Managing change during an information systems transition

Barbara J. Barr

A massive communication paradigm shift associated with information systems technology currently is occurring in health care. This shift will have a profound effect on nursing because it offers bedside documentation of patient care. Improving health care effectiveness through patient-driven, cost-sensitive ventures requires a coordinated approach that ensures best practices are achieved through data-driven and evidence-based practice.

Policy makers, administrators, nurse executives, and practitioners need to base decision-making on evidence derived from patient experiences, professional judgment, expertise, and research findings. Staying focused on quality, cost-effective patient care requires collecting and interpreting data that translate into patient care activities. Computers can provide the means to collect and interpret this data; however, leaders also must educate nursing staff members about new technology. This is an additional investment that must accompany any computer system purchase.

THE CHANGING ENVIRONMENT

The trend toward managed care has broadened the geographic areas of the perioperative environment and increased the need to share health care information. The perioperative milieu encompasses areas outside the surgical suite, including day surgery areas, endoscopy suites, postanesthesia care units (PACUs), and physician's offices. In these areas, large amounts of data are collected that must be integrated to facilitate quality and continuity of care.

Although a computer system that combines an integrated delivery system with a solid information infrastructure can lead to increased data exchange between hospital departments, as well as data analysis, a 1996 study shows that 58% of surveyed health care organizations spent less than 4% of their budget on information technology, and only 11% spent 5% or more. (1) To capitalize on the power of information technology in health care organizations, executives must be committed to fully supporting the acquisition and maintenance of an adequate information system.

A vital part of restructuring in hospitals is finding ways to meet caregivers' growing demand for efficient methods of entering and retrieving patient information. Studies suggest that nurses spend an estimated 30% of their time documenting patient care. (2) Computerization has the potential to save nurses' time, which then can be spent with patients. Computerization further offers such benefits as accuracy, legibility, timeliness, completeness, and ways to collect clinical outcomes measurement information.

Information is a critical resource for managing health care organizations. It is essential to support patient care, administrative operations, and strategic decision-making. The health care industry has been slow to embrace computers or provide sufficient funding for current computer hardware, software, technical support, or staff member development. Clinicians must use technology correctly and exhibit confidence in tailoring the technology to their specific needs to take full advantage of the information available.

Although computer systems may be capable of collecting the data needed, the resulting measurements will be flawed if nurses do not have a clear understanding of the importance of entering information that is accurate, reliable, and trustworthy. The organizational climate and individual practitioners must be receptive to change, which may require implementing change strategies. One theory that may be useful for operationally addressing change processes and adopting technological innovations is the innovation-diffusion theory. (3)

LITERATURE REVIEW

In the health care environment, patient documentation requirements are growing because of risk management issues, standards of practice, and external regulatory agency requirements (eg, Joint Commission on Accreditation of Healthcare Organizations, Centers for Medicare and Medicaid Services). Computer systems provide nurses with an alternative to time consuming and ineffective manual documentation and data collection methods. Information technology has the potential to change the nature of nurses' work, but it also presents implementation challenges because nurses are inadequately prepared to embrace computer technology. (4)

Coping with the rapidly changing health care environment calls for professional nurses who have the ability to identify problems and carry out planned change through communication and understanding. (5) Bedside terminal use by nursing staff members can offer many benefits, including increased accountability, efficiency, and data collection and retrieval. Unfortunately, this technology has not been adopted as rapidly as predicted. (6) A key to fostering positive attitudes and facilitating successful learning is acceptance of the computer by nursing staff members. (7) Nurses as a group are unsophisticated about the potential represented by computers. Their lack of computer skills is a major drawback when trying to meet the high-technology challenges of the professional nursing domain. (8)

A number of studies have been conducted to measure nurses' attitudes toward computers and computerization, and results generally are positive. (9) There is a need, however, to understand how the diffusion of new information technology occurs among nurses and how their attitudes are translated into the behaviors of adoption and use.

In the literature, many studies focus on nurses' computer knowledge, attitudes, age, and skills as key variables that present significant obstacles to the adoption of new technology. (10) In a meta-analysis, researchers predict that the quality of nursing care should improve with increased use of computers and information technology. (11) Another author suggests that computers offer many benefits for nurses, including increased accountability and efficiency in patient documentation; (12) however, developing nurse-computer interaction depends on each nurse's rate of learning.

One researcher found that using bedside computer terminals resulted in a significant increase in appropriate and necessary charting. In addition, errors that had been occurring in 25% of handwritten flow sheets were virtually eliminated. (13) Although there are studies that indicate a negative relationship between computers and the quality of nursing documentation, most concerns identified in these studies relate to computer software that lacks programming options to prohibit nurses from closing out the documentation screen before completing the required fields. (14)

All the above factors identify barriers to successfully implementing an information system in the health care setting; however, leaders also must understand what effect change has on nurses. This is key to facilitating adoption of technology that supports nurses in their practice.

THEORETICAL FRAMEWORK

Having the best computer system on the market serves no useful purpose if the end user is not motivated to learn how to use the system. Innovation-diffusion theory involves examining, via social channels in a particular group or organization, the process by which innovation is communicated. This theory has several phases including the

* knowledge phase,

* persuasion phase,

* decision phase,

* implementation phase, and

* conformation phase.

This theory considers social change an innovation when it generates widespread consequences for individuals and organizations.

The intrinsic power of innovation to affect change, in conjunction with its movement through diffusion channels, does not imply passivity or powerlessness on the part of the change agent, which is identified in this context as those advocating for information systems technology. Rather, the change agent actively facilitates and regulates the diffusion process by recognizing and capitalizing on group strengths and identifying and managing factors that may impede diffusion. When communicating information and interacting with nurses involved in the change, educators must establish a rapport with nurses, share information via a user-centered orientation, and establish compatibility between the information available and nurses' needs.

The first stage of the diffusion process begins when individuals acquire initial knowledge or awareness of the change and begin to gather information based on that exposure. During the persuasion phase, nurses begin grappling with the information and integrate it, along with personal and external factors, to form perceptions of the proposed change. The decision phase commences with the acceptance or rejection of the innovation, a decision that may be characterized by some degree of instability. During the implementation phase, the individual participates in the practice required by the change. Finally, individuals seek validation to support their choice during the conformation phase. Progression through these phases does not signify unequivocal acceptance, and nurses may retreat backward to a previous phase until the decision to accept or conform to the change is made.

In planning for implementation, it is important to recognize that social groups, such as nursing units, are composed of individuals who differ in their progression and patterns of innovation adoption. The five adopter categories characteristically present in groups of individuals include

* risk-taking innovators, who comprise a small percentage of the population;

* early adopters, who are influential leaders on new ideas;

* the early majority, who usually are not leaders but are willing to adopt change;

* the late majority, or those in need of intense encouragement; and

* laggards, who represent the resistance in the group. (15)

This discussion provides a general overview of the innovation-diffusion theory, but a multitude of other factors may shape the role of the change agent. With an increasing orientation toward a multidisciplinary focus in clinical informatics, understanding how diffusion factors relate to the culture of the nursing profession is critical for implementation success. Communication between individuals who share the same language, professional culture, and work environment is a key factor in the adoption of technology; (16) therefore, application of organizational theories related to innovation adoption can be helpful in understanding similar phenomena in the perioperative setting.

THE ENVIRONMENT OF CARE

In one hospital, nursing staff members were completely without a computer system to document and collect patient care data. This 125-bed acute care facility in the mid-Atlantic region operates a 10-room surgical suite, a three-room endoscopy suite, a six-bay PACU, and an eight-bay day surgery unit. Approximately 6,000 procedures are performed annually, including all surgical services except transplantation and heart procedures. Originally, the facility was an independent health care agency with local origins, but it became part of a larger for-profit corporation in 1992. The corporation owns and operates five acute care facilities along the east coast.

In 1999, the corporation agreed to purchase a new computer system for the OR. The system chosen was intended to meet all surgical service needs, including scheduling, documentation, charge capture, utilization reports, and materials management. Unfortunately, the system was plagued by problems associated with the year 2000, and on January 1, 2000, it crashed. For the next year, the corporation refused to purchase replacement software for the facility, and all data were collected manually or not at all.

In January 2001, the parent corporation entered into negotiations to sell the facility. The computer system used in the new owner's facilities had modest capabilities to provide required functions related to data collection. Nursing staff members had a number of concerns related to computer documentation. Although the new owners agreed to move to a fully functional information system for the perioperative area within 18 months, retaining motivated nursing staff members who were willing to learn during this highly stressful transitional period was difficult. The long-range goal was to facilitate employee training; prepare policies, procedures, and protocols; and design all of the perioperative records for the system. The delay provided an opportunity for educators to address commitment and preparedness barriers among nursing staff members and in the organization.

No matter how carefully planned and executed, converting to a computer documentation system requires adaptation and acceptance by individual nurses. The perioperative nurses in this facility questioned how computer documentation would make a difference in their practice. It was not uncommon for nursing staff members to make disparaging remarks about hospital administrators when discussing the past two computer systems. This period of intense uncertainty and indecision provided an opportunity to begin the knowledge and persuasion phases of information systems implementation.

ACCEPTING THE CHALLENGE

The introduction of computerized clinical information systems and knowledge management mechanisms allows clinical practice environments to better support the work of nurses. Computerization provides a wide range of available resources. Putting information technology systems into an area without examining and understanding the clinical processes that the system is designed to affect, however, is risky and can result in wasted resources.

Improving clinical effectiveness is a challenge that requires a coordinated effort to ensure that information about which medical interventions work is available to those in a position to use such information. The computer system in this facility would not be in place until May 2001, so hands-on computer training would not take place until that time. This provided educators an opportunity to prepare nursing staff members for the implementation. Educators had the time to initiate some of the phases in the innovation-diffusion theory conceptual framework.

Multiple factors facilitate or impede diffusion and adoption of various innovations and technology, but two factors seem critical to successful implementation--commitment and preparedness. Commitment in this context refers to nurses' support of adoption of the computer system. Preparedness refers to the structural changes made on the part of the nurse administrator to assign authority, accountability, and creativity to teams charged with creating dissemination plans. These changes also empower nurses to take risks and embrace change.

THE KNOWLEDGE PHASE

Trust in the organization's leaders is the foundation on which successful health care organizations build the environment necessary for social change and inspire people to achieve excellent clinical outcomes. To create a sustained trusting environment, leaders must act in ways that produce constancy, congruity, reliability, and integrity when interacting with those being led. (17) During the knowledge phase at this facility, it was necessary for the perioperative leader to introduce the information system to nursing staff members. She realized that staff members needed her to be available and accessible. She also needed to communicate with staff members, ensure confidentiality, and be willing to invest time in staff member development.

The steps taken by the perioperative leader to establish and sustain trust included providing computer updates and other pertinent unit information during weekly meetings. This information also was shared in a written memo that was posted for staff members unable to attend meetings. The perioperative leader visited each perioperative department daily to be available for staff members seeking information. This also provided her with timely and reliable feedback related to current issues. In addition, the perioperative leader established open meeting times for staff members who wanted to discuss individual concerns.

The plan for the hands-on phase of computer education involved computer-learning modules that recognize each individual staff member's ability to learn basic computer skills. The initial nursing staff member computer skills assessment included typing and basic computer functions. It is important to identify staff members with significant computer knowledge. These people can serve as in-house super users who can solve minor user problems.

After a series of information sharing sessions with staff members, a survey was prepared to collect data to assess staff members' computer skills and their attitudes toward computer documentation and data analysis for improving practice. The sample for this survey consisted of 43 staff nurses in the perioperative area, including the OR suite, PACU, endoscopy suite, and day surgery unit. The survey comprised 10 true or false questions designed to assess basic computer skills, such as typing, word processing (eg, edit, copy, delete, insert, format), saving information to disk, and opening files. The survey also assessed attitudes toward computers via positive readiness statements, such as

* do you think computerized documentation is valuable,

* would you like to learn more about computers, and

* do you think having data to analyze will help improve nursing practice.

Respondents could answer true or false to each question. One week after distribution, 37 completed questionnaires were returned (ie, 86%).

The results show that 81% of nursing staff members have typing skills, but only 8% have an understanding of computer functions used consistently when working with text (Table 1). When asked about the value of computer documentation and the desire to increase their computer skills, 94% of respondents answered positively. When asked about the value of having data to analyze, 54% answered positively about using this method to improve practice.

PERSUASION PHASE

During the persuasion phase, nurses tend to internalize computer knowledge and develop an attitude about the information system. This phase of learning involves perceptions, peer influences, and the incorporation of variety into the training content. Peer trainers serve as effective resources for communicating information and exerting a positive influence on the group. During this phase, it was important to provide training information that described the advantages of computerized documentation and its compatibility with perioperative nursing functions. The leader presented 50-minute inservice programs for staff members to outline the positive aspects and challenges of computerized documentation. Topics covered included

* identifying the benefits and advantages of using computer technology versus current practice;

* ensuring that computerized records are compatible with values and beliefs and uphold the standards and recommended practices of AORN;

* ensuring that computerization improves efficiency and effectiveness without diminishing nurses' role as care providers; and

* identifying nurses influential in current documentation practices and including them in record design and development of policies, procedures, and protocols.

For staff members unable to attend inservice programs, the leader prepared an outline of the information discussed and planned to repeat the information again six weeks before hands-on computer training. The lecture series was deemed successful because discussions were lively, thoughtful questions were asked, nurses freely expressed their concerns related to computer knowledge, and they showed interest in data collection. Unfortunately, 54% of nursing staff members were unable to attend the morning sessions; therefore, the next sessions were repeated in the afternoon.

ADDING NURSING SKILLS

Perioperative nurses must become skilled users of nursing knowledge and accept information systems as tools of the trade. Having a full understanding of current regulatory requirements is central to documentation, but having staff members involved with computer documentation is imperative. Nursing staff members need to be aware of the positive aspects of computer documentation. Having staff members excited about designing a computer record that fulfills all the domains of practice can help ensure the successful adoption of information technology. Encouraging nursing staff members to join individual teams for developing each aspect of the computer implementation process, including policy, care planning, and record development, recognizes their importance and includes them in the change process.

The long-range plan for computer training does not begin or end with the keyboard; it starts with each nurse's acceptance of computerization, which can lead to improved practice through the study of outcomes. Increased prominence is being given to the use of best practices and program management decision-making. Much clinical practice is based on limited evidence, mostly in the form of textbook information, obsolete premises, untrustworthy research or case studies, partial or unendorsed reviews, or anecdotal or personal clinical experiences. (18) To use evidence-based decision-making, nurses must be skilled in searching, evaluating, storing, and using information and knowledge. To do this, they must embrace the computer as a tool of their trade. By exposing staff members to current research material pertinent to perioperative nursing, leaders can reinforce the value of accurate data collection. By encouraging them to speculate on data collection options relevant to perioperative topics (eg, surgical site infection, unplanned returns to surgery), leaders continue to develop the groundwork for future perioperative research. It is through research that leaders can advance perioperative nursing knowledge and support the use of evidence-based decisions that improve nursing practice.

Frequent and effective communication among individuals who share the same language, professional culture, and work environment is a key factor in the adoption of technology. By communicating in a manner that is constant, congruent, reliable, and honorable, leaders can move the information system innovation concept through the diffusion channels that enhance adoption by perioperative staff members.

Computer acceptance is a key determinant in fostering positive attitudes and facilitating successful learning. Information systems are critical resources for providing information essential to supporting patient care, administrative operations, and strategic decision-making. Many factors determine the direction of emerging health care technology, including new laws that mandate how nurses are expected to protect and distribute patient information. The implementation of a clinical information system represents a time of change and a significant challenge for nursing.

Table 1

ASSESSING COMPUTER SKILLS AND DATA IMPORTANCE (N=37)

Assessed Information                      Yes   Percent   No   Percent

Typing skills                              30        81    7        19
Edit text                                   3         8   34        92
Delete text                                 3         8   34        92
Insert text                                 3         8   34        92
Format text                                 3         8   34        92
Saving to disk                              3         8   34        92
Opening files                               3         8   34        92
Is computerized documentation valuable?    35      94.5    2       5.5
Want to learn more computer skills?        35      94.5    2       5.5
Is having data to analyze helpful for
  improving practice?                      20        54   17        46

NOTES

(1.) J L Parker, P A Abbott, "The new millennium brings nursing informatics into the OR," AORN Journal 72 (December 2000) 1011-1017.

(2.) E Miller, E Arquiza, "Improving computer skills to support hospital restructuring," Journal of Nursing Care Quality 13 (June 1999) 44-56.

(3.) E M Rogers, Diffusion of Innovations, fourth ed (New York: The Free Press, 1995).

(4.) S Grobe, "Nursing informatics competencies for nurse educators and researchers," in Preparing Nursing for Using Information Systems: Recommended Informatics Competencies, ed H E Peterson, U Gerdin-Jelger (New York: National League for Nursing, 1988) 25-40.

(5.) E P Geraci, "Computers in home care: Applications of change theory," Computers in Nursing 15 (July/August 1997) 199-203.

(6.) R Nahm, I Poston, "Measurement of the effects of an integrated, point-of-care computer system on quality of nursing documentation and patient satisfaction," Computers in Nursing 18 (September/October 2000) 220-229; B A Happ, "The effect of point of care technology on the quality of patient care," Proceedings--The Annual Symposium on Computer Applications in Medical Care (1993) 183-187.

(7.) M Hebert, "Implementing Computers on Nursing Units at Red Deer Regional Hospital Centre" (PhD dissertation, University of Alberta, Edmonton, Alberta, 1986); M Hebert, I Benbasat "Adopting information technology in hospitals: The relationship between attitudes/expectations and behavior," Hospital & Health Services Administration 39 (Fall 1994) 369-383; D G Lacey, "Nurses' attitudes towards computerization: A review of the literature," Journal of Nursing Management 1 (September 1993) 239-243.

(8.) A Brodt, J H Strange, "Nurses' attitudes towards computerization in a Midwestern community hospital," Computers in Nursing 4 (March/ April 1986) 82-86.

(9.) P B Friel, M Reznikoff, M Rosenberg, "Attitudes towards computers among nursing personnel in a general hospital," Connecticut Medicine 33 (May 1969) 307-308; S Krampf, S Robinson, "Managing nurses' attitudes toward computers," Nursing Management 15 (July 1984) 29-34; P Ngin, L M Simms, M Erbin-Roesemann, "Work excitement among computer users in nursing," Computers in Nursing 11 (May/June 1993) 127-133.

(10.) K Hannah, "Using computers to educate nurses," in Nursing Informatics: Where Caring and Technology Meet, second ed, M J Ball ed (New York: Springer, 1988) 289-299; R D Henderson, F P Deane, "User expectations and perceptions of a patient management information system," Computers in Nursing 14 (May/June 1996) 188-193; Hebert, Benbasat, "Adopting information technology in hospitals: The relationship between attitudes/expectations and behavior," 369-383.

(11.) K Saranto, H Leino-Kilpi, "Computer literacy in nursing: Developing the information technology syllabus in nursing education," Journal of Advanced Nursing 25 (February 1997) 377-385.

(12.) N Staggers, P L Parks, "Description and initial applications of the Staggers & Parks Nurse-Computer Interaction Framework," Computers in Nursing 11 (November/December 1993) 282-290.

(13.) J Hammond et al, "A qualitative comparison of paper flowsheets vs a computer-based clinical information system," Chest 99 (January 1991) 155-157.

(14.) C Marasovic et al, "Attitudes of Australian nurses toward the implementation of a clinical information system," Computers in Nursing (15) (March/April 1997) 91-98.

(15.) L M Hilz, "The informatics nurse specialist as change agent: Application of innovation-diffusion theory," Computers in Nursing 18 (November/December 2000) 272-278.

(16.) R E Gilder, F Koch, S McBride, "Enhancing perioperative nursing effectiveness through informatics," AORN Journal 69 (May 1999) 978-990.

(17.) W Bennis, R Townsend, Reinventing Leadership: Strategies to Empower the Organization (New York: William Morrow & Co, 1995).

(18.) K Gerrish, J Clayton, "Improving clinical effectiveness through an evidence-based approach: Meeting the challenge for nursing in the United Kingdom," Nursing Administration Quarterly 22 (Summer 1998) 55-65.

Barbara J. Barr, RN, is director of surgical services at Henrico Doctor's Hospital, Mechanicsville, Va.

COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group