Nursing Staff Readiness for Change based on EHR/EMR Implementation: An Exploratory

Qualitative Inquiry

Arturo Perez

The Problem• The problem is organizational leadership not attending to the

individual readiness for change to ensure staff transitions promptly through the change stages.

• The change stages are known as the transtheoretical model, fulfilling a successful implementation of an EHR system in the organization.

Research Question• What are the experiences to achieve readiness for change of

experienced nursing staff in a metropolitan area in a Pacific State who has completed a successful implementation of an electronic health record/electronic medical record?

Results Sample.

Results Themes

Results Understanding of EHR:

•What systems did your organization adopt as a part of Meaningful Use?

•Tell me in your words how you describe what an Electronic Health Record is?

•Tell me about the ways in which EHR/EMR influences your work.

Results Understanding of EHR Cont.

•The organization made the decision to implement the EHR to meet Meaningful Use requirements.•RNs were excited for getting HI-TECH

Results Understanding of EHR Cont.

• All RNs understood what an EHR is. • The nurses referred to their EHR as “Soarian.”

– PRN0006 identified it as “a Siemens product called Soarian.» Soarian Clinicals is a Siemens Healthcare Product.

• RNs identified EHR as:– A snapshot of patient history and patient care (PRN0006)– the data …put into a program…test results, vital statistics… kept

electronically (PRN0002)

ResultsStages of Change

• The evidence supports that healthcare organizations and vendors have the potential to improve user satisfaction and readiness for change during the EHR implementations and development

• The nurses of the participating healthcare institution indicated that the use of EHR will improve human error, and customization is required to improve the healthcare service provided.

• The prominent message from the nurses demonstrated that more education and nursing input is required to obtain a successful implementation of an EHR.

ResultsStages of Change

– RNs change:• PRN0001 stated was frustrating, and Siemens and ISD could have done more to fix the errors• PRN0008 had total panic attack overwhelming feeling of hatred.

– RNs faced with:• Technical issues • Systematic issues

– hiccups in the program (PRN0001)

– It was difficult the first day (PRN0003)– I do not know how change happens in the county, and my experience is the more I

roll with it, the happier I am, and I know it was coming (PRN0003)– Change was forced – PRN0007 had not had an opportunity to transition because was “told to do it.” – PRN0008 stated, “For me it was overwhelming.”

• The evidence was clear that nurses did not transition to take action of using the EHR.

ResultsStages of Change

• The interviewed nurses were at different stages as the implementation took place. – It was difficult the first day (PRN0003)– I do not know how change happens in the county, and my

experience is the more I roll with it, the happier I am, and I know it was coming (PRN0003)

– Change was forced – PRN0007 had not had an opportunity to transition because was

“told to do it.” – PRN0008 stated, “For me it was overwhelming.”

• The evidence was clear that nurses did not transition to take action of using the EHR.

ResultsStages of Change

• Age was not a factor with in the study– Jr nurses identified they had a better transition

over the Sr nurses. • PRN0001 stated, “I am young, I am 30 years of age. I am

ready for working with computers and typing.”

• It is clear that all nurses were at different stages of change.– Common factor• FORCED TO DO IT

ResultsStages of Change

• PRN0002 stated “better orientation would help” transition through change.

• PRN0003 mentioned, “the staff needs to be trained or have a better understanding before they go live, some of the staff had a hard time with it.”

• PRN0003 mentioned, “It was difficult the first day.”

• PRN0004 was ready for it “I do not know change happens in the county, and my experience is the more I roll with it, the happier I am, and I know it was coming!”

ResultsStages of Change

• PRN0006 was more experienced using EHRs because the nurse came from an institution using EHR to a paper environment “I was extremely happy, and it was extremely hard coming here and having a paper chart.”

• PRN0007 had not had an opportunity to transition because was “told to do it.”

• PRN0008 stated, “For me it was overwhelming.”

• The evidence was clear that nurses did not transition to take action of using the EHR.

Results Efficacy of Change

.

• The underlying theme from the nurses correlated to lack of preparedness and limited education. – All nurses were provided two days of training and

on the job live hands-on practice – RNs expressed this was not enough time to adapt

to the mandatory change.

Results Efficacy of Change

.

• Super users were Identified in the study– Super user was educated to support the day of implementation

• Implementation of new computer devices– Computers on wheels were deployed throughout the institution– PRN0001 identified that age and lack of computer education

created challenges in the environment.• “someone around age 40 or 50 years old and did not grow up with

computers, and learning how to type or pushing the keys on the keyboard is going to be difficult for them.”

Results Efficacy of Change

.

• RNs identified issues that created uncertainty of a successful implementation of this practice. – computer is not user-friendly, and it breaks down a lot

(PRN0008)– big screen blocks the nurse and interferes communication

with the patient (PRN0001,PRN0004,PRN0005)– it was mandatory! You want to get paid; you better do

this(PRN0006)– Looking back also probably there could have been more

of the training (PRN0007)

Results Efficacy of Change

.

• The perspective of PRN0006:– “We did not have adequate resources or the time set aside. So

there were many of meetings were we had many people missing. It just did not seem the organization, as a whole did not invest the resources necessary to getting it to be a quality program. Because, it seemed that it was something on the side but in reality, it was a big project. I guess, they could have done and given us a little bit more time.”

• The nurses’ comments illuminate that training and computer issues were a component of their transition to accepting the change.

ResultsImpact of Change

• The nurses expressed their readiness for change and understood that the change was going to happen regardless.

• It is nice for the reason you can access everything easily (PRN0003)• it made the patient information much more accessible (PRN0006 )• the system made the environment safer

– because it alerts … if patients are taking half a pill, three pills, things one could easily overlook with the paper med administration (PRN0005).

• RNs spend quite a lot of time charting and documenting (PRN0004,PRN0005)

• less time is spent with patients (PRN0003)

ResultsImpact of Change Cont.

• The nurses referenced that technology hindered the patient interaction and bedside manner while documenting in the EHR. – PRN0001 “issues with wireless workstations affect the use of

EHR.” – PRN0008 mentioned, “the actual computers that we use fall

apart all the time and pieces do not work.” • The three nurses attributed – “we are removed from the bedside, and the computer blocks

us and interferes communication with the patient.”

ResultsImpact of Change Cont.

• All nurses described the change transition during the EHR use or implementation.

• The workflow of a paper environment guided the workflow of the EHR. – PRN0006 identified how it influenced their work. Prior to the EHR the organization

“had a lot of forms were multiple people were contributing to one document” – PRN0006 felt “It influence the work “because they couldn’t just go back to the old

ways to use one document that is passed around” a computer is now required. – PRN0007 mentioned, “It is giving me double work.”– PRN0008 identified their prior practice, “two and a half years ago …did not have to

use a computer at all. Now, everything I do is computer. I dislike it immensely.”

Conclusions• The findings were consistent with various literatures on readiness for change. • The data collection, coding, and analysis process revealed contributing factors

impending nursing understanding of EHR, impacts of change, efficacy of change, and stages of change during an implementation.

• The majority of the nurses accepted the change because it was part of their job and did not have a choice.

• The nurses felt there was a higher need of education to ease the transition using the new EHR.

• The results of the study are significantly related to the readiness for change theory and implementation science during the individual transition of change.

• The results of the study reinforce the urgency of preparation to transition and accept technological change in healthcare.

• The research further adds to Weiner’s theory of readiness for change; highlighting the need for healthcare administration to develop a process or program for nurses; using a full integration of ways and means; while eliminating the blind spots that now make nurses frustrated using the new EHR.

Recommendations• Researchers should consider the findings of the study and expanding the

parameters in the following areas: – understanding of HER– impacts of change– the efficacy of change– stages of change during an implementation.

• Future researchers may also want to consider physicians for the sample group.

• The sample size was designed for 20 to 30 participants; however, only eight nurses participated, and saturation was met.

• Therefore, replacing the study with a larger sample may expand the generalizability of the findings.

• Future studies may provide further details on the nursing experience using or implementing a new EHR.