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Nurses’ adoption of technology: Application of Rogers’ innovation-diffusion model
Nurses’ Adoption of Technology: Application of Rogers’ Innovation-Diffusion Model Ting-Ting Lee
This qualitative study applied Everett Rogers’ innovation-diffusion model to analyze nurses’ perceptions toward using a computerized care plan system. Twelve nurses from three respiratory intensive care units in Taiwan voluntarily participated in a one-on-one, in-depth interview. Data were analyzed by constant comparative analysis. The content that emerged was compared with the model’s five innovation characteristics (relative advantage, compatibility, complexity, trialability, and observability), as perceived by new users. Results indicate that Rogers’ model can accurately describe nurses’ behavior during the process of adopting workplace innovations. Related issues that emerged deserve further attention to help nurses make the best use of technology. © 2004 Elsevier Inc. All rights reserved.
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HE USE OF computers in patient care and documentation represents an innovative change and significant challenge for nurses. Traditionally, nursing as a discipline has been care oriented and not concerned with applying advanced information technology that may require nurses to make decisions and think critically about charting changes in patient condition using assessment forms, care plans, or documentation software. Modern nursing must take into consideration the explosion of new technology and find new and better ways to deliver care (Romano, 1990a, 1990b). Although nurses have long been using computer systems to order and look up laboratory tests, their motivation for using these systems and the outcomes/effectiveness of using them have seldom been reported. Because nurses represent the largest group of technology users in health care organizations, their perceptions of computer use are a key determinant in the successful implementation of a computer system (Hilz, 2000). The most frequently applied method for evaluating the successful implementation of computer systems in health care organizations has been to assess nurses’ attitudes toward computer use (Dennis, Sweeney, Macdonald, & Morse, 1993). Nurses were assumed to have negative attitudes toward computers, thus needing assistance with technology use. More recent studies have revealed that with the increasingly popular use of computers, nurses no longer have negative attitudes toward using them (Alpay & Russell, 2002; Dillon, McDowell, Salimian, & Conklin, 1998; Simpson & Kenrick, 1997). Nonetheless, barriers to technology adoption have
been proposed (Sobol, Alverson, & Lei, 1999), and Lee (2000) advised that the success of technology innovation relies on the individual’s decision to adopt it or not. Lee (2000) therefore used a combination of Rogers’ innovation-diffusion model and technology acceptance concepts to develop an instrument for evaluating information systems. Unlike most nursing models that focus on four major concepts (person, environment, health, and nursing) (Fitzpatrick & Whall, 1989), Everett Rogers’ innovation-diffusion model emphasizes the process by which an innovation or new knowledge is accepted or rejected by a particular group or organization over time (Rogers, 1995). Studies have used Rogers’ model to examine the outcome of using innovations such as nursing interventions, standard of care, or quality of documentation (Landrum, 1998; Lekan-Rutledge, 2000; Pearcey & Draper, 1996; Zerwekh, Thibodeaux, & Plesko, 2000). Although researchers have recommended using Rogers’ model to explore the process of how nurses adopt technology in care delivery (Hilz, 2000; Romano, 1990a, 1990b), no study has foTing-Ting Lee, PhD, RN, Assistant Professor, Nursing Department, National Taipei College of Nursing, Taipei, Taiwan. Supported by a grant from the National Science Council (NSC90-2314-B-182-067). Address reprint requests to Ting-Ting Lee, PhD, RN, Assistant Professor, Nursing Department, National Taipei College of Nursing, No. 365 Min-Te Rd., Taipei, Taiwan 112. E-mail: [email protected] © 2004 Elsevier Inc. All rights reserved. 0897-1897/04/1704-0003$30.00/0 doi:10.1016/S0897-1897(04)00071-0
Applied Nursing Research, Vol. 17, No. 4 (November), 2004: pp 231-238
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Nurses were assumed to have negative attitudes toward computers, thus needing assistance with technology use.
cused on the process by which a computerized nursing care plan is adopted. This study examined the applicability of Rogers’ model, specifically users’ perceptions of an innovation’s characteristics, for analyzing nurses’ perceptions toward using a computerized care plan system and how they adopt this new technology. The underlying assumption of this study was that by identifying the major factors affecting nurses’ use of new technology, related administration or education strategies and programs could be better designed to assist nurses in this adoption process. LITERATURE REVIEW
Rogers (1995) proposed that an innovation is an idea, a practice or objective perceived as new by an individual, a group, or organization. Diffusion is a process of social change in which an innovation is communicated over time through certain channels (mass media or interpersonal) among members of a social system. An individual’s decision to adopt or reject an innovation is conceptualized in several stages. He/she begins with an awareness of an innovation and then forms an attitude toward it based on his/her perception of the innovation (its characteristics). The individual next decides to either adopt or reject the innovation, then implements it, and, finally, confirms his/her decision. The perceived characteristics of an innovation include its relative advantage, compatibility, complexity, trialability, and observability (Rogers, 1995). According to Rogers (1995), perceived attributes are an innovation’s characteristics that make it more or less appealing to the individual. Relative advantage is the degree to which an innovation is perceived as better than the current idea or practice; the greater the perceived relative advantage of an innovation, the more rapid its rate of adoption. Compatibility is the degree to which an innovation is perceived as consistent with the individual’s existing values, beliefs, past experi-
ences, and needs. Complexity is the degree to which an innovation is perceived as difficult to understand or use. Trialability refers to the degree to which users can alter or implement an innovation on a small scale. Observability is the degree to which the results of an innovation are visible to others. Innovations whose outcomes are easily observed tend to be adopted faster than those with more subtle outcomes (Rogers, 1995). Rogers’ model has been applied to implementing new practices in different clinical settings, for example, to explore nurses’ perceptions toward research-based practice (Pearcey & Draper, 1996), to implement a new standard of care (Landrum, 1998; Lekan-Rutledge, 2000), or to examine nursing documentation (Zerwekh, Thibodeaux, & Plesko, 2000). By understanding the definition and characteristics of each stage in the innovationdiffusion process, new policies and procedures can be more smoothly implemented and colleagues more easily persuaded to accept change. Landrum (1998) advises that examining the perceived attributes of an innovation provides an opportunity to modify the innovation and to strengthen the probability of its adoption. Barriers to cardiologists adopting computerized technology for writing reports on laboratory tests and letters to patients have been reported (Sobol, Alverson, & Lei, 1999), for example, the physical location of computer technology, training problems associated with typing or keyboarding, and the design of a database and its integration with an existing system. In addition, the use of the system might have been based on organizational policy, rather than an option an individual might choose (Lee, 2000). Another barrier to adopting computer technology could lie in its incompatibility with the traditional nursing value of physical touch in patient care (Frantz, 2001). Hilz (2000) emphasizes that by understanding the psychological phenomena of Rogers’ innovation-diffusion process, nurse managers can identify the factors relevant for designing training interventions. METHODS
Setting This study was conducted from March to May 1999 at three respiratory intensive care units in a medical center in northern Taiwan. This 3,300-bed hospital implemented the computerized nursing
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care plan (CNCP) in 1998 for all in-patient units. The CNCP provides a selection of nursing diagnoses, expected goals, and related nursing interventions. Nurses are required to pick items that match patient condition and to print out the care plan for every newly admitted patient. The printout of the care plan was filed in the nursing documentation section of the patient’s medical record. After the hospital’s institutional review board approved this study, a recruitment statement was posted in the three respiratory intensive care units stating the study purpose, interview procedure, assurance of participants’ confidentiality, and voluntary participation. These units were chosen based on their early adoption of the CNCP (the system was first pilot tested on these units). Research Participants To participate in the study, nurses must have been using the CNCP for at least 6 months. This criterion ensured participation of nurses who had mastered use of the system. After 2 weeks of posting for volunteers, head nurses nominated potential participants. These potential nurse participants were approached for interviewing. After being interviewed, interviewees recommended other potential participants. Twelve nurses in total participated in a one-on-one, in-depth interview regarding their experiences using this system. Semistructured interviews were guided by questions such as, “What do you think about the CNCP?” “How does it affect your work?” and “What suggestions would you offer for implementing or maintaining the system?” Each interview was tape recorded with the consent of the participant. The recruitment processed ended when no new content or repeated topics emerged in the interview process. A one-time interview, lasting 30 to 45 minutes, was used for most participants; a second interview (10-15 minutes) was used to clarify content with two participants. All participants were female nurses. The majority (n ⫽ 9) had served in the hospital for more than 3 years, with ages ranging from 20 to 30 years. Eight had associate degrees, three had graduated from college, and one was in a nursing master’s program. All but two had taken computer courses in school (e.g., Windows or Word), and six participants had previously worked with computers (e.g., charting or order entry systems).
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Data Analysis The tape-recorded interview content was transcribed verbatim and confirmed by participants. The original narrative analysis of these interviews has been reported (Lee, Yeh, & Hu, 2002). Because the present study’s purpose was to examine the applicability of Rogers’ model’s perceived characteristics of innovation adoption, the study design focused on comparing how the proposed model characteristics and interview content described the nurses’ pattern of adopting the CNCP. Therefore, constant comparative analysis (Glaser, 1992) was used to examine the relation between Rogers’ model and interview content. The interview data were first open coded, line by line, into a term or word that best represented the essence of the datum. Specific attention was paid to the process of adopting the new system, especially the transition from the old paper system to computerization. These representative terms or words were then analyzed for similarities or differences to identify major themes in adopting the new system. Finally, these themes were compared with Rogers’ proposed perceived characteristics of the innovation: its relative advantage, compatibility, complexity, trialability, and observability. Trustworthiness To ensure trustworthiness of the data, methods for increasing rigor in qualitative research were applied (Glaser 1992; Lincoln & Guba, 1985; Sandelowski, 1986). Each transcript was first reviewed by the participant before data analysis (member check) to ensure data accuracy. Data were triangulated by different methods (interview, observation, and chart review) to increase credibility (Lincoln & Guba, 1985; Sandelowski, 1986). For example, while waiting in the nursing station for the interview, the researcher spontaneously observed participants using the CNCP and reviewed the content of care plans from the medical record. Data analysis of frequently used nursing diagnoses and interventions has been reported (Lee, Wang, & Lee, 2002). To increase theoretical sensitivity in the present study (Glaser, 1992), the authors reviewed the nursing literature on computer use and applied Rogers’ theory and computer technology research. The researcher recorded memos, notes, and reflective thoughts during periods of data collection and analysis. The data were then transcribed as either
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Table 1. Comparison of Innovation Characteristics Perceived by Users (Rogers’ Model) to Nurses’ Experiences With the CNCP Innovation Characteristic
Themes in Nurses’ Experiences Using the CNCP
Relative advantage
1. Paper saving and sense of control 2. Added work stress
Compatibility
1. Lack of linkage between care plan and patient care 2. Improved assessment sequence
Complexity
1. User-friendly system 2. Need for education on using nursing diagnoses 1. Inadequate nursing content 2. Format rigidity and inadequate space
Trialability
Observability
1. Charting evaluations and outcomes 2. Symbol of professionalism
short notes or verbatim for periodic discussions with colleagues (peer debriefing) regarding the data analysis from a technology innovation-diffusion perspective (Lincoln & Guba, 1985; Sandelowski, 1986). FINDINGS
Central themes from participants’ experiences with the CNCP and their explanations related to Rogers’ innovation characteristics as perceived by users are summarized in Table 1. The supporting interview content is presented later.
Comments Made by Nurses About Using the CNCP
1. CNCP content is better organized and easier to read 2. Stress incurred by delays in the charting process or the shift report 1. No need for shift reports, focus on signs, symptoms, and medical treatments 2. CNCP describes wound in detailed sequence: its appearance, interventions, goals, and evaluation 1. Little thinking or writing required 2. Avoidance of difficult or psychological diagnoses 1. No available items for related factors or interventions 2. Doesn’t allow for reporting a full range of nursing efforts and patient problems 1. Abundant documentation for accreditation purpose, but no feedback regarding outcomes of the CNCP use 2. Befits working in a medical center; no more handwriting
Added work stress. Nurses used to pick the paper care plan they wanted, make notations, and then put the plan in the chart. With the CNCP, they have to make a care plan on the computer and save it before they can print. Sometimes the computer response time can take up to a couple of minutes. Most nurses complained about this long wait. Nurses also reported hardware problems such as paper jams, needing to replace ink cartridges, or system down time, which could delay the charting process for the next shift. Nurses admitted feeling stressed by leaving the task (making care plans) to the next shift.
Relative Advantages Paper savings and sense of control. Most nurse participants thought that the CNCP saved them a lot of paper. The old system printed all care plans, from which nurses picked only what they needed. Therefore, some care plans were used all the time and others not at all. In addition, the old paper system listed the following items on a single sheet of paper: nursing diagnosis, related factors, defined characteristics, expected goals, and interventions. Nurses made check marks, resulting in some difficulty understanding patient conditions. With the CNCP, nurses select and print only what they need in a neater and better-organized format. Nurses commented that the CNCP gave them a sense of control in making care plans.
Compatibility Lack of linkage between care plan and patient care. Some nurses disclosed that although they were required to use care plans, on-the-job continuing education still focused on a pathophysiological perspective and medical-treatment orientation that were difficult to reconcile. In addition, shift reports still focused on signs and symptoms and whether doctors’ orders were carried out. No one talked about care plans or nursing diagnoses. Thus, the nurses interviewed did not feel that care plans helped any more with their daily care than the previous paper system did. Improved assessment sequence. Some nurses viewed the care plan as another form of the nursing
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process for assessing patients. For example, nurses described wound conditions in more detail with the CNCP than with the paper system. The CNCP care plan content first led them to describe the wound appearance, then chart interventions to take and goals to set, and finally how to evaluate. Nurses commented that the CNCP helped them provide more detailed documentation in patient assessments. Complexity User-friendly system. Nurses generally viewed the computer system as very user friendly. They just picked the items needed and printed, thus producing a complete care plan in seconds. However, some nurses questioned the logic of this process. They wondered whether it was rational to apply a nursing diagnosis first and then match it with related factors and patient characteristics. Other nurses were concerned that getting used to the CNCP’s “click and print” approach would diminish their critical thinking process. They would no longer think about the patients’ real problems but finish the care plans as a routine procedure. Therefore, true patient conditions might not be assessed but replaced by general descriptions. Need for education on using nursing diagnoses. Nurses admitted ignoring some complex nursing diagnoses that posed data collection problems. For example, an imbalance of electrolytes or gas exchange might require a blood specimen to establish and evaluate the problem. Psychological problems such as stress or anxiety might be ignored as well. Nurses generally didn’t think it was easy to perform the associated assessment since most patients were either in a coma or sedated condition. Some nurses mentioned that they might help families with psychological (life or death decisions) or economical (social worker referrals) problems, but they wouldn’t spend time documenting these interventions and evaluations. They preferred continuing education focusing on the use of nursing diagnoses, which was not available as part of their on-the-job training. Trialability Inadequate nursing content. Some nurses complained that the content of the computerized care plan did not meet their needs. For example, the existing CNCP system had many unspecified or not yet documented factors, such as related factors
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for patients with endotracheal tubes. Some nurses also thought that they performed more interventions than those listed. Therefore, many nursing efforts were not accounted for by the CNCP system. Nurses were concerned that the CNCP system should be designed for nurses, but nursing contributions appeared to be lacking. Some nurses questioned whether the listed items represented the true problems of individual patients or merely gave an overall description of patients under a given care protocol. Format rigidity and inadequate space. The old paper system listed one nursing diagnosis per page, leaving space for nurses to add information. The computer system listed selected nursing diagnoses with related content next to each diagnosis. Nurses said that they had no space to add information. Although some participants said that the space was insufficient, others commented that they just skipped adding information to save time; other nurses questioned the advantage of a computer system if they had to write in everything. Some nurses were concerned that much patient information was omitted due to inadequate space and rigid content design. Observability Charting evaluations and outcomes. Because the CNCP did not have a patient evaluation mechanism, nurses had to chart evaluations and related outcomes in the nursing record every shift. This handwritten procedure certainly added to their paperwork load. Therefore, nurses usually selected the minimum required nursing diagnoses with which they were familiar. Some expressed a desire to know the outcomes of using the CNCP (such as commonly used nursing diagnoses or interventions), so they would be aware of what changes had been made in patient care (e.g., whether the most used nursing diagnoses represented patient problems or if interventions improved care outcomes), but they perceived that the administration put more emphasis on paperwork than on patient care. Symbol of professionalism. Some nurses said they would not miss the system if it was taken away because they viewed it as paperwork oriented and they already had many assessment forms to complete every hour. Others considered the CNCP system a symbol of professionalism befitting a medical center. Computerized care plans have been
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viewed as important criteria for hospital accreditation. In addition, some nurses admitted that they had already become used to the system and did not want any more changes; they especially did not want to go back to using the paper system or any other handwritten process. DISCUSSION
Rogers’ innovation-diffusion theory states that users’ acceptance of an innovation is influenced by their perception of its relative advantage, compatibility, complexity, trialability, and observability. The benefits and burdens of a change will first be weighed to determine its relative advantage. Benefits include reduction in discomfort, savings in effort and time, and other incentives (Rogers, 1995). Nurses in the current study believed that the CNCP saved paper, had an easy-to-read format, and brought them a sense of control. However, participants also saw drawbacks to using the CNCP: slow response time, printer problems, and system down time. Location and access to computers have been reported as physical barriers to adopting computerized technology (Charles, 2000; Sobol, Alverson, & Lei, 1999). Laundrum (1998) cautioned that failure to convince colleagues of the relative merit of an innovation could prevent its adoption. Barnard (2000) proposed that technology could sometimes make nursing practice more demanding, time consuming, and distracting. Inconveniences related to computer use indicate a need to study nurses’ stress because of delays in the charting process, which might decrease nurses’ acceptance of using a CNCP.
Inconveniences related to computer use indicate a need to study nurses’ stress because of delays in the charting process, which might decrease nurses’ acceptance of using a CNCP.
The second factor influencing acceptance of an innovation is its compatibility with users’ existing values and experiences. Care plans have been valued as structured guides to provide a systematic method of planning and recording patient care (El-
lenbecker & Shea, 1994; Lowry, 1993; Shea, 1986; Stokke & Kalfoss, 1999). However, clinicians have also criticized care plans as adding to paperwork (Darbyshire, 2000; Newton, 1995), diminishing patient individuality and nurses’ ability to think independently (Harris, 1990; Kerr & Lewis, 2000) and not having a direct connection to patient care (Harris, 1990; Newton, 1995). Frantz (2001) cautioned that when using technology in health care, professional values and beliefs should be evaluated. In the current study, using the CNCP did not seem to change nurses’ attitudes toward care plans nor were nursing practice behaviors influenced. This observation could be due to the CNCP not being used in direct patient care, but as a recordkeeping tool. Nonetheless, some nurses preferred the sequence of patient assessment given by the CNCP. The researchers propose that with appropriate use, computers can be very useful to nurses in documenting the care process (Bjo¨rvell, ThorellEkstrand, & Wredling, 1999; Ehrenberg & Ehnfors, 1999; Shea, 1986; Stokke & Kalfoss, 1999). The third major factor influencing acceptance of an innovation is its complexity or how easy it is to use. Nurses in the current study generally viewed the CNCP as very user friendly. However, some nurses worried that they might get used to this time-saving process and miss the patients’ real problems. After all, making a detailed assessment or description of patient problems does take time, involving the thinking process. Barnard (1997) has proposed that technology should be used after thinking has been completed, so nurses can take advantage of technology instead of being led by its use. One report from Japan indicates cultural and educational difficulties with applying computerized nursing diagnoses. For example, offering psychological and emotional support based on religious belief is not effective for many people in Japan because of fewer counselors and social support groups (Kurihara et al., 2001). Researchers suggest training issues include operational skills, typing or keyboarding ability, and information management (Alpay & Russell, 2002; Sobol, Alverson, & Lei, 199l). Because the CNCP was very user friendly, nurses in the current study preferred to have classes focus more on using nursing diagnoses than on computer operation skills.
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Trialability refers to whether users can experiment with the innovation. Sobol et al. (1999) suggested that computer technology must be flexible to incorporate patient-specific care parameters, whereas simultaneously allowing care providers speedy access to medical records. In the current study, nurses were not happy with the content design of the CNCP (e.g., no appropriate nursing diagnoses, too few nursing interventions and no available selective care evaluation). Shea (1986) proposed that nurses generally view handwritten notes as important patient information, but the amount of effort required is overwhelming, preventing them from adhering to this process. Information in handwritten notes is difficult to retrieve for later use (Alpay & Russell, 2002). Nurses were less inclined to write information with the CNCP than they had been with the old paper system. For this reason, they viewed the CNCP as a system that did not meet their needs, which could have decreased their motivation to use it. The last factor influencing user acceptance of an innovation is observability, whether the outcomes of an innovation are visible to its users. Abundant evaluation documentation in the CNCP led nurses in the current study to question the rationale for using the CNCP. Barnard (1997, 2000) has suggested that nurses’ normal moral principles could be lost when linked to duty, orders, and protocol requirements. Nurses in the current study also expressed a desire to know whether the outcomes of their care plan use made a difference in care quality, but no information was provided. Frantz (2001) suggested that, when nurses get immediate feedback from computer use such as laboratory data, their perception of the new technology tends to be more positive. Strategies such as rewards, increased social image, or enhanced decision-making ability have been proposed as incentives for individuals to adopt an innovation (Ash, 1996; Barnard, 2000; Lee, 2000). Despite nurses’ criticism of extra paperwork, using the CNCP gave them a sense of professionalism. Participation in the current e-health care trend might also heighten nurses’ sense of professionalism, which would be an observable outcome of using the CNCP. CONCLUSION AND SUGGESTIONS
This study applied Rogers’ innovation-diffusion theory to examine nurses’ adoption of a computerized care plan system. Although the study was
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More research on nursing administrators might reveal different innovation-diffusion effects from an organizational perspective.
conducted in three respiratory intensive care units in Taiwan and may not be generalized to nurses in other care areas, the findings indicate that Rogers’ model appropriately described nurses’ perceptions toward new technology use in their daily practice. Although researchers have recognized the benefits of applying Rogers’ model to the adoption of new interventions (Landrum, 1998) or protocols in clinical settings (Pearcey & Draper, 1996), Lee (2000) suggested replacing Rogers’ characteristics of complexity and observability with others, such as image, ease of use, results, demonstrability, and visibility. Nonetheless, more detailed and precise definitions of variables may be necessary. These different applications could serve as references for the design of future studies exploring Rogers’ model. The major limitation of this study was its exclusive focus on characteristics perceived by users of an innovation. This focus did not include other innovative components proposed by Rogers, such as relative knowledge status, decision-making types, and different channels of communication. Future studies should explore the effects of these factors on the innovationdiffusion process. In addition, the unit of analysis in this study was the individual. The effects of organizational variables on individuals cannot be ignored (Ash, 1996; Charles, 2000; Van Der Weide & Smits). More research on nursing administrators might reveal different innovationdiffusion effects from an organizational perspective. Lastly, the innovation-diffusion process is dynamic. Whether an innovation can be adopted, continued or later rejected needs further investigation. A longitudinal study of different stages in the innovation adoption process and related factors might assist decision-makers in applying relevant strategies to smooth this process. More research on nursing administrators might reveal different innovation-diffusion effects from an organizational perspective.
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This qualitative study applied Everett Rogers’ innovation-diffusion model to analyze nurses’ perceptions toward using a computerized care plan system. Twelve nurses from three respiratory intensive care units in Taiwan voluntarily participated in a one-on-one, in-depth interview. Data were analyzed by constant comparative analysis. The content that emerged was compared with the model’s five innovation characteristics (relative advantage, compatibility, complexity, trialability, and observability), as perceived by new users. Results indicate that Rogers’ model can accurately describe nurses’ behavior during the process of adopting workplace innovations. Related issues that emerged deserve further attention to help nurses make the best use of technology. © 2004 Elsevier Inc. All rights reserved.
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HE USE OF computers in patient care and documentation represents an innovative change and significant challenge for nurses. Traditionally, nursing as a discipline has been care oriented and not concerned with applying advanced information technology that may require nurses to make decisions and think critically about charting changes in patient condition using assessment forms, care plans, or documentation software. Modern nursing must take into consideration the explosion of new technology and find new and better ways to deliver care (Romano, 1990a, 1990b). Although nurses have long been using computer systems to order and look up laboratory tests, their motivation for using these systems and the outcomes/effectiveness of using them have seldom been reported. Because nurses represent the largest group of technology users in health care organizations, their perceptions of computer use are a key determinant in the successful implementation of a computer system (Hilz, 2000). The most frequently applied method for evaluating the successful implementation of computer systems in health care organizations has been to assess nurses’ attitudes toward computer use (Dennis, Sweeney, Macdonald, & Morse, 1993). Nurses were assumed to have negative attitudes toward computers, thus needing assistance with technology use. More recent studies have revealed that with the increasingly popular use of computers, nurses no longer have negative attitudes toward using them (Alpay & Russell, 2002; Dillon, McDowell, Salimian, & Conklin, 1998; Simpson & Kenrick, 1997). Nonetheless, barriers to technology adoption have
been proposed (Sobol, Alverson, & Lei, 1999), and Lee (2000) advised that the success of technology innovation relies on the individual’s decision to adopt it or not. Lee (2000) therefore used a combination of Rogers’ innovation-diffusion model and technology acceptance concepts to develop an instrument for evaluating information systems. Unlike most nursing models that focus on four major concepts (person, environment, health, and nursing) (Fitzpatrick & Whall, 1989), Everett Rogers’ innovation-diffusion model emphasizes the process by which an innovation or new knowledge is accepted or rejected by a particular group or organization over time (Rogers, 1995). Studies have used Rogers’ model to examine the outcome of using innovations such as nursing interventions, standard of care, or quality of documentation (Landrum, 1998; Lekan-Rutledge, 2000; Pearcey & Draper, 1996; Zerwekh, Thibodeaux, & Plesko, 2000). Although researchers have recommended using Rogers’ model to explore the process of how nurses adopt technology in care delivery (Hilz, 2000; Romano, 1990a, 1990b), no study has foTing-Ting Lee, PhD, RN, Assistant Professor, Nursing Department, National Taipei College of Nursing, Taipei, Taiwan. Supported by a grant from the National Science Council (NSC90-2314-B-182-067). Address reprint requests to Ting-Ting Lee, PhD, RN, Assistant Professor, Nursing Department, National Taipei College of Nursing, No. 365 Min-Te Rd., Taipei, Taiwan 112. E-mail: [email protected] © 2004 Elsevier Inc. All rights reserved. 0897-1897/04/1704-0003$30.00/0 doi:10.1016/S0897-1897(04)00071-0
Applied Nursing Research, Vol. 17, No. 4 (November), 2004: pp 231-238
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Nurses were assumed to have negative attitudes toward computers, thus needing assistance with technology use.
cused on the process by which a computerized nursing care plan is adopted. This study examined the applicability of Rogers’ model, specifically users’ perceptions of an innovation’s characteristics, for analyzing nurses’ perceptions toward using a computerized care plan system and how they adopt this new technology. The underlying assumption of this study was that by identifying the major factors affecting nurses’ use of new technology, related administration or education strategies and programs could be better designed to assist nurses in this adoption process. LITERATURE REVIEW
Rogers (1995) proposed that an innovation is an idea, a practice or objective perceived as new by an individual, a group, or organization. Diffusion is a process of social change in which an innovation is communicated over time through certain channels (mass media or interpersonal) among members of a social system. An individual’s decision to adopt or reject an innovation is conceptualized in several stages. He/she begins with an awareness of an innovation and then forms an attitude toward it based on his/her perception of the innovation (its characteristics). The individual next decides to either adopt or reject the innovation, then implements it, and, finally, confirms his/her decision. The perceived characteristics of an innovation include its relative advantage, compatibility, complexity, trialability, and observability (Rogers, 1995). According to Rogers (1995), perceived attributes are an innovation’s characteristics that make it more or less appealing to the individual. Relative advantage is the degree to which an innovation is perceived as better than the current idea or practice; the greater the perceived relative advantage of an innovation, the more rapid its rate of adoption. Compatibility is the degree to which an innovation is perceived as consistent with the individual’s existing values, beliefs, past experi-
ences, and needs. Complexity is the degree to which an innovation is perceived as difficult to understand or use. Trialability refers to the degree to which users can alter or implement an innovation on a small scale. Observability is the degree to which the results of an innovation are visible to others. Innovations whose outcomes are easily observed tend to be adopted faster than those with more subtle outcomes (Rogers, 1995). Rogers’ model has been applied to implementing new practices in different clinical settings, for example, to explore nurses’ perceptions toward research-based practice (Pearcey & Draper, 1996), to implement a new standard of care (Landrum, 1998; Lekan-Rutledge, 2000), or to examine nursing documentation (Zerwekh, Thibodeaux, & Plesko, 2000). By understanding the definition and characteristics of each stage in the innovationdiffusion process, new policies and procedures can be more smoothly implemented and colleagues more easily persuaded to accept change. Landrum (1998) advises that examining the perceived attributes of an innovation provides an opportunity to modify the innovation and to strengthen the probability of its adoption. Barriers to cardiologists adopting computerized technology for writing reports on laboratory tests and letters to patients have been reported (Sobol, Alverson, & Lei, 1999), for example, the physical location of computer technology, training problems associated with typing or keyboarding, and the design of a database and its integration with an existing system. In addition, the use of the system might have been based on organizational policy, rather than an option an individual might choose (Lee, 2000). Another barrier to adopting computer technology could lie in its incompatibility with the traditional nursing value of physical touch in patient care (Frantz, 2001). Hilz (2000) emphasizes that by understanding the psychological phenomena of Rogers’ innovation-diffusion process, nurse managers can identify the factors relevant for designing training interventions. METHODS
Setting This study was conducted from March to May 1999 at three respiratory intensive care units in a medical center in northern Taiwan. This 3,300-bed hospital implemented the computerized nursing
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care plan (CNCP) in 1998 for all in-patient units. The CNCP provides a selection of nursing diagnoses, expected goals, and related nursing interventions. Nurses are required to pick items that match patient condition and to print out the care plan for every newly admitted patient. The printout of the care plan was filed in the nursing documentation section of the patient’s medical record. After the hospital’s institutional review board approved this study, a recruitment statement was posted in the three respiratory intensive care units stating the study purpose, interview procedure, assurance of participants’ confidentiality, and voluntary participation. These units were chosen based on their early adoption of the CNCP (the system was first pilot tested on these units). Research Participants To participate in the study, nurses must have been using the CNCP for at least 6 months. This criterion ensured participation of nurses who had mastered use of the system. After 2 weeks of posting for volunteers, head nurses nominated potential participants. These potential nurse participants were approached for interviewing. After being interviewed, interviewees recommended other potential participants. Twelve nurses in total participated in a one-on-one, in-depth interview regarding their experiences using this system. Semistructured interviews were guided by questions such as, “What do you think about the CNCP?” “How does it affect your work?” and “What suggestions would you offer for implementing or maintaining the system?” Each interview was tape recorded with the consent of the participant. The recruitment processed ended when no new content or repeated topics emerged in the interview process. A one-time interview, lasting 30 to 45 minutes, was used for most participants; a second interview (10-15 minutes) was used to clarify content with two participants. All participants were female nurses. The majority (n ⫽ 9) had served in the hospital for more than 3 years, with ages ranging from 20 to 30 years. Eight had associate degrees, three had graduated from college, and one was in a nursing master’s program. All but two had taken computer courses in school (e.g., Windows or Word), and six participants had previously worked with computers (e.g., charting or order entry systems).
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Data Analysis The tape-recorded interview content was transcribed verbatim and confirmed by participants. The original narrative analysis of these interviews has been reported (Lee, Yeh, & Hu, 2002). Because the present study’s purpose was to examine the applicability of Rogers’ model’s perceived characteristics of innovation adoption, the study design focused on comparing how the proposed model characteristics and interview content described the nurses’ pattern of adopting the CNCP. Therefore, constant comparative analysis (Glaser, 1992) was used to examine the relation between Rogers’ model and interview content. The interview data were first open coded, line by line, into a term or word that best represented the essence of the datum. Specific attention was paid to the process of adopting the new system, especially the transition from the old paper system to computerization. These representative terms or words were then analyzed for similarities or differences to identify major themes in adopting the new system. Finally, these themes were compared with Rogers’ proposed perceived characteristics of the innovation: its relative advantage, compatibility, complexity, trialability, and observability. Trustworthiness To ensure trustworthiness of the data, methods for increasing rigor in qualitative research were applied (Glaser 1992; Lincoln & Guba, 1985; Sandelowski, 1986). Each transcript was first reviewed by the participant before data analysis (member check) to ensure data accuracy. Data were triangulated by different methods (interview, observation, and chart review) to increase credibility (Lincoln & Guba, 1985; Sandelowski, 1986). For example, while waiting in the nursing station for the interview, the researcher spontaneously observed participants using the CNCP and reviewed the content of care plans from the medical record. Data analysis of frequently used nursing diagnoses and interventions has been reported (Lee, Wang, & Lee, 2002). To increase theoretical sensitivity in the present study (Glaser, 1992), the authors reviewed the nursing literature on computer use and applied Rogers’ theory and computer technology research. The researcher recorded memos, notes, and reflective thoughts during periods of data collection and analysis. The data were then transcribed as either
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Table 1. Comparison of Innovation Characteristics Perceived by Users (Rogers’ Model) to Nurses’ Experiences With the CNCP Innovation Characteristic
Themes in Nurses’ Experiences Using the CNCP
Relative advantage
1. Paper saving and sense of control 2. Added work stress
Compatibility
1. Lack of linkage between care plan and patient care 2. Improved assessment sequence
Complexity
1. User-friendly system 2. Need for education on using nursing diagnoses 1. Inadequate nursing content 2. Format rigidity and inadequate space
Trialability
Observability
1. Charting evaluations and outcomes 2. Symbol of professionalism
short notes or verbatim for periodic discussions with colleagues (peer debriefing) regarding the data analysis from a technology innovation-diffusion perspective (Lincoln & Guba, 1985; Sandelowski, 1986). FINDINGS
Central themes from participants’ experiences with the CNCP and their explanations related to Rogers’ innovation characteristics as perceived by users are summarized in Table 1. The supporting interview content is presented later.
Comments Made by Nurses About Using the CNCP
1. CNCP content is better organized and easier to read 2. Stress incurred by delays in the charting process or the shift report 1. No need for shift reports, focus on signs, symptoms, and medical treatments 2. CNCP describes wound in detailed sequence: its appearance, interventions, goals, and evaluation 1. Little thinking or writing required 2. Avoidance of difficult or psychological diagnoses 1. No available items for related factors or interventions 2. Doesn’t allow for reporting a full range of nursing efforts and patient problems 1. Abundant documentation for accreditation purpose, but no feedback regarding outcomes of the CNCP use 2. Befits working in a medical center; no more handwriting
Added work stress. Nurses used to pick the paper care plan they wanted, make notations, and then put the plan in the chart. With the CNCP, they have to make a care plan on the computer and save it before they can print. Sometimes the computer response time can take up to a couple of minutes. Most nurses complained about this long wait. Nurses also reported hardware problems such as paper jams, needing to replace ink cartridges, or system down time, which could delay the charting process for the next shift. Nurses admitted feeling stressed by leaving the task (making care plans) to the next shift.
Relative Advantages Paper savings and sense of control. Most nurse participants thought that the CNCP saved them a lot of paper. The old system printed all care plans, from which nurses picked only what they needed. Therefore, some care plans were used all the time and others not at all. In addition, the old paper system listed the following items on a single sheet of paper: nursing diagnosis, related factors, defined characteristics, expected goals, and interventions. Nurses made check marks, resulting in some difficulty understanding patient conditions. With the CNCP, nurses select and print only what they need in a neater and better-organized format. Nurses commented that the CNCP gave them a sense of control in making care plans.
Compatibility Lack of linkage between care plan and patient care. Some nurses disclosed that although they were required to use care plans, on-the-job continuing education still focused on a pathophysiological perspective and medical-treatment orientation that were difficult to reconcile. In addition, shift reports still focused on signs and symptoms and whether doctors’ orders were carried out. No one talked about care plans or nursing diagnoses. Thus, the nurses interviewed did not feel that care plans helped any more with their daily care than the previous paper system did. Improved assessment sequence. Some nurses viewed the care plan as another form of the nursing
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process for assessing patients. For example, nurses described wound conditions in more detail with the CNCP than with the paper system. The CNCP care plan content first led them to describe the wound appearance, then chart interventions to take and goals to set, and finally how to evaluate. Nurses commented that the CNCP helped them provide more detailed documentation in patient assessments. Complexity User-friendly system. Nurses generally viewed the computer system as very user friendly. They just picked the items needed and printed, thus producing a complete care plan in seconds. However, some nurses questioned the logic of this process. They wondered whether it was rational to apply a nursing diagnosis first and then match it with related factors and patient characteristics. Other nurses were concerned that getting used to the CNCP’s “click and print” approach would diminish their critical thinking process. They would no longer think about the patients’ real problems but finish the care plans as a routine procedure. Therefore, true patient conditions might not be assessed but replaced by general descriptions. Need for education on using nursing diagnoses. Nurses admitted ignoring some complex nursing diagnoses that posed data collection problems. For example, an imbalance of electrolytes or gas exchange might require a blood specimen to establish and evaluate the problem. Psychological problems such as stress or anxiety might be ignored as well. Nurses generally didn’t think it was easy to perform the associated assessment since most patients were either in a coma or sedated condition. Some nurses mentioned that they might help families with psychological (life or death decisions) or economical (social worker referrals) problems, but they wouldn’t spend time documenting these interventions and evaluations. They preferred continuing education focusing on the use of nursing diagnoses, which was not available as part of their on-the-job training. Trialability Inadequate nursing content. Some nurses complained that the content of the computerized care plan did not meet their needs. For example, the existing CNCP system had many unspecified or not yet documented factors, such as related factors
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for patients with endotracheal tubes. Some nurses also thought that they performed more interventions than those listed. Therefore, many nursing efforts were not accounted for by the CNCP system. Nurses were concerned that the CNCP system should be designed for nurses, but nursing contributions appeared to be lacking. Some nurses questioned whether the listed items represented the true problems of individual patients or merely gave an overall description of patients under a given care protocol. Format rigidity and inadequate space. The old paper system listed one nursing diagnosis per page, leaving space for nurses to add information. The computer system listed selected nursing diagnoses with related content next to each diagnosis. Nurses said that they had no space to add information. Although some participants said that the space was insufficient, others commented that they just skipped adding information to save time; other nurses questioned the advantage of a computer system if they had to write in everything. Some nurses were concerned that much patient information was omitted due to inadequate space and rigid content design. Observability Charting evaluations and outcomes. Because the CNCP did not have a patient evaluation mechanism, nurses had to chart evaluations and related outcomes in the nursing record every shift. This handwritten procedure certainly added to their paperwork load. Therefore, nurses usually selected the minimum required nursing diagnoses with which they were familiar. Some expressed a desire to know the outcomes of using the CNCP (such as commonly used nursing diagnoses or interventions), so they would be aware of what changes had been made in patient care (e.g., whether the most used nursing diagnoses represented patient problems or if interventions improved care outcomes), but they perceived that the administration put more emphasis on paperwork than on patient care. Symbol of professionalism. Some nurses said they would not miss the system if it was taken away because they viewed it as paperwork oriented and they already had many assessment forms to complete every hour. Others considered the CNCP system a symbol of professionalism befitting a medical center. Computerized care plans have been
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viewed as important criteria for hospital accreditation. In addition, some nurses admitted that they had already become used to the system and did not want any more changes; they especially did not want to go back to using the paper system or any other handwritten process. DISCUSSION
Rogers’ innovation-diffusion theory states that users’ acceptance of an innovation is influenced by their perception of its relative advantage, compatibility, complexity, trialability, and observability. The benefits and burdens of a change will first be weighed to determine its relative advantage. Benefits include reduction in discomfort, savings in effort and time, and other incentives (Rogers, 1995). Nurses in the current study believed that the CNCP saved paper, had an easy-to-read format, and brought them a sense of control. However, participants also saw drawbacks to using the CNCP: slow response time, printer problems, and system down time. Location and access to computers have been reported as physical barriers to adopting computerized technology (Charles, 2000; Sobol, Alverson, & Lei, 1999). Laundrum (1998) cautioned that failure to convince colleagues of the relative merit of an innovation could prevent its adoption. Barnard (2000) proposed that technology could sometimes make nursing practice more demanding, time consuming, and distracting. Inconveniences related to computer use indicate a need to study nurses’ stress because of delays in the charting process, which might decrease nurses’ acceptance of using a CNCP.
Inconveniences related to computer use indicate a need to study nurses’ stress because of delays in the charting process, which might decrease nurses’ acceptance of using a CNCP.
The second factor influencing acceptance of an innovation is its compatibility with users’ existing values and experiences. Care plans have been valued as structured guides to provide a systematic method of planning and recording patient care (El-
lenbecker & Shea, 1994; Lowry, 1993; Shea, 1986; Stokke & Kalfoss, 1999). However, clinicians have also criticized care plans as adding to paperwork (Darbyshire, 2000; Newton, 1995), diminishing patient individuality and nurses’ ability to think independently (Harris, 1990; Kerr & Lewis, 2000) and not having a direct connection to patient care (Harris, 1990; Newton, 1995). Frantz (2001) cautioned that when using technology in health care, professional values and beliefs should be evaluated. In the current study, using the CNCP did not seem to change nurses’ attitudes toward care plans nor were nursing practice behaviors influenced. This observation could be due to the CNCP not being used in direct patient care, but as a recordkeeping tool. Nonetheless, some nurses preferred the sequence of patient assessment given by the CNCP. The researchers propose that with appropriate use, computers can be very useful to nurses in documenting the care process (Bjo¨rvell, ThorellEkstrand, & Wredling, 1999; Ehrenberg & Ehnfors, 1999; Shea, 1986; Stokke & Kalfoss, 1999). The third major factor influencing acceptance of an innovation is its complexity or how easy it is to use. Nurses in the current study generally viewed the CNCP as very user friendly. However, some nurses worried that they might get used to this time-saving process and miss the patients’ real problems. After all, making a detailed assessment or description of patient problems does take time, involving the thinking process. Barnard (1997) has proposed that technology should be used after thinking has been completed, so nurses can take advantage of technology instead of being led by its use. One report from Japan indicates cultural and educational difficulties with applying computerized nursing diagnoses. For example, offering psychological and emotional support based on religious belief is not effective for many people in Japan because of fewer counselors and social support groups (Kurihara et al., 2001). Researchers suggest training issues include operational skills, typing or keyboarding ability, and information management (Alpay & Russell, 2002; Sobol, Alverson, & Lei, 199l). Because the CNCP was very user friendly, nurses in the current study preferred to have classes focus more on using nursing diagnoses than on computer operation skills.
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Trialability refers to whether users can experiment with the innovation. Sobol et al. (1999) suggested that computer technology must be flexible to incorporate patient-specific care parameters, whereas simultaneously allowing care providers speedy access to medical records. In the current study, nurses were not happy with the content design of the CNCP (e.g., no appropriate nursing diagnoses, too few nursing interventions and no available selective care evaluation). Shea (1986) proposed that nurses generally view handwritten notes as important patient information, but the amount of effort required is overwhelming, preventing them from adhering to this process. Information in handwritten notes is difficult to retrieve for later use (Alpay & Russell, 2002). Nurses were less inclined to write information with the CNCP than they had been with the old paper system. For this reason, they viewed the CNCP as a system that did not meet their needs, which could have decreased their motivation to use it. The last factor influencing user acceptance of an innovation is observability, whether the outcomes of an innovation are visible to its users. Abundant evaluation documentation in the CNCP led nurses in the current study to question the rationale for using the CNCP. Barnard (1997, 2000) has suggested that nurses’ normal moral principles could be lost when linked to duty, orders, and protocol requirements. Nurses in the current study also expressed a desire to know whether the outcomes of their care plan use made a difference in care quality, but no information was provided. Frantz (2001) suggested that, when nurses get immediate feedback from computer use such as laboratory data, their perception of the new technology tends to be more positive. Strategies such as rewards, increased social image, or enhanced decision-making ability have been proposed as incentives for individuals to adopt an innovation (Ash, 1996; Barnard, 2000; Lee, 2000). Despite nurses’ criticism of extra paperwork, using the CNCP gave them a sense of professionalism. Participation in the current e-health care trend might also heighten nurses’ sense of professionalism, which would be an observable outcome of using the CNCP. CONCLUSION AND SUGGESTIONS
This study applied Rogers’ innovation-diffusion theory to examine nurses’ adoption of a computerized care plan system. Although the study was
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More research on nursing administrators might reveal different innovation-diffusion effects from an organizational perspective.
conducted in three respiratory intensive care units in Taiwan and may not be generalized to nurses in other care areas, the findings indicate that Rogers’ model appropriately described nurses’ perceptions toward new technology use in their daily practice. Although researchers have recognized the benefits of applying Rogers’ model to the adoption of new interventions (Landrum, 1998) or protocols in clinical settings (Pearcey & Draper, 1996), Lee (2000) suggested replacing Rogers’ characteristics of complexity and observability with others, such as image, ease of use, results, demonstrability, and visibility. Nonetheless, more detailed and precise definitions of variables may be necessary. These different applications could serve as references for the design of future studies exploring Rogers’ model. The major limitation of this study was its exclusive focus on characteristics perceived by users of an innovation. This focus did not include other innovative components proposed by Rogers, such as relative knowledge status, decision-making types, and different channels of communication. Future studies should explore the effects of these factors on the innovationdiffusion process. In addition, the unit of analysis in this study was the individual. The effects of organizational variables on individuals cannot be ignored (Ash, 1996; Charles, 2000; Van Der Weide & Smits). More research on nursing administrators might reveal different innovationdiffusion effects from an organizational perspective. Lastly, the innovation-diffusion process is dynamic. Whether an innovation can be adopted, continued or later rejected needs further investigation. A longitudinal study of different stages in the innovation adoption process and related factors might assist decision-makers in applying relevant strategies to smooth this process. More research on nursing administrators might reveal different innovation-diffusion effects from an organizational perspective.
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