Running head: ROLE CHALLENGE

Implementation of Technology with Resistance Patricia Barnard, Nicole Cory & Jennifer Williams Ferris State University

ROLE CHALLENGE Abstract

This paper explores the phenomenon of resistance to technology within the healthcare field. This process was initiated in order to develop a plan to assist the informatics nurse specialist (INS) in the implementation of the electronic health record system (EHRS). There is a discussion of the challenge of resistance to technology and how it affects nursing practice and the INS role. Each element of the standard is addressed and explained with additional literature to support the application of this standard to the role challenge. Resistance to technology is identified as a significant issue in the role of the INS and the implications of project delay. A suggested plan is offered to improve resistance to technology and successfully implement the EHRS into the clinical setting. Details of the plan include maintaining relationships, management involvement, and identification of individual, organization, and community needs. Additional information is provided on how this plan is applicable to the INS role.

ROLE CHALLENGE Implementation of Technology with Resistance Implementing change within an organization can be a challenge (Oreg & Sverdlik,

2010). This project was initiated to identify a challenge in the INS role and apply this challenge to meeting a selected standard from the American Nurses Association (ANA). The informatics nurse specialist (INS) is often involved in technological change within the nursing environment (Sensmeier, 2010). The informatics nurse specialist is responsible for the implementation of technological changes in the healthcare environment (Sensmeier, 2010). There will be discussion on the elements of the INS role related to the standard of implementation and how the selected challenge can interfere with this process. The literature on resistance in healthcare will be utilized to support the claim that resistance to the implementation of technology can influence the informatics nurse specialists ability to complete the implementation process. In addition to applied research, a strategy that can reduce resistance will be utilized to create a plan for the implementation process. The goal for this plan will be to increase acceptance to healthcare technology and the implementation of the electronic health record system (EHRS). This plan will identify the needed components to provide an inductive learning environment that will improve collaboration, develop adequate relationships, and meet individual learning needs. The plan will also be applied to the INS role during the attempt to implement a new EHRS in the clinical environment of a health care organization. The conclusion will identify the need for a successful strategy during this process and the appropriateness of the provided plan.

ROLE CHALLENGE Role Challenge

In healthcare, the adoption of change is often met with resistance and this resistance has resulted in failure to adopt technological solutions to problems in healthcare quality (Morton & Wiedenbeck, 2010). The implementation and integration of the EHRS initiates continuing change within the healthcare organization (Sensmeier, 2010). The success of the implementation of the EHRS is reliant on acceptance of the change by staff members (Huryk, 2010). Having an understanding of factors that influence staff perceptions and acceptance of change prior to the implementation of an EHRS can assist the INS in reducing or preventing staff resistance. Identified rationale for resistance includes the concern of losing personal investment, misunderstandings regarding the change and its implications, individual perception of the change, individual low tolerance or predisposition to change, and poor trust (Reid & Gallagher, 2011). Because resistance is typically identified as negative, those that resist are typically labeled as the rival (Reid & Gallagher, 2011). This labeling can lead to seclusion and increased anxiety of the resistor (Reid & Gallagher, 2011). Change with the complication of resistance can be problematic, however there are both philosophies and frameworks available to limit or decrease this resistance (Reid & Gallagher). On the other hand, the implementation of change can be successful with anticipation of resistance, good communication and recognition of the need for the change (Reid & Gallagher, 2011). It is vital to be familiar with the motivation of resistance and to tackle any issues prior to the change (Reid & Gallagher, 2011). All things considered, resistance can be defeated with the employment of proper strategy, excellent planning, established trust and ample communication (Reid & Gallagher, 2011).

ROLE CHALLENGE Implementation: Standard Application

The INS utilizes an evidenced-based systematic approach to identifying the problem and to obtain plan outcomes (ANA, 2008). He or she must have a high level of empirical knowledge that he or she can apply to gain understanding of a situation and be able to accurately predict the potential outcomes of his or her actions (ANA, 2008). The INS must encompass and utilize applied wisdom during technology integration to support nursing practice (ANA, 2008) Despite the many benefits that technology has on patient care, the human factor presents the greatest barrier to implementations (Luo, Hilty, Worley & Yager, 2006). Resistance needs to be considered for its purpose and reconstructed into possibilities (Reid & Gallagher). It is important to allow clear expression of resistance and provide insights and additional information to those who have concerns; this can assist in moving forward with the change (Reid & Gallagher, 2011). Individuals can become resistant to change when they are unaware of what the change is (Oreg & Sverdlik, 2010). Many people have fear of the unknown (Oreg & Sverdlik, 2010). It is important for the INS to utilize his/her ability to educate staff in understanding and accepting technological changes (Oreg & Sverdlik, 2010). When implementing change, the INS should identify the persons orientation to the change using interactive communication techniques. The INS incorporates appropriate elements into the plan that address quality, project, or systems management (ANA, 2008). He or she may be involved in organizational change implemented to meet new legal mandates (ANA, 2008). The INS must also have a complete understanding of legal requirements and national standards (ANA, 2008). These standards include those from the Food and Drug Administration (FDA), National Institutes of Health (NIH), and accreditation organizations such as the Joint Commission (ANA, 2008).

ROLE CHALLENGE Resistance to the use of EHRS in healthcare can impact the quality of patient care.

Electronic health record systems can impact patient outcomes as technology is increasingly used as a strategy to improve patient safety (Kutney-Lee & Kelly, 2011). EHRS have also been linked to improvements in clinical-decision making processes (Smith et al., 2009). Studies have also shown that EHRS improve continuity and efficiency of patient care (Kutney-Lee & Kelly, 2011). It will be important that the INS create relationships in regards to the appropriate changes needed to meet the new standards for quality of care (Blumenthal, Tavenner, 2010). Specifically, provider order- entry can reduce medical errors by eliminating transcription problems and they also provide alerts and warnings to the providers when entering orders (Szydlowski & Smith, 2009). Electronic medical records increase communication, help to facilitate patient knowledge and accountability as well as help to standardize patient care within the healthcare world (Szydlowski & Smith,2009). The INS can continue to face challenges regarding implementing appropriate technological needs within organization related to resistance issues. The INS utilizes appropriate relationships within the organization and recognizes the needs of the organization throughout the implementation process (ANA, 2008). The INS must perform in multidisciplinary settings and in several functional areas (ANA, 2008). Manger-staff relationships may shape the behaviors and interactions of both parties (Furst & Cable). Organizations rely on the members willingness to support change (Furst & Cable, 2008). Management plays a large role in influencing change in employee beliefs and motivating acceptance to change (Furst & Cable, 2008). Lack of employee participation in change has been found to hinder the implementation of change (Furst & Cable, 2008). The involvement of

ROLE CHALLENGE

management within the change environment is an important aspect of change delivery (Furst & Cable, 2008). The ability to promote strong systematic interactions, in support of the implementation of the plan, is essential to the INS role (ANA, 2008). The INS often acts as a project manager and serves as a liaison between information technology (IT) staff and the end-users of an IT solution (ANA, 2008). The INS interprets across disciplines and with IT professional to insure adequate understanding of the implementation process (ANA, 2008). The organization must be strong and in a good position to present, support, encourage, and implement change (Hamelin, 2007). Success depends on many factors one of the most profound is how well the organization has prepared and able to strategize and overcome resistance to change (Luo, Hilty, Worley & Yager, 2006). Organizations that incorporates fair and appropriate change-management processes, may find themselves frustrated over the continued resistance associated with the change (Caldwell et al., 2009). When goals are not met, alternative methods and techniques should be utilized by the INS to alleviate project issues (ANA, 2008). The INS often is involved in the development of strategic plans, creates national or system policies and procedures, or serves as a leader in complex projects with multiple types of system users (ANA, 2008). However, even with in depth consideration and utilization of all resources to implement change, there will continue to be unsuccessful results of desired outcomes (Reid & Gallagher). There are four specific reasons why resistance may overpower change (Reid & Gallagher, 2011). These reasons include a hostile non-permitting environment, lack of sufficient planning by leaders, inconsistent leadership, and the reinstitution of a previously resisted change

ROLE CHALLENGE (Reid & Gallagher, 2011). The application of a successful plan will not be possible with an environment that persistently resists change (Reid & Gallagher, 2011). The INS is able to identify and appropriately utilize available resources to assist in implementation (ANA, 2008). Primarily, nurses are the users and analysts of information in healthcare (ANA, 2008). The INS utilizes tools based on nursing knowledge and input (ANA,

2008). The INS advocates for the organization by following financial guidelines and defining the organizations needs (ANA, 2008). Community and consumer needs must also be considered during the implementation process (ANA, 2008). The informatics role can be fundamental to many areas of nursing. A few of these areas include: education, organization & community. The INS incorporates insight, knowledge, and wisdom into the direct care nurses environment (Schleyer, Burch, & Schoessler, 2011). The competencies of the INS are vital to this role by assisting with the integration of health care technology into patient care. The direct patient care nurse will learn to confide in the nurse information specialist as both a mentor and an educator (Schleyer et al., 2011). The collaboration between INS and the education community is important in the creation of both informatics informed nursing graduates as well as the creation of new informatics faculty (Sensmeier, 2007). This relationship is important to incorporate and create IT standards within nursing programs and continuing this process within healthcare organization (Sensmeier, 2007). Change within the educational setting is as relevant as the needed change within nursing practice (Ozbolt & Saba). Meeting organizational needs is essential in the change process (Hamelin, 2007). It is important to identify organizational needs that my influence access to service, cost reduction,

ROLE CHALLENGE

improved care efficiency, and quality of care (Hamelin, 2007). The organization must be strong and in a good position to present, support, encourage, and implement change (Hamelin, 2007). The INS tracks the progress of the plan while reporting and documenting any need to modify from the original strategy (ANA, 2008). He or she must be able to identify and document any deficiencies in the current system (ANA, 2008). In turn, the system may need to be redesigned in order to enhance safety or remedy any inadequacies (ANA, 2008). In response to changes in the original plan, nurses may create workarounds with resistance to lengthy processes (Lalley & Malloch, 2010). Workarounds can impede progress and cause the appearance of effectively meeting goals (Lalley & Malloch, 2010). While these workarounds can present a challenge for the INS, this opportunity can be utilized to create improvements in the plan (Lalley & Malloch, 2010). Although, additional changes to the plan can often increase resistance amongst end users and in turn create additional tasks for the INS, thus lengthening the change process (Kotter & Schlesinger, 2008). The plan should be carried out timely and adhere to all safety standards required by the organization (ANA, 2008). With knowledge of appropriate safety standards the INS will be able to design and implement a system with optimal patient safety (ANA, 2008). The INS must be knowledgeable of technology safety usability testing in order to insure the successful implementation of an EHR system (ANA, 2008). The assessment of usability is performed to determine the efficiency and effectiveness of a program (ANA, 2008). Ambivalence toward change can be prominent when communication and orientation to the change are not present (Oreg & Sverdlik). Common knowledge indicates that issues related to ambivalence and resistance to change can interfere and slow the process of change. Without a

ROLE CHALLENGE good understanding of the diverse forms of resistance the INS may experience ongoing issues related to the completion of the plan (Reid & Gallagher). Technology has been used to reduce medical error rates by reducing errors in the

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documentation of vital signs (Smith et al., 2009). EHRS have also been linked to improvements in clinical-decision making processes (Smith et al., 2009). Studies have also shown that EHRS improve continuity and efficiency of patient care (Kutney-Lee & Kelly, 2011). Resistance to the usability process can contribute to unidentified issues relate to safety measures within the EHRS (Smith et al., 2009). Plan for Implementation The application of an implementation plan to the informatics specialist role can be explained simply by utilizing a hypothetical situation where implementation and integration of a new electronic health record system (EHRS) is needed in an acute clinical setting. In this case, the informatics nurse specialist would be the project manager (change agent) and would identify the needs of individuals, groups, departments, organization, and community during the change. The INS will serve as the translator between the information technology department and the identified clinical departments that will be involved in the change. In a typical situation of EHRS implementation, the medical/surgical unit (med/surg), critical care unit (CCU), emergency room (ER), pharmacy, lab, imaging, and admissions would be involved. However, med/surg, CCU, and ER will be the most involved and affected by the change. With the involvement of multiple clinical departments, the focus of this project would be the identification of anticipated resistance prior to the implementation and integration of the technological change. The INS would also be the change agent involved in the successful implementation and integration of the EHRS (see Appendix Table 1).

ROLE CHALLENGE

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The main project tasks would include (1) meeting with management and administration to determine organizational needs, systems product choice, and budget, (2) identifying organizational needs in regards to financial, cultural and ethical implications, (3) utilizing organizational knowledge regarding receptive social groups within each department, and (4) considering additional resources along with the affects of the project on consumers and community. In addition to these main tasks, the INS would need to insure the creation of an EHRS team to include representation of all departments. Meetings with this team will serve as a discussion point between choice of the EHRS, design, and changes made to the system; this will allow for identification of departmental needs and concerns. The INS will also utilize this plan along with his/her knowledge to involve management and administration in the implementation and integration process. This will include assistance with educating and informing staff of the advantages and disadvantages of the change. Managers could also be challenged with intermittent visits to departments as well as discussion of the change in departmental meetings. In addition to this, it will be imperative to consult management & administration regarding issues of continued resistance despite all efforts to include, inform, and educate the staff involved. The INS will identify community needs and consider the incorporation of additional organizations in the process plan. Due to the possible effects of new technology implementation on other disciplines in the community, maintaining good relationships with these disciplines will be essential. The INS should identify any additional requirements that may be needed to meet the needs of consumer and community relationships. Within the clinical setting, the INS will need to create a clinical team to discuss the inclusion of clinical and practice needs, identified by nurses, into the development of the system.

ROLE CHALLENGE

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Also, the incorporation and support of clinical judgment will be needed during the development of the new systems. This process will be utilized to confirm adequate clinical needs as identified by the appropriate clinical groups. In many cases, individual needs will need to be identified in order to create an effective educational program for implementation and integration of the EHRS. During group or departmental education, the INS will also need to identify individuals that may need alternative education regarding the change. This process will assist in providing unique learning techniques to those experiencing difficulty or anxiety related to the change. In addition to staff education, adequate time should be provided for individuals to participate in usability testing before the system is finalized. This will assist in identifying issues or concerns related to the safety and efficiency of the system prior to the integration of the new program into the clinical setting. Feedback and input from these sessions will assist in the involvement of staff in creating a user friendly system. Conclusion Understanding resistance can aid in strengthening organization and individuals during change (Reid & Gallagher). The INS should be able to identify resistance as an issue prior to the implementation of the EHRS. It is vital to identify the motivation of the resistance and to tackle any issues prior to the change (Reid & Gallagher, 2011). Utilizing community resources to assist in a better understanding of the consumer utilization of the EHRS is essential to the implementation process. High-quality relationships should be maintained with multiple disciplines throughout the community. Utilizing the input from resources and disciplines in the community can assist in understanding consumer needs during the implementation process.

ROLE CHALLENGE Resistance may cause issues while the INS attempts to follow the standard of

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implementation within the role. The identification of both organization and individual needs can assist with this process. Creating an implementation plan that is individual to the organization can assist in the staffs understanding of the need for the change. The inclusion of management throughout the process as well as usability testing prior to the final implementation of the EHRS is vital. Management can assist in dealing with issues related to continued resistance, while usability testing allows end users to identify any issues with safety or functionality of the EHRS. All things considered, resistance can be defeated with the employment of ample communication, adequate relationships, appropriate planning, proper strategy, and excellent planning.

ROLE CHALLENGE References

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American Nurses (2008). Nursing Informatics: Scope and Standards of Practice. Silver Springs, MD: Nursebeooks.org. Blumenthal, D., Tavenner, M. (2010) Meaningful use: Regulation for electronic health records. The New England Journal of Medicine, 36 (3), 501-504. doi:10.1056/ NEJMp1006114 Caldwell, S., Liu, Y, Fedor, D.B., Herold, D.M. (2009). Why are perceptions of change in the ''eye of the beholder''? : The role of age, sex, and tenure in procedural justice judgments. Journal of Applied Behavioral Science, 45 (3), 437-459. doi:10.1177/0021886309336068 Furst, S., & Cable, D. (2008). Employee resistance to organizational change: Managerial influence tactics and leader-member exchange. Journal of Applied Psychology, 93 (2), 453-462. doi:10.1037/0021-9010.93.2.453 Hamelin, B. (2007). Engaging health care workers in improving their work environment. Journal of Nursing management, 15 (3), 331. doi:10.1111/j.1365-2843.2007.00678.x Huryk, L. A. (2010). Factors influencing nurses attitudes towards healthcare information technology. Journal of Nursing Management, 18 (5), 606-612. doi:10.1111/j.13652834.2010.01084.x Kotter, J. P. & Schlesinger, L. A. (2008). Choosing strategies for change. Harvard Business Review, 86 (7), 130-41. Retrieved from http://0.go.galegroup.com.libcat.ferris.edu/ ps/i.do?id=GALE%7CA182071257&=2.1&u=lom_ferris Kutney-Lee, A., & Kelly, D. J. (2011). The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety. Journal of Nursing Administration, 41 (11), 466-472. doi:10.1097/NNA.0b013e3182346e4b

ROLE CHALLENGE Lalley, C. & Malloch, K. (2010). Workarounds: The hidden pathway to excellence. Nurse Leader, 8 (4), 29-32. doi:10.1016/j.mml.2010.05.009 Luo, J. S., Hilty, D. M., Worley, L. L., & Yager, J. (2006). Considerations in change management related to technology. Academic Psychiatry, 30 (6), 465-469. doi:10.1176/appi.ap.30.6.465

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Morton, M. E. & Wiedenbeck, S. (2010). EHR acceptance factors in ambulatory care: A survey of physician perceptions. Perspectives in Health Information Management, 7 (1), 1-17. Oreg, S. & Sverdlik, N. (2010). Ambivalence toward imposed change: The conflict between dispositional resistance to change and the orientation toward the change agent. Journal of Applied Psychology, 96 (2), 337-349. doi:10.1037/a0021100 Ozbolt, J.G., & Saba, V.K. (2008). A brief history of nursing informatics in the United States of American. Nursing Outlook, 56 (5), 199-205.doi:10.1016/j.outlook.2008.06.008 Reed, J. & Gallagher, M. (2011). Resistance to change: Friend or foe. Health Progress, 92 (4), 14-19. Retrieved from http://www.chausa.org/2011_Annual_Index.aspx Schleyer, R. H., Burch, C. K., Schoessler, M. T. (2011). Defining and integrating informatics competencies into a hospital nursing department. CIN: Computer, Informatics, Nursing, 29 (3), 167-173. doi:10.1097/NCN.0b013e3181f9db36 Sensmeier, J. (2010). Alliance for nursing informatics statement to the Robert Wood Johnson foundation initiative on the future of nursing: Acute care, focusing on the area of technology, October 19, 2009. CIN: Computers, Informatics, Nursing, 28 (1), 63-67. doi:10.1097/NCN.0b013e3181c9017a Sensmeier, J. (2007). The future of IT: Aggressive educational reform. Nursing Management, 38 (9), 2-8. doi:10.1097/01.NUMA.0000288833.71770.68

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Smith, L., Banner, L., Lozano, D., Olney, C., & Friedman, B. (2009). Connected care: Reducing errors through automated vital signs upload. CIN: Computers, Information, Technology, 27 (5), 318-323. doi:10.1097/NCN.0b013e3181b21d65 Szydlowski, S. & Smith, C. (2009). Perspectives from nurse leaders and chief information officers on healthcare information technology implementation. Hospital topics, 87 (1), 39.

ROLE CHALLENGE Appendix Hypothetical Implementation Plan Table 1 Hypothetical application of implementation plan to the nurse informatics specialty: Project: creation, implementation and integration of new electronic health record system (EHRS) in the acute care setting. Project Manager: Informatics Nurse Specialist Involved Departments: Med/Surg unit, CCU, ER, Pharmacy, Lab, Imaging, Admissions Departments most affected by the change: Med/Surg unit, CCU, ER Focus: Clinical department resistance during implementation and integration of technological change. Project tasks: Organizational needs & Management involvement:

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Meet with management and administration to determine organizational needs, systems product choice and budget. Identify organizational needs in regards to financial, cultural and ethical implications. Utilize organizational knowledge regarding receptive social groups within each department. Create an EHRS team to include representation of all departments. Meetings will serve as a discussion point between choice of EHRS system, design and changes made to the system; this will allow for identification of departmental needs and concerns. Involve management & administration in integration to assist with educating and informing staff of the advantages and disadvantages of the change. This can be completed with intermittent visits to departments as well as in departmental meetings. Involve management & administration during issues regarding continued resistance despite all efforts to include, inform and educate the staff involved.

ROLE CHALLENGE Clinical judgment & Clinical practice: Create a clinical team to discuss inclusion of clinical and practice needs, identified by nurses, into the development of the system. Incorporate and support clinical judgment, during development of the new system, to confirm adequate clinical needs. Individual needs: Create educational program for implementation and integration of the EHRS. During group/departmental education, identify individuals that may need alternative education regarding the change. Provide unique learning techniques to those experiencing difficulty or anxiety related to the change.

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Provide individuals time to practice in test, with the new system, to identify issues or concerns regarding the integration of the new program into the clinical setting. Consumer & Community Needs: Identify and utilize community resources by creating informational meetings regarding the plan. Maintain relationships with other disciplines throughout the community. Identify consumer needs in relation to patient involvement with the EHRS.