of health-care managers with the process of unlearning?
To what extent does the health-care setting affect the level of engagement with the process of unlearning by health-care managers?
Having provided a comprehensive review of the literature and provided a brief summary of the key changes in the NHS that were being implemented at the time of data collection, in Chapter 3 we explain the methods adopted for the study and the process of data collection and analysis.
