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1. Introduction

  1. chapter and author info
  2. Getting physicians to accept new information technology: insights from case studies
  4. 1. Introduction

In the other 2 cases, the implementers' responses reinforced the resistance behaviours. Three types of responses had such an effect in these cases: implementers' lack of response to resistance behaviours, antagonistic responses, and supportive responses aimed at the wrong object of resistance. The 3 cases we analyzed showed the importance of the roles played by implementers and users in determining the outcomes of a CIS implementation.

The potential contribution of a clinical information system CIS to the quality of health care 1—3 is generally acknowledged, and numerous hospitals have been engaged in their implementation. Physicians play a critical role in the success of CIS implementation, 10—13 but many are reluctant to use IT tools.

We also sought to determine whether resistance was an a priori reaction or whether it developed only later, during the implementation. For our analytical framework, we drew from a model that suggests that, when a CIS is introduced, resistance behaviours occur if users perceive threats from the interaction of initial conditions and system features. For our study, we selected 3 hospitals in which CIS had been or was being implemented.

The cases were selected with enough similarities and differences so as to maximize variation and allow for comparison Table 1. For data collection, we used direct observation, documentation and interviews, with interviews being the principal source of data. The initial people interviewed were the project manager, the nursing director and the medical director at each hospital. A snowball sampling strategy 21 , 22 was then used, whereby those interviewed identified additional people whom they thought held critical information about the project, had exhibited extreme behaviours of acceptance or resistance, or portrayed the typical behaviours of their professional group.

Data collection ended when information obtained from additional respondents could not be justified in terms of effort and resources. Following an interview protocol, additional questions were prompted to ensure data completeness and comparability. Interviews lasted one hour on average. Data gathered through observation and documentation were used to validate and complement the interview data. Forty-five segments of the transcripts were coded by several judges; intercoder reliability was found to be adequate.

Data were analyzed in 2 stages. Second, common patterns were revealed through cross-case analysis. The analysis of CIS implementation at the 3 hospitals revealed the dynamics of resistance in each case. CIS implementation was planned at a new community hospital. At the time of staff recruitment, all nurses and physicians were informed that they would be using the CIS.

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A multidisciplinary committee of physicians, nurses and other professionals was formed to evaluate available systems and identify the one best suited to meet the hospital's needs. After an exhaustive review, the committee selected Alpha the real name of the system has been withheld to protect the anonymity of the hospital. The implementers the head of physicians, the head of nursing, the hospital's chief executive officer [CEO] and the project manager , invited physician department heads as well as some nurses and clinicians to try the system.

To promote the system, they also created committees to encourage the participation and involvement of the users. With the system's introduction 2 years later, the principal tool in medical practice, the paper file, was replaced with a computer monitor. Use of the CPOE computer physician order entry module for test requisitions and results represented a major change in the interface between physicians and patient files.

The system not only affected work methods, it also required that physicians spend more time — up to 1. Although the doctors put little effort into learning how to use the system, the implementers decided to continue with the project as scheduled. Eighteen months later, a second module, the computerized care plan, was added for documenting prescriptions for care and treatment. Previously, physicians usually prescribed care and treatment by giving oral instructions to nurses. With the new computerized module, prescriptions had to be entered into the system only by physicians.

Several doctors refused to do so. During these interactions, the object of resistance changed from the system's features to the system's significance as physicians started to feel that the system was undermining their relationship with the nurses. Although physicians reacted to this change at first by voicing their personal indignation, they then united and informed the hospital's CEO that they could not accept such a situation.

The implementers chose not to intervene at this point and asked the physicians to try to be more cooperative. In the following months, physicians' complaints escalated. When physicians demanded the system's withdrawal, the implementers stated that the project would continue as scheduled and told the physicians to continue using the system while attempts were made to modify some features. The hospital's board of directors decreed that 6 physicians who refused to use the system be denied the right to admit patients.

At this point, the system's implementers became the object of resistance. Some doctors resigned. Those who remained asked their professional association for assistance. As a result of the resignations, the emergency department could no longer function, and concerns arose that the hospital might have to close. The provincial ministry of health intervened, dismissed the CEO and put the hospital under trusteeship.

CIS implementation was planned at a university hospital where all of the health care professionals, including physicians and residents, saw the new system as a way to prepare for the 21st century. The implementers the head of physicians, the head of nursing, the hospital CEO, a physician project manager and another, non-physician project manager agreed to a common implementation strategy.

A multidisciplinary committee, including physicians, nurses and other health care professionals, was formed to review the systems available on the market. As in case 1, the Alpha system was chosen. The first steps in the implementation process included promotional and training activities that targeted primarily physicians and nurses. The first module that was introduced handled admissions, transfers and discharges. It was soon followed by a CPOE module for test requisitions and results.

Most physicians initially adopted the system without any major incidents. Some seemed more reluctant than others to use the system; their respective department head met with each of them and reiterated the importance of the project. Other physicians reacted through humour.

chapter and author info

An example involved requests for radiographs. Formerly, one requested a radiograph by completing a form. In response, the physician responsible for the CIS implementation sent the physician a referral for a psychiatric consultation. That ended the story. When the pharmacy module was introduced a few months later, it was quickly perceived as an inefficient way to prescribe medications. The physicians considered the system a threat to patient safety and their ability to deliver quality care.

The residents sent a letter to management in which they requested among other things the withdrawal of the pharmacy module. They stated that they would return their keys to the system, which would have meant a return to paper files. The hospital administration took the residents' requests for changes into consideration and responded wherever possible.

As a result, the schedule of system implementation was relaxed and the pharmacy module withdrawn so that necessary improvements could be made. Four years after the start of the implementation process, all parties were using the system, and the project was considered a success Fig.

See Fig. This case involved a university hospital. Once the decision was made to acquire a CIS, a multidisciplinary selection committee was formed. The committee assessed several systems and chose Delta the real name of the system has been withheld to protect the anonymity of the hospital. The medical staff, especially on the surgery units, were enthusiastic about the idea of getting a computerized system.

To keep up the momentum, the implementers the head of physicians, the head of nursing, the hospital CEO and the project manager created a medical committee and organized training sessions. They chose the surgery units to be the pilot sites because all of the surgeons and residents had a positive attitude toward the system and had participated enthusiastically in the training sessions.

Getting physicians to accept new information technology: insights from case studies

Despite their initial enthusiasm, when the CPOE module for test requisitions and results was implemented, the surgeons quickly developed reservations about how well the system met their needs. Entering prescriptions was tedious and time-consuming. The surgeons and the residents complained forcefully about the system's complexity and the fact that it had resulted in abrupt changes in their work habits.

The implementers did not respond to these complaints. The physicians' dissatisfaction with the computer system stirred up pre-existing conflicts with the nurses and resulted in new confrontations between the 2 groups. The physicians felt as if they were doing nurses' work, because the prescription data they had to enter were used to create nursing care plans.

The nurses refused to enter orders when asked by the physicians. Heated discussions occasionally ensued. In an attempt to find a peaceful solution and satisfy the physicians, the implementers asked nurses to enter data for the surgeons and even appointed a full-time nurse for the task.

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  • Although this solution brought peace for a while, the use of the newly introduced pharmacy module brought unorthodox prescription procedures to the attention of the pharmacists, who reacted by insisting that the rules be followed to the letter. The module's introduction raised the issue of the entire process by which professional responsibility is exercised by physicians and pharmacists, and the latter group wanted to take control of the process of prescribing and distributing medications.

    This request increased resistance among the surgeons. The surgeons chose a representative to discuss the issue with the hospital's CEO. Eight months after the introduction of the system, the representative demanded that the CIS be withdrawn. The communication of change from the onset could make or break change because it falls under the planning phase of change. If employees do not understand the need for change, why ask for a buy in the first place?

    When upper management plans and communicates early and effectively with all employees and explains the reasoning behind the change, employees are much more likely to buy into it. If there is no immediate information to communicate during the change, telling employees that there is no update regarding the ongoing change is communication! Be present and available for questioning. Miscommunication is if you communicate insignificant or insensitive information. See Effective Communication Tools. During periods of change, some employees may feel the need to cling to the past because it was a more secure, predictable time.

    If what they did in the past worked well for them, they may resist changing their behavior out of fear that they will not achieve as much in the future. The less the organization knows about the change and its impact on them, the more fearful they become. The organization needs to be prepared for the change. In the absence of continuing a two-way communication with leadership, grapevine rumors will fill the void and sabotage any change effort.

    Loss of Control: This is a key reason why employees resist change. Familiar routines help employees develop a sense of control over their work environment. Being asked to change the way they operate may make employees feel powerless and confused. People are more likely to understand and implement changes when they feel they have some form of control.

    Keeping the doors of communication open and soliciting input, support, and help from employees let them know that their contributions matter. Involve them, elicit their feedback, let them volunteer for participatory roles in the change and all of these, in turn, will help give them a sense of control during periods of change.

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    Lack of Competence: This is another major reason out of the 12 reasons why employees resist change in the workplace. This is a fear that is difficult for employees to admit openly. Therefore, the only way for them to try and survive is to kick against the change. Some employees resist change because they are just hesitant to try new routines, so they express an unwillingness to learn anything new. Frankly, they also hinder their own personal growth and development. Sometimes it is not what a leader does, but it is how, when and why she or he does it that creates resistance to change!

    Organizational employees will resist change when they do not see anything in it for them in terms of rewards. This often means that organizational reward systems must be altered to support the change that management wants to implement. The reward does not have to always be major or costly. Office Politics: Every organization has its own share of in-house politics. They may also resist showing that the person leading the change is not up to the task.

    These employees are committed to seeing the change effort fail. Changing the organizational structures may shake their confidence in their support system. They may worry about working for a new supervisor, in a new team, or on unfamiliar projects because they fear that if they try and fail, there will be no one there to support them.

    Former Change Experience: Our attitudes about change are partly determined by the way we have experienced the change in the past. For instance, if in your organization, you have handled change badly in the past, the employees will have good reasons for rebelling. Employees, who live in the same house, shop at the same stores, visit the same social club, and drive the same routes daily throughout their formative years may have more difficulty dealing with change than people who grew up in several different neighborhoods.

    Organizational stakeholders will resist change to protect the interests of a group, team friends, and colleagues. It is normal for employees to resist change to protect their co-workers. This could be pure because they sympathize with their friends because of the change that has been thrust at them. Managers too will resist change to protect their work groups or friends. All these behaviors can sabotage the success of any change.

    Successful organizational change does not occur in a climate of mistrust. Trust, involves faith in the intentions and behavior of others. Mutual mistrust will be the bane of an otherwise well-planned change initiative. Any sweeping changes on the job can cause employees to fear for their roles in the organization.

    Employees resist change because they are worried that they may not find another job easily and quickly. As an employee, see the slides below to know how you can deal with Change in the Workplace —. As a leader in an organization, see these slides below showing how you can initiate and manage Change in the Workplace:. Change Management by Catherine Adenle. The following five tips will help an organization move forward, even if it faces a sea of resistance. Leaders must develop the proper attitude towards resistance to change and realize that it is neither good nor bad.

    In fact, resistance can serve as a signal that there are ways in which the change effort should be modified and improved. Organisations should share information with employees as soon as possible. However, this is a dilemma for public companies, where investor communication is a priority and then employees hear about a merger or reorganization on their car radio while on their way to work. Once fear and insecurity are heightened, an organization will waste a lot of time getting back to a place of order, understanding, and productivity, and many people will first head to their desks to update their CV call employment agencies and their families.

    Communication — Must be timely, straightforward, true, and consistent. Must contain reasons for the change, the plan, what needs to be achieved, a question and answer segment at the end. Remember to use a variety of communication pathways and vehicles. Some organizations make an enormous mistake in using only one vehicle, such as e-mail or the company intranet site. Find out what their fears are. What would it take for them to overcome those fears and support them?

    Usually, people with high self-esteem and self-confidence are better equipped to deal with changes in both their personal and organizational life. They can see the change process from a broad perspective. They have confidence, not only in themselves but in the leadership above them. Self-confident people have an understanding of their part in the change process and see the value of dealing with change positively. This positive mental outlook enables them to consider the possibility that the change process might even provide greater opportunities for them and enhance their personal and career growth.

    Managers should look to use these employees first as their change evangelists. These are the people that can help convert the employees that are resisting change. Getting them involved will alert you to potential drawbacks and challenges. Listen, Listen and Listen — When you use questioning strategies to engage employees in searching for solutions gathering support for change efforts, listening is highly critical.

    Listen with an open mind. Listen to all input. The Blokehead. Building Effective Teams. John Power. Selling Techniques. Mark L Rushworth. Problem-Solving: The Owner's Manual. Pierce Howard. Interview Confidence. Nick J. Managing People. Martin Farrelly. Jeremy Cruz. Get That Job!


    How To Succeed At Interview. Trevor Anderson. From Problem-Solving to Problem-Finding. Michael A. Managing in Changing Times. Tom McConalogue. Mastering Interview Skills, 2nd edition. Dato' R. Palan Ph. Robert Bacal. Zoe Wilkes. Listening: the Art of Speech Evaluation. Val Adolph. Strategic Career Development. Katamani A. Job Interview Essentials. Matt McGinniss. Profiting from the Clash of Ideas. Dr Jim Porter. Wolfgang Matejek. Christopher Schroeder. Effective Communications. McKinsey Seven S Model. Thomas Egner.

    1. Introduction

    Gathering Business Information. John Cullen. Classroom Instruction from A to Z. Barbara Blackburn. Collecting primary data.

    Job Rejection

    John Fisher. Helen Metz. Consumer Buying Behaviour. Wanchat Kengthon. Ciaran Fenton.