What’s involved in thinking differently?
Note: This content is taken, with permission from the NHS Institute for Innovation and Improvement, from ‘Thinking Differently’, by Lynne Maher, Paul Plesk, Sarah Garrett and Helen Bevan.
Before you can effectively use the tools we describe in this guide, it is important to understand some basic concepts behind both usual thinking and thinking differently.
Natural thinking as mental valleys
While there are many complex explanations of how we think, Edward de Bono’s simple model of mental valleys and streams of thought provides a good illustration. Hills and valleys in nature organise the rain that falls randomly over an area into flowing streams. In a similar way, the mind organises words and phrases – “language” – into streams of thought.
Image copyright: NHS Institute for Innovation and Improvement
The terms
mental models,
assumptions,
paradigms,
simple rules,
the way we do things,
mental boxes,
and similar words and phrases are roughly equivalent to what we are calling a mental valley.
As we learn the language of the world we live and work in, a metaphorical valley is created in the mind to hold concepts that tend to flow together in our thinking. For example, in the mental valley of “A&E” we hold and link together the concepts of a physical space… with a car park and separate ambulance bays… with a main entrance and reception desk where you must register… with waiting areas… with examination rooms … where the nurse does an initial triage and tells you that the doctor will see you later… etc. We have learned that all of these concepts naturally go together. They flow in what we sometimes call a stream of thought. That is just the way it is; it is the “usual” way to think about A&E. Simply saying “A&E” naturally puts us in this mental valley and activates the stream of thought. The same thing happens when we think of a “GP Surgery”, “Patient”, “Medical Record” or any other of the many words that are common in the language of health care.
We spend most of our time thinking as we have been taught to think. The mental valley is comfortable. It is also very efficient in that all one has to say is “A&E” and all these other thoughts just come streaming along. There is nothing wrong with that. That is, there is nothing wrong until we need to think differently.
We might ask for new ideas for A&E redesign, but if everyone remains in the usual valley of “A&E” all we are likely to get are slight variations on existing themes (for example, “let’s put a television and drinks machine in the waiting area”).
Thinking differently is about making “creative connections”. It involves challenging, connecting and rearranging information in our mental valleys. We might challenge the usual stream of thought that uses reception and triage as control gates before gaining access to a doctor, and simply have a process where a doctor sees everyone who comes into A&E immediately, in order to begin the process of care. We might connect to the valley of “fast food restaurants” and rearrange our thinking by borrowing the idea of a drive-through window as a way to provide some hospital services. Or we might imagine some sort of hand-held GPS device to guide patients through our physical space because someone has suggested that we think for a moment about the randomly selected word “automobile”.
Note: That laughter is a natural physiological reaction to a novel connection in the mind. In fact, someone initially laughing at an idea is often a good signal that it is, indeed, creative!
The difference between first-order and second-order change
Another set of terms that you may hear is first-order and second-order change. First-order change occurs when we make an improvement, but stay firmly within, the current mental valley; for example, a voluntary worker to greet patients in the A&E waiting area or reducing the time it takes to register at the reception. There is nothing wrong with that; first-order change is good.
Having a doctor as the first person you see when you come to the A&E, providing some hospital services via a drive-through window, or providing patients with a hand-held navigation device instead of relying on signage, are examples of fundamentally different approaches: second-order change. In general, second-order change often has more impact, creates more satisfaction, and has more beneficial effects than first-order change.
Image copyright: NHS Institute for Innovation and Improvement
Thinking differently requires: Attention, Escape and Movement
In his book Creativity, Innovation and Quality, Paul Plsek notes that the process of rising out of and exploring mental valleys to get more ideas for second-order change relies on three deliberate mental activities: Attention, Escape, and Movement. Thinking differently involves managing these three mental processes.
Attention - When you take the time to list some of the current mental valleys, assumptions or simple rules in the system, you are practicing mental attention. (“Patients who come to A&E must first report to reception”). Attention involves looking closely, observing with fresh perspective, and really noticing things.
Escape - When you challenge or block an existing rule, you are encouraging escape from the current mental valley. (“The government has made it illegal to have a receptionist and desk in the A&E!”). We often describe this as “blue sky thinking” or “thinking outside the box” that purposefully moves away from the existing situation.
Movement - When you then play imaginatively with this suggestion and generate several ideas from it without judgement or criticism, you are encouraging mental movement. (“Let’s try to generate at least seven ideas for ways to manage patient arrivals in the A&E without a receptionist and a desk”) Mental movement is free association that is just allowed to flow in any direction it wishes without constraints for the moment.
While usual thinking involves mental movement, it rarely takes the time to pay explicit attention to underlying assumptions, and rarely challenges “the way we do things around here” or escapes from the comfortable mental valley. You will notice that all of the tools for thinking differently that we present in this guide involve some combination of these three mental activities.
Thinking is of better quality when we put some structure around it
Often, our mind becomes a jumble as we try to think, particularly when we try to think differently. We are trying to come up with new ideas and we can see some benefits from that… but there is also the downside and risk… and we wonder if there is any data or experience to support the idea… and perhaps we feel that this is scary, and we each wonder what others will think of us… and so on.
This jumble occurs whether we are thinking alone or in a group. Some people are their own worst critics, while others experience the worst criticism in groups. Some people are naturally positive in their outlook, while others are naturally more negative. Some people are naturally analytical (“The facts are…”), while others are more intuitive (“I feel that…”).
When you want to think differently, it helps if you minimise the mental jumble and focus on one aspect of thinking at a time. For example, you might want to loosely structure your individual thinking, or that of a team along the following lines:
- Generate new ideas and possibilities without judgment. (Imagination)
- Think first about the positives and benefits of each idea generated or selected for further consideration. (Positives)
- Think about the negatives, risks, and pitfalls. (Negatives)
- Review or consider gathering facts, data and information to either support or rule out the ideas. (Facts)
- Express feelings and intuitions about the ideas. (Feelings)
These five aspects are essential to comprehensive thinking. The important point is that it helps to take them one at a time, rather than allowing them to become a jumble.
While this structure may at first seem limiting, it has been shown repeatedly to lead to better thinking – both in individuals, but especially in groups. The structure is formalised in Edward de Bono’s Six Thinking Hats®*, a tool that we will describe in a later section.
* © The McQuaig Group.
Simple rules for better idea generation
The seemingly paradoxical notion that thinking differently benefits from a little bit of structure applies even to times when we want to be our most free-thinking – during idea generation.
In the 1930s, psychologist J. P. Guilford identified characteristics of individuals and groups that were able to generate the best new ideas. Advertising executive Alex Osborn, in whose industry effective idea generation was particularly important, built on this work and coined the term “brainstorming” to describe the process of deliberate idea generation. Osborn suggested that idea generation sessions would be more successful if everyone agreed to a few simple rules. These have since been restated and enhanced by many others (for example, Tom Kelly, the chief executive of IDEO and author of The Art of Innovation) and can be stated as follows:
Criticism is ruled out There are no bad ideas at this point. There will be plenty of time to judge later.
Go for quantity – Don’t settle for 3 or 4 ideas; aim for 10-20.
Encourage wild ideas – It’s the wild ideas that often provide the breakthrough insights. These insights might lead to further ideas that are not so far fetched.
Build on the ideas of others - What can you add? What else? What other ideas does it bring to mind?
One conversation at a time – This way all ideas can be heard and built upon.
Cycles of divergent and convergent thinking
A final important concept for thinking differently is another one of J. P. Guilford’s insights involving the importance of deliberately alternating between divergent and convergent thinking.
Divergent Thinking: Expanding the list of possibilities; purposefully looking for more, or looking at the issue from a variety of directions. Divergent thinking stresses quantity of thought, imagination, long lists, and many different ways. Divergent thinking is necessary in order to challenge “the way we have always done it”. The downside of divergent thinking is that it can go on forever and we end up with lots of new ideas but never actually do anything about them.
Convergent Thinking: Reducing the list of possibilities; purposefully looking to condense, summarise, focus or select. Convergent thinking stresses quality of thought, good judgment, short lists, and a few selected ways. Convergent thinking is a necessary prerequisite to action, and without action ideas are not valuable. The downside of convergent thinking is that we might miss a possibility, or prematurely discard one and end up being very focused on an idea, but not on the best one.
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You may know individuals who tend to favour one mode over the other, or you may work in an organisational culture that tends to emphasise one over the other. For example, some people are naturally full of ideas when faced with challenges and offer lots of alternatives (divergent thinkers), while others prefer to select a single idea and start to work on it (convergent thinkers). However, cycling between both divergent and convergent thinking is more effective when we want to think differently.
As illustrated in the figure, we might start with a specific issue, but it is useful to spend some time looking at it from a variety of angles. This may bring a new perspective, which leads to a different statement of the issue and a refocus of our work rather than the same old way of looking at it. We might then generate lots of ideas, initially without judgment, but in the end we will need to apply some criteria to select those ideas that we wish to take forward. And so it continues, alternating cycles of divergent and convergent thinking that get the benefits of both while avoiding the pitfalls of either.
“If we can occasionally be prepared to let go of our cherished beliefs about the rules and hierarchies of healthcare we may find there’s a better way of doing things. In our case, accepting patients as equal partners in designing services has opened up a repository of knowledge and experience that would not otherwise have been available to us.”
John Pickles, Consultant Head & Neck Surgeon, Luton & Dunstable NHS Foundation Trust
