CIN: Computers, Informatics, Nursing

March/April 2003

CIN: Computers, Informatics, Nursing Vol. 21, No. 2, 80-85 2003 Lippincott Williams & Wilkins, Inc.

C O N T I N U I N G E D U C A T I O N

CE
Change is a regular occurrence in the healthcare environment. The computerization of nursing systems is one aspect of the changes taking place in the information revolution. As a result, nurses have widely varying attitudes toward computers and change in the workplace. To transition the nursing team effectively from one system to another, the nurse informaticist must be aware of the factors that encourage and those that impede the change. Strategies must be developed to assist nurses in moving forward with the transition. This article presents a theoretical discussion of how Lewins Force Field Analysis Model could be applied in the practice setting to implement a nursing information system successfully. KEY WORDS Field theory Change Information system Nursing Attitudes

Using Lewins Force Field Analysis in Implementing a Nursing Information System

MARILYNN G. BOZAK, RN, MS, OCN

From bar code technology for medication administration to wireless bedside documentation systems to clinical decision support systems, technology is an integral part of the daily workflow for nurses. Rapidly developing technologies are changing the way nurses manage information and deliver care. In acute care settings, there is an increasing focus on managing both high-risk patients and those with chronic diseases. Integrated delivery networks are moving to the forefront, and the Internet is becoming a source of health and medical information for clinicians and patients alike.1 Many nurses are skeptical of information technology and may resist learning or using a new system.1 Recognizing this resistance and planning strategies to work through these barriers may be the key to implementing a successful nursing information system in a complex healthcare organization. As change becomes an increasingly common occurrence in the healthcare environment, change theory offers one way of understanding the dynamic interaction between individuals and social systems. As opposed to unplanned or accidental change, planned change is the direct result of a conscious effort between the individual who works to bring about the change and those on whom the change has a direct impact.2 By understanding the principles of change theory, the nurse informaticist can strategically plan and successfully implement the transition from one nursing system to another. This article focuses on using Kurt Lewins model of change to implement a nursing information system. 80

Lewins model can provide the guidance needed to analyze the process of change and assist in identifying forces that either propel the change forward or create barriers that stagnate the change.

LEWINS THEORETICAL FRAMEWORK

Regarded as the father of change theory, Kurt Lewin concerned himself with offering a deeper explanation of human behavior while uncovering ways to improve human behavior.3 His theory of change provides the structure for understanding nurses behavior during times of change and ways to improve the behavior when introducing change into the workplace. Lewin4 stated that all change is the result of certain forces in a field or particular environment. Although field theory was developed originally in the physical sciences as a method of analyzing phenomena, Lewin expanded the concept to the area of psychology.3 He in-

From the University of South Florida, Tampa, Florida. Corresponding author: Marilynn Bozak, RN, MS, OCN, 10714 Carrollwood Drive, Tampa, FL 33618 (e-mail: [email protected]). March/April 2003

CIN: Computers, Informatics, Nursing

cluded all psychological activity that confronts an individual and applied concepts of psychological movement toward a particular goal. Simply stated, field theory is a method of identifying and analyzing causal relations and applying scientific constructs to those relations. Lewins operational framework for change is his Force Field Analysis Model.3 This model provides an understanding of individual and group behavior as determined by motivation and intention. Lewin4 identified two dynamic, yet opposing, forces that have an impact on the change process in an environment. Driving forces move toward a positive region and encourage the change to occur. Static forces that attempt to maintain the status quo are identified as restraining forces. A driving force might be the result of external forces compelling the change. It may also result from internal problems with a current system or simply the desire to improve a situation. Restraining forces can prevent a change from occurring by creating barriers. For example, concerns that a project will fail, a past negative experience with unsuccessful change, or the fear of losing the current state of contentment are typical restraining forces.2 For change to transpire successfully, the driving forces must be strengthened in favor of the change while the restraining forces are weakened or eliminated.4 Lewin considered three steps when describing the process of change: unfreezing the current level, changing or moving to the new level, and freezing at the new level.4 Current literature identifies the third step as refreezing.2,5 However, Lewin used the term freezing3,4 in his theoretical works. Both terms are interchangeable and used to identify the state of permanency achieved at the new level. To avoid confusion with current literature, the term refreezing will be used rather than freezing. The first step of Lewins process, unfreezing, involves the identification of the current need or problem. At this stage, there may be feelings of discomfort, apprehension, and upset among the participants. The nurse informaticist facilitates activities that distinguish the driving forces and restraining forces in this step. Strategies are developed to strengthen the driving forces and weaken or reduce the restraining forces. It is during this phase that people in the organization begin to realize that the change is necessary and valuable to the success of the organization.2 The second step of the process involves changing or moving to a new level. It is here that the actual change occurs and the driving forces have equalized or overcome the restraining forces. The nurse informaticist has gathered the necessary information to move forward with the proposed change. A detailed plan is constructed for implementing the change, and the change is executed within the organization.2

In the final step of Lewins process, refreezing, the change is stabilized at the new level within the organization. The nurse informaticist assists with maintenance and evaluation as functions stabilize and the change is incorporated into the system.2 Although Lewin included the idea of permanency at the new level, he did not imply that the organization was now immune to future change.4

NURSES ATTITUDES TOWARD CHANGE AND COMPUTERS

Change in the workplace can evoke varied responses in individuals, and rarely is the response one of indifference. Some nurses may feel that the change is challenging and exciting, presenting an opportunity for growth. Others may have an opposite reaction to change, viewing the situation as threatening and disrupting.5 Nurses often resist technological change because of concerns about intrusions into the normal and routine way of performing activities. Barriers may be self-imposed to protect and preserve convention rather than face a new and uncertain situation.2 Individual reactions to change occur for many different reasons. Previous involvement in similar situations that were unsuccessful may cause nurses to react negatively to the proposed change. Individual life skills, knowledge, and abilities have an impact on how nurses view change and whether they feel capable of handling the change. Levels of involvement in the organization and relationships with other individuals all have an effect on the process of change.2 Elys6 qualitative study of pediatric nurses perceived barriers to change identified organizational factors that inhibit change. The nurses questioned the certainty and security of their jobs during organizational change as well as feelings of powerlessness when faced with transformation in the workplace. Of major concern to the nurses was the rampant, widespread, and accelerated process of change in the healthcare environment as a whole. Change in the workplace may be perceived as the loss or death of the status quo. Research blending change theory with the grieving process was one attempt to explain nurses perceptions in the midst of organizational change. Schoolfield and Orduna7 examined the beliefs, behaviors, emotions, and actions of oncology nurses involved with change in the workplace. Phases of the grieving process included disbelief or denial of the current situation, anger or resentment toward the proposed change, turmoil and confusion, and eventual acceptance and readiness for the change. These factors can have an impact and inhibit successful change, and the nurse informaticist must support nurses through this process. Other researchers have identified feelings of loss, anger, and despair as common responses to organiza March/April 2003

CIN: Computers, Informatics, Nursing

81

tional change.8 Decreased morale among nurses and an increased mistrust of management also have been identified as frequent reactions to change in the workplace. Some nurses have reported physical and emotional symptoms such as exhaustion, irritability, and crying during their attempt to cope with the disruption of routine and feelings of uncertainty related to emerging roles and responsibilities. Studies examining nurses attitudes toward computers have shown conflicting results. For example, early studies indicated a correlation between positive attitudes toward computers and increased years of nursing experience.9 However, in later studies, nurses with more years of experience have exhibited negative attitudes toward computers.10 Stronge and Brodts9 study of nurses attitudes toward computerization found that years of nursing experience and the education level of the nurse correlated with positive attitudes about computers. Nurses with more than 21 years of experience in healthcare had a more positive attitude toward computers than nurses who had worked in the field fewer than 10 years. They also found significant differences in attitudes among nurses in various nursing units. For example, nurses who worked in rehabilitation pediatrics and nursing administration exhibited more agreeable attitudes toward computers than nurses in the medical-surgical unit. The researchers did not find any significant difference among various age groups (older nurses compared with younger nurses) and their attitudes toward computers. Sultana11 agreed with Stronge and Brodt,9 and found no significant difference in attitudes among nurses of various ages. However, this study concluded that there were no significant differences in attitudes toward computers among nursing units, and that years of nursing experience were not a factor in determining negative or positive attitudes toward computers. An Australian study compared the relation of age, education, and years of nursing experience to nurses attitudes in the implementation of an information system.12 The study looked at factors related to user satisfaction, beliefs, and motivation. Results indicated that nurses with more years of clinical experience exhibited increased resistance to the implementation of an information system. Nurses with less clinical experience tended to be more accepting and motivated toward the change. The researchers did not find any significant correlation between age or education and nurses attitudes toward computers. A study of 208 staff nurses in a British hospital also examined the attitudes of nurses toward computers.10 A significant association was identified among age, years of clinical experience, and clinical units in which nurses worked with positive or negative attitudes toward computers. The study found that nurses 29 years of age or younger were most likely to exhibit positive attitudes 82

toward computers. Nurses 30 years of age or older and nurses with more years of nursing experience were most likely to exhibit negative attitudes toward computers. Clinical areas in which nurses worked also affected attitudes toward computers. Nurses in rehabilitation, medical, and elderly care units were most likely to display negative attitudes toward computers. McBride and Nagle 13 looked at attitudes toward computers among baccalaureate nursing students and registered nurses currently employed in a large hospital setting. They found that both groups had positive attitudes toward computers despite years in nursing or clinical experience. Although the student group had more computer experience, it was not a significant factor differentiating the two samples. Research indicates that nurses have differing and often conflicting attitudes toward change and computers. Nurses may feel powerless in the midst of change or challenged by an exciting opportunity. They may grieve over the loss of a system with which they are familiar and will need to process and integrate their feelings to accept the change. Older nurses in a particular practice setting may actively resist computerization, whereas younger nurses in another area may embrace it. The differences in the study findings suggest the influence of other characteristics unique to the samples studied, and the ability to make generalizations from these studies is limited. This may contribute to the complexity of understanding nurses attitudes toward change and computers, but the use of Lewins Force Field Analysis Model will assist the nurse informaticist in identifying and addressing these concerns.

APPLICATION OF FORCE FIELD ANALYSIS

In analyzing a situation, Lewin4 stated that one must characterize the situation in the entire context and not just isolated elements. The psychological atmosphere is of fundamental importance and must be determined when one is identifying driving and restraining forces. The nurse informaticist must have an understanding of how each unit is governed and how project decisions are made. Each unit will have distinct psychological characteristics and rules for facilitating change. It is important to be aware of these decision-making factors when navigating the processes of unfreezing, moving, and refreezing.

Step 1: Unfreezing
In step 1, the problem is identified. In this example, the current nursing system needs to be replaced with a new nursing information system. The nurse informaticist must
March/April 2003

CIN: Computers, Informatics, Nursing

Table 1 Examples of Driving Forces and Restraining Forces

Driving Forces
Viewed favorably by management Viewed positively by staff Prior computer experience Personal needs addressed/supported Aware of improvement needed in current practices Positive past experience with change Desire to learn a new system Management approval and acceptance High level of autonomy in organization Educational/training needs provided for Adequate financial resources Constructive, positive social culture High level of commitment by management, staff, and individuals

Restraining Forces
Viewed unfavorably by management Viewed negatively by staff Lack of prior computer experience Personal needs not addressed/supported Negative past experience with change Aversion to learning a new system Management critical/nonaccepting Authoritarian organizational culture Lack of accommodation for education/training Lack of financial resources Destructive, negative social culture Low level of commitment by management, staff, and individuals

identify the people who will be affected by this change and include all users of the system: nursing management, administration, and information support services. Open communication with nursing management and staff is essential. The nurse informaticist must create a sense of security and trust in all those involved with the proposed change.2 Active listening affirms to the nurses that what they are saying is being heard and understood. The nurse informaticist must show others they are valued and important by being on time and prepared for meetings. During this phase, driving forces and restraining forces are identified. Table 1 suggests examples of forces that may be considered driving forces and restraining forces. This information can be gathered by conducting brainstorming sessions with nursing management and staff. Using a flip chart or chalkboard is an easy way to keep track of the driving forces and the restraining forces. With the group, the nurse informaticist clarifies and strengthens the driving forces, reinforcing the concept that these forces will assist in moving the project forward toward a successful outcome. The group members are encouraged to identify obstacles they perceive may inhibit or prevent the goal from being reached. Once the driving forces and restraining forces have been identified, the nurse informaticist leads the group in selecting common themes and prioritizing each of the forces. Lewin14 used various and sometimes complex geometric frameworks for measuring the strength, direction, and valence of the driving and restraining forces. A computerized tool is not necessary for the analysis. However, a software application called Pathmaker from SkyMark Corporation, Pittsburgh, Pa, is available.15 White2 suggested creating a diagram of driving forces and restraining forces and assigning a score to designate the size or strength of the force. For example, if using numeric values between 1 and 5, the number 1 would

indicate a weak force, whereas the number 5 would indicate a strong force. Figure 1 presents a simple example of an analysis diagram. The state of equilibrium has been disrupted as a result of the driving forces propelling the change. The goal of the driving forces is to overcome or substantially weaken the restraining forces so that the desired outcome can be accomplished. Lewin4 cautioned that the aim is to achieve a state of equilibrium again, but strengthening a driving force may have the opposite effect of strengthening a restraining force rather than weakening it. Once the forces have been clarified and scores assigned designating the relative strength of each force, the nurse informaticist must devise strategies to strengthen and enhance the driving forces and to weaken or reduce the restraining forces. Strategies the nurse informaticist may use for this include involving nurses in all phases of implementation from selecting a vendor to testing the new system. Nursing staff must be informed of all events relative to the progression of the project and what new roles or responsibilities may result from the project. It is important to communicate to nurses the administrations commitment to the project. The nurse informaticist also must organize regular meetings with nursing staff to facilitate open communication and encourage the support of the new system.2,16

Step 2: Moving
Once the change has been recognized and accepted by the nursing management and staff, the process of planning and implementing the new information system can move forward. During this phase, the nurse informaticist continues to encourage open communication and group discussion. Nurses should be encouraged to assist with decisions related to screen design and layout. They
March/April 2003

CIN: Computers, Informatics, Nursing

83

FIGURE 1. Example of a force field analysis diagram.

can participate in the development of contingency procedures in the event of system down time. Once the staff feels actively involved and personally committed to the project, they will be more likely to support a successful implementation. The nurse informaticist must be aware of possible underlying or residual resistance to the project and deal with it to keep the project moving. For example, although initial resistance to the proposal is no longer present, resistance may occur as the result of challenges associated with workflow once the system is implemented. The activities discussed during the process of unfreezing may need to be used again during this phase to facilitate forward movement of the project. Once the change from the current system to the new nursing information system has been implemented, the nurse informaticist must offer ongoing evaluation and support.

change is maintained by providing continued assistance and support to people using the information system. Once the process is completed and deemed stable, the nurse informaticist begins withdrawing from the project. Individuals within the organization now are entrusted with providing ongoing support of the new information system to nursing management and staff.

CONCLUSION
When implementing change in a healthcare organization, the nurse informaticist must ensure that the proposed change is viewed as a challenge rather than a threat. Adjusting to change may be difficult and demanding. Therefore, a well-formulated strategy will encourage adaptation to change rather than resistance. Setting of project goals, careful planning, good communication skills, involvement of those affected by the change, and support of nursing management and staff are essential components in the implementation of a successful nursing information system. Integration of Lewins Force Field Analysis Model can provide the necessary framework for planning, implementing, and evaluating the acceptance and success of a nursing information system.
March/April 2003

Step 3: Refreezing
The final step in Lewins model is the refreezing stage. The nurse informaticist has strategically planned and implemented the nursing information system, and what now follows is a period of stability and evaluation. The 84

CIN: Computers, Informatics, Nursing

REFERENCES
1. Ball MJ, Lillis JC. Health information systems: challenges for the 21st century: managing clinical and economic outcomes. Adv Pract Acute Crit Care. 2000;11(3):386-395. 2. White KM. Planned change. In: Ricchiccioli JT, Tilbury MS, eds. Clinical Leadership in Nursing. Philadelphia: WB Saunders; 1998:179-195. 3. Marrow AJ. The Practical Theorist: The Life and Work of Kurt Lewin. New York: Teachers College Press, Columbia University; 1977. 4. Lewin K. Field Theory in Social Science: Selected Theoretical Papers. Westport, CT: Greenwood Press; 1975. 5. Lancaster J. Nursing Issues in Leading and Managing Change. St. Louis, MO: Mosby; 1999. 6. Ely B. Pediatric nurses pain management practice: barriers to change. Pediatr Nurs. 2001;27(5):473-480. 7. Schoolfield M, Orduna A. Understanding staff nurse responses to change: utilization of a grief-change framework to facilitate innovation. Clin Nurse Spec. 1994;8(1):57-62. 8. Ingersoll GL, Fisher M, Ross B, Soja M, Kidd N. Employee re-

9. 10. 11. 12. 13. 14. 15. 16.

sponse to major organizational redesign. Appl Nurs Res. 2001;14(1):18-28. Brodt A, Stronge JH. Nurses attitudes toward computerization in a midwestern community hospital. Comput Nurs. 1986;4(2):18-28. Simpson G, Kenrick M. Nurses attitudes toward computerization in clinical practice in a British general hospital. Comput Nurs. 1997;15(1):37-42. Sultana N. Nurses attitudes toward computers in clinical practice. J Adv Nurs. 1990;15(6):696-702. Marasovic C. Attitudes of Australian nurses toward the implementation of a clinical information system. Comput Nurs. 1997;15(2):91-98. McBride SH, Nagle LM. Attitudes toward computerization: a test of construct validity. Comp Nurs. 1996;14(3):164-170. Lewin K. The Conceptual Representation and the Measurement of Psychological Forces. New York: Johnson Reprint Corporation; 1968. SkyMark Corporation Website. Available at: http://www.skymark.com/resources/tools/force_field_diagram.asp. Accessed May 28, 2002. Glancy TS, Brooks GM, Vaughn VS. Hospital information systems: nursings integral role. Comput Nurs. 1990;8(2):55-59.

CIN: Computers, Informatics, Nursing

March/April 2003

85