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Nurses and Clinical Technology: Sources of Resistance and Strategies for Acceptance

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Nurses and Clinical Technology: Sources of Resistance and Strategies for Acceptance Information Systems & Technology Debra Kirkley Maribeth Stein Nurses and Clinical Technology: Sources of Resistance And Strategies for Acceptance To explore the specific reasons behind this resis- Executive Summary tance, an electronic roundtable was conducted fol- ᮣ Many organizations in the process of introducing lowed by phone interviews with nurse leaders at four online clinical documentation and other nursing health care organizations: three in the United States functionality have experienced resistance — at and one in the United Kingdom. The goal was to elic- least initially — from the nursing staff. it candid opinions and anecdotes from nurse execu- ᮣ Rather than meeting these objections individual- tives on the front lines of technology initiatives. ly, implementing clinical information systems (CIS) requires organization-wide change manage- These individuals are nurse leaders in organizations ment initiatives that put the need for automated that have successfully made the leap to automated processes in a global perspective. systems, and their experiences provide insight into ᮣ A roundtable discussion with nurse leaders identifying and circumventing the obstacles that can revealed that cultural and societal factors may arise during technology rollouts. play a larger role in nurses’ willingness to The respondents focused on three fundamental embrace the CIS than attitudes toward computers questions: themselves. •Why are some nurses reluctant to adopt CIS? •Can you identify the types of nurses who are more SMOREHEALTHCAREorganizations seeking or less likely to embrace CIS? improvements in patient safety and increases •What are successful methods to overcome this in productivity take the plunge to adopt clin- resistance? ical information systems (CIS), an increasing Within the framework of these questions, several Anumber of nurse executives face the prospect of getting consistent themes emerged from the discussions, their staffs engaged with using information technology most relating to the idea that resistance has less to do (IT) to directly support nursing workflow. with specific functionality of the technology — Significant change can be unsettling for employ- screen design or the mouse, for example — than with ees in any setting, and health care certainly is no dif- cultural factors such as lack of time and loyalty to the ferent. Many organizations in the process of intro- historic model of paper documentation. The follow- ducing online clinical documentation and other ing is a discussion of those themes, which highlights nursing functions have experienced resistance — at direct feedback from respondents with the hopes of least initially — from the nursing staff. Rather than suggesting opportunities for further inquiry. meeting these objections individually, implementing CIS requires organization-wide change management Why Are Nurses Reluctant to Adopt Clinical initiatives that put the need for automated processes Information Systems? in a global perspective. According to a 2004 Nielsen/Net Ratings study, Despite recognition that user response largely nearly 75% of Americans — more than 200 million determines the success of a technology implementa- people — have access to the Internet from home, tion, and the fact that significant resources are spent using the Internet to shop, conduct research, and on strategic programs to promote acceptance, there is communicate via e-mail, among other activities. As a dearth of research examining the factors that con- personal computers, the Internet, and ATMs become tribute to nurses’ resistance to CIS. In one of the most more ubiquitous, roundtable respondents said that recent studies on nurses’ opposition to IT, Timmons nurses also are increasingly familiar with fundamen- (2003) found that resistance takes a variety of forms tal activities such as typing on a keyboard, using a and is a complex, multidimensional phenomenon mouse, or navigating multiple screens. worthy of additional study. “In the past 5 years, comfort or experience with computers has become much less of an issue. Now that nurses have more experience with computer DEBRA KIRKLEY, PhD, RN, is former Director of Nursing technology in varied aspects of life, we’re not seeing Informatics, IDX Systems Corporation, Seattle, WA. the computer phobia we saw 10 years ago,” said MARIBETH STEIN, MN, MBA, RN, is Director of Sales Operations, Demi Rewick of PeaceHealth, an integrated delivery IDX Systems Corporation, Seattle, WA. network in the Pacific Northwest. This column is sponsored under an educational grant from 216 NURSING ECONOMIC$/July-August 2004/Vol. 22/No. 4 So why does a nurse, who may enjoy browsing always ‘user friendly,’ can become time consuming. for the latest New York Times best seller on Practitioners feel that they are somewhat taken away Amazon.com, recoil at the announcement that she from the important roles as a nurse for yet again more soon will be charting online? administration.” Respondents and researchers attribute initial For some nurses, time pressure may contribute to resistance to a wide array of factors, often from spec- incomplete documentation on paper. If nurses in an ulative fears or perceptions of the system prior to organization have routinely “saved time” by submit- actually using it. Because these points of resistance ting incomplete paper documentation, then the are cultural in nature, it takes a global change man- “completeness” of documentation ensured by a good agement program to overcome them. While it’s technology implementation may actually take more impractical to tackle each single reason independent- time. Studies support the idea that a CIS may not ly, many organizations have successfully developed reduce the time a nurse spends on documentation, strategic internal communication programs that but also suggest that technology use helps to increase address points of resistance as a whole. the quality of the data and charting compliance Nurses do not resist technology itself. What they (Fraenkel, Cowie, & Daley, 2003). The payoff is a resist is the addition of one more item to their work- complete medical record; an outcome essential to day. A significant point of resistance may come down patient safety. to the nurses’ fear that online charting will take more There are steps that organizations can take to time than paper charting. According to Timmons help nurses make up the additional time spent on the (2003), the most common criticism from nurses about more comprehensive documentation. Building in CIS was that the systems were time consuming. timesavers by eliminating redundancy, replacing Last year, the Institute of Medicine (IOM, 2003) human activities (for example, phone calls, referrals) published Keeping Patients Safe: Transforming the with electronic alternatives, and ensuring compli- Work Environments of Nurses, calling for substantial ance with documentation standards by using system improvements to nurses’ work environments to capabilities such as required fields that must be filled increase patient safety. A cornerstone of the report is in by the user all are effective methods. the idea that currently most nurses’ schedules are Jan Wilson of Lehigh Valley Hospital and Health overloaded, and they must care for an inordinate Network (LVHHN) also argues that some disdain for number of patients on any given shift. In addition to online clinical documentation comes not from docu- a hefty patient load, nurses must deal with increas- menting on the computer, but from the act of docu- ingly acute populations, as well as more complex menting itself. documentation requirements. The thought of adding “Nurses don’t see a benefit in general for docu- one more task to an already frantic day can justifiably mentation; they see it as a legal necessity,” Wilson seem daunting. said. “Do nurses like documenting on paper? No. Do According to Mary Ann Anderson of Wake Forest nurses like doing it online any better? No.” University Baptist Medical Center (the Medical Clinicians’ reluctance to document is often Center), when the organization first undertook its thought of as a new problem, but that is hardly the major implementation effort 9 years ago, some nurs- case. While paper-based records are today considered es were wary of using the new technology. the gold standard in documentation, patient-centered “In the beginning, nurses can see a computer as hospital care records did not even exist in the early getting in the way because they have so many com- 1900s. At the turn of the century, the only records of peting initiatives,” she said. “They think, ‘I’ve got a care maintained were the occasional entries made in patient who needs medication, I have to get them on a physician’s private notebook, kept in his office to a bed pan, and answer a doctor’s questions — and aid his research. now I have to log in and input information, too?’” It was not until 1919, when the American College This is even more apparent on busy critical care of Surgeons decided “they could only guarantee high units, said Kimberly Evans at the Medical Center. quality surgical care by setting minimal standards for “Nurses in ICU settings have an even higher frequen- the hospitals in which their surgeons worked” that a cy of activities; they’re taking vital signs every 15 new standard was born (Timmermans & Berg, 2003, minutes instead of every 4 hours,” she said. “Nurses p. 42). One of their “core criteria was the presence of in those settings feel they don’t have time to deal a complete, accessible and accurate
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