Introduction
In order to ensure the highest quality of care, healthcare institutions undergo continuous improvements. The present report considers the plans for the implementation of a new clinical information system in the King Fahad Hospital (KFH) with a focus on the impediments to this change. KFH is a hospital in Almadinah, Saudi Arabia; with 500 beds, it is the biggest one in its region, and it serves a very large population as well.
As a result, the efficiency and other benefits, which come with the introduction of the most recent clinical information systems (Aldosari,2014,p331), are important for KFH. Indeed, with the volume of the information flow that the hospital experiences, modern information systems are crucial for it (Kahouei et al.,2014,p30). However, any change is associated with challenges (Spear,2016,p58), and several factors that can potentially impede the innovation in KFH will be discussed in this report with the help of Lewin’s Force Field Analysis (FFA).
There is some research devoted to the impanation of information systems in the healthcare organisations of Saudi Arabia. Additionally, the researcher has some insider knowledge of KFH, which has been used to determine the issues that might arise. Based on the two sources, the following five potential impediments have been identified: resistance to change, lack of training, technical problems, resource shortages, and the task of refreezing the change (making it sustainable).
By applying FFA to the mentioned issues, the present paper will uncover the forces which resist the change, as well as the forces that support it and, therefore, can be used to combat the effects of the impediments during the three stages of change (Hussain et al.,2018,p124-123; Spear,2016,p58-59). Thus, the present paper demonstrates that the use of FFA can help to determine change-related issues and solutions to them, which are based on best practices.
Kurt Lewin’s Force Field Analysis
Kurt Lewin’s investigation of and ideas about change have become fundamentally important for the modern understanding of change management (Cummings, Bridgman, & Brown,2015,p33-34). FFA was developed by Lewin in the previous century (Spear,2016,p58). Basically, FFA consists of the idea that there are the forces that prevent or resist change (the restraining forces) and those that promote it (driving forces).
In order to manage these forces to the benefit of any change, it is necessary to understand them, which implies the need for their identification and analysis (Spear,2016,p58; Tappen et al.,2017,p221). It should be pointed out that initially, FFA was meant for behavioural factors (Spear,2016,p58), but it has been applied to those that are not related to behaviours as well (Tappen et al.,2017,p225). The present paper will consist of FFA, in which the focus will be on the restraining forces.
A specific change model is associated with FFA; it includes three major steps: unfreezing, changing, and refreezing (Hussain et al.,2018,p123-124; Tappen et al.,2017,p221). According to FFA, the status quo consists of an equilibrium between the driving and restraining forces (Hussain et al.,2018,p123). Therefore, a change would require destabilising the status quo by reducing the restraining forces and encouraging those that promote change; this stage is described as unfreezing (Swanson & Creed,2014,p30). After the equilibrium is unbalanced, the change can be successfully carried out, after which it should be refrozen: turned into the new status quo to avoid regressing back to the pre-change equilibrium (Spear,2016,p59). Thus, FFA is the cornerstone of this model.
On its own, the three-stage model is very basic and might be considered simplistic (Cummings et al.,2015,p33-34; Tappen et al.,2017,p221); however, the simplicity makes its use easier, which is a benefit. Furthermore, it is possible to augment the model with other approaches; each of the stages can incorporate varied activities depending on the plan of the user; they might be based on other models and theories (Cummings et al.,2015,p43-44). In fact, it has been argued that augmenting the model is necessary to adapt it to every specific situation and change (Hussain et al.,2018,p123). Thus, by being simple, the model provides a basic framework which is then employed to the benefit of the user.
Additionally, when FFA is considered, the model stops being simple; its primary focus becomes the investigation of change and its analysis, which makes it a very powerful tool in change management (Swanson & Creed,2014,p32). Finally, the model applies to healthcare and has been employed in such settings (Spear,2016,p58-59). Therefore, it fits the needs of the present report, and FFA will be used in this work to analyse the five mentioned impediments to the introduction of a new information system for KFH and the related solutions based on best practices.
Impediments and Solutions
Resistance to Change
A very common issue that is described as resistance to change is the wish to uphold the status quo. It is relatively common for people to resist change (Tappen et al.,2017,p225), and the healthcare settings are not different in this regard. Furthermore, the introduction of information technology in healthcare is often met with resistance (Kahouei et al.,2014,p30-31), and there are specialists who have negative attitudes towards computerisation (Kipturgo, Kivuti-Bitok, Karani, & Muiva,2014,p2).
There is some evidence which indicates that such perspectives can be present in Saudi Arabia (El Mahalli,2015,p34). The experience of various minor changes in KFH shows that KFH innovations are often met with at least some resistance. Also, the upcoming change is reported to cause anxiety, even though KFH’s organisational culture is generally supportive of change. Therefore, this common impediment must be reviewed in this report.
Resistance to change may be associated with different issues; it is a very multifaceted and complex problem that requires extensive analysis (Anders & Cassidy,2014,p139; Appelbaum, Degbe, MacDonald, & Nguyen-Quang,2015,p76). For example, resistance can be caused by the benefits of the existing technology, the concerns about the new system, the lack of confidence in one’s ability to master the new system, and so on (Maillet, Mathieu, & Sicotte,2015,p41-42; Spear,2016,p58). In other words, it is not possible to determine a single reason for resistance.
Still, some theories can assist a leader in finding relevant issues. For example, Rogers presented several attributes of innovation, which can be used to explain change resistance (Pashaeypoor, Ashktorab, Rassouli, & Alavi-Majd,2016,p85,88). They include “Relative advantage, Compatibility, Complexity, Trialability, Observability” (Mannan, Nordin, Rafik-Galea & Ahmad Rizal,2017,p318). For instance, if a person does not view the new system as superior to the previous one (relative advantage), they may be reluctant to adopt the change.
Similarly, if the new system is somehow incompatible with KFH or appears to be viewed as too complex, resistance can be explained. By analysing the reasons for resistance, a leader can apply FFA’s analytical approach to particular, smaller forces that constitute the general restraining force of resistance to change.
It should be mentioned that resistance to change can have some positive outcomes. Mostly, they are related to the criticisms of a change, which can be viewed as another approach to analysis and might provide the information necessary for improvement (Appelbaum et al.,2015,p77). For the described project, the criticism can be used to monitor the issues that are encountered by the participants. The above-presented examples of complexity and incompatibility can serve as an illustration of this principle. The positive perspective on impediments can yield positive results (Swanson & Creed,2014,p34), but it is important to remember the negative outcomes of resistance (slower, less effective change).
In order to address this restraining force, a driving force should be used: leadership. Leadership is a major enabling force (Swanson & Creed,2014,p33; Tappen et al.,2017,p225); basically, it is the primary force that is crucial for change (Appelbaum et al.,2015,p73-74; O’Rourke, Higuchi, & Hogg,2016,p5). A leader should employ the above-presented dimensions of change to determine the reasons for resistance to change and address them accordingly.
For example, it has been established that a system which is perceived as easy to use is likely to be met with less resistance (Aldosari, Al-Mansour, Aldosari, & Alanazi,2018,p85-87), and a leader can demonstrate the ease of use with the help of training, trials, and other approaches (Pashaeypoor, et al.,2016,p85,88). Thus, by using FFA to determine the forces which cause resistance, a leader will be able to use it as a criticism and avoid its negative outcomes by addressing uncovered issues with the help of customised solutions in a timely manner.
Lack of Training
Even though KFH’s staff is generally well-educated and skilled with respect to information systems, the introduction of a new one will require some training to ensure its comfortable use. In other words, the lack of training in the use of the new system is inevitable. Additionally, a recent questionnaire conducted in KFH demonstrated that at least some nurses in its intensive care unit view their information system-related skills as lacking.
This issue may be encountered in other units as well. In fact, the lack of training is a major and relatively common concern during innovations in various settings, including healthcare and Saudi Arabia (Ahmadian, Khajouei, Nejad, Ebrahimzadeh, & Nikkar,2014,p3-4; Sadeghi-Bazargani, Tabrizi, & Azami-Aghdash,2014,p4). Training is also an important determinant of the success of innovation (Aldosari,2014,p331); it tends to improve the attitudes of users towards the new equipment as well (Kipturgo et al.,2014,p5). Thus, this impediment may be among the most significant ones.
The only obvious solution is training, but there are some details about it that are based on best practices and theories. When considering this issue, an inverse approach to FFA may be employed. In particular, instead of viewing training as a barrier or problem, one can regard it as a motivator, an opportunity for change, or a challenge (Swanson & Creed,2014,p34). In fact, training itself can be viewed as a force that promotes change (Tappen et al.,2017,p225).
To make sure that this impediment is perceived as an opportunity rather than an issue, the driving force of leadership should be used once again: leaders should frame the need for training accordingly and motivate the staff to participate in it. This task will be facilitated by KFH’s organisational culture, which supports continuing education. This intervention should be carried out throughout the three stages of change.
Furthermore, it is important to ensure that the participants’ learning needs are assessed, taken into account, and met; this element of the task can be led by the training department (Kahouei et al.,2014,p33). The needs assessment may begin during the unfreezing stage together with the choice of the system, but it will have to be completed during the second stage because the training plans will need to be completed for it. Thus, to resolve the issue, it is necessary to plan the training intervention in accordance with the needs of the employees and use effective leadership to promote a positive approach to the impediment. Again, the restraining force is resolved by a driving one.
Technical Issues
Changes which are associated with technology are likely to face the restrictive forces that related to it. A typical issue consists of outdated or insufficient hardware and software, and it is an anticipated impediment, which is why it must be considered (Tappen et al.,2017,p226). In KFH, computer resources are regularly updated, but the introduction of a new system must be associated with their revision to enable planning. This element of combating the restricting force will take place during the unfreezing stage.
Naturally, the monitoring of the systems will also be required throughout the change and after it. The technical difficulties are often cited by Saudi Arabian healthcare providers as a major issue in adopting and using informational systems (El Mahalli,2015,p34). However, KFH already has processes that ensure the management of its equipment; they detect and eliminate issues as they are encountered. Therefore, the leaders of the change will not need to develop specific procedures for managing technical problems, but they might need to take into account the potential delays associated with technical issues when developing the plan.
Finally, it will be important to engage KFH’s specialists who work with hardware and software in the project. Technical assistance is the primary means of combating the issue of technical issues (Tappen et al.,2017,p226). The task of the engagement of the professionals will be performed by the leaders, and it will occur during the unfreezing stage to ensure that the necessary consultations are acquired at any time. Thus, the restrictive force of technical issues is resolved by the forces of leadership and skilled workforce (in this case, informatics specialists).
Shortage of Resources
Any change is resource-consuming; the most significant resources include funding, time, and effort. The shortage of resources can become a major barrier to change (Bjarnadottir, Herzig, Travers, Castle, & Stone,2017,p422; Sadeghi-Bazargani et al.,2014,p4; Tappen et al.,2017,p220, 226). It is not unlikely for KFH because it is forced to maximise its efficiency while attempting to reduce the expenditure of resources. The problem is generally common for Saudi Arabia; even though healthcare is well-funded in the country, the recent years have seen an increase in spending, which is mostly associated with the costs of equipment and growth in population (Aldosari,2014,p339). Therefore, the shortage of resources is a significant impediment that must be considered.
The lack of resources would be regarded as a restraining force according to FFA, and in this case, change managers need to ensure the provision of resources, each of which may require a specific approach. The support of the stakeholders, especially management, is crucial (Silver et al.,2016,p1-2), and it can be obtained during the unfreezing stage. Furthermore, the budget plan for the project needs to be carefully drafted and justified to ensure that the necessary funds are allocated at the same time (possibly, prior to obtaining the support of the management).
Additionally, the monitoring of the fund’s use is crucial to avoid excessive expenditures throughout the change stage and, potentially, refreezing (Anders & Cassidy,2014,p139). In a similar way, time and effort should be managed: they require planning, monitoring, and the engagement of the relevant stakeholders. Thus, the accurate management of resources, which can be viewed as another important driving force, is the best-practice approach that would prevent or mitigate their lack.
Refreezing
The final stage of the three-part model is unique in its difficulty (Anders & Cassidy,2014,p139). It could be suggested that for the presented project, the refreezing is inevitable since, eventually, the new system will have to replace the old one. However, the inefficient refreezing of this adoption can result in the reluctance to use and avoidance of the new system; additionally, it can be used inefficiently. For instance, it is rather common for Saudi Arabia professionals to underutilise their informational systems (El Mahalli,2015,p34). Therefore, the potential difficulties associated with the finalisation of change are applicable to the project and are among the impediments that can render it ineffective.
To make the change sustainable, the project needs to incorporate the means of monitoring the adoption of the new system; criteria for the evaluation of the innovation should also be developed (Anders & Cassidy,2014,p139). By continuously reviewing the adoption process, KFH will be able to detect and address issues in a timely manner, find the means of encouraging the change, and make the process as smooth and swift as possible. Additionally, an important strategy is the celebration of achievements because they have been shown to improve motivation and assist participants in persisting with the change (Spear,2016,p60; Tappen et al.,2017,p227). By demonstrating and solidifying meaningful changes, a leader will promote the sustainability of the system’s adoption.
Commonly, when considering change, the topic of organisational culture is mentioned. Depending on its specifics, culture can either facilitate or complicate the adoption process; in the latter case, it may need to be revised (Anders & Cassidy,2014,p139). However, in the case of KFH, the organisational culture would be expected to support the change. Indeed, KFH’s primary goal consists of providing high-quality care while also improving its efficiency. Both of these outcomes are typically associated with the use of information systems (Aldosari,2014,p331). Therefore, the adoption of a new system is generally in line with KFH’s culture, and it may help to facilitate and cement the change.
To make use of this driving force, leadership should be used once again. In particular, leaders need to highlight the compatibility of the change with the hospital’s culture. As suggested by Rogers, compatibility is among the parameters of innovation that make adopter more responsive to it (Mannan et al.,2017,p318). Therefore, by employing the forces of the organisational culture and leadership, leaders can help to refreeze the new status quo, thus assisting the organisation in adopting its new system effectively.
Interconnection of Issues
The above-presented impediments can be interconnected. For instance, the lack of training may affect a participants’ perception of the complexity of the system, which, in turn, may result in the resistance to change and be generally demotivational (Kipturgo et al.,2014,p5). Similarly, the lack of resources might affect the quality of training or the available equipment, which can lead to technical issues. This feature of the barriers highlights the importance of investigating and analysing them, which is promoted by FFA: by identifying and addressing them during appropriate stages, a leader can prevent their detrimental effects on other forces.
Conclusion
The present paper offers an FFA for the upcoming implementation of an information system for KFH, which is a large hospital in Saudi Arabia. The results indicate that there are five major restricting forces that should be anticipated: resistance to change, training issues, resource shortages, technological problems, and the need to ensure the refreezing of the change. As shown by FFA, most of these issues can be resolved with the help of driving forces: effective leadership, careful management, skilled workforce, and organisational culture.
Additionally, some of the issues, especially training and resistance to change, can have positive outcomes if managed well. Thus, FFA demonstrates the interplay of different forces that would be anticipated during change and suggests patterns for their management, which are supported by the literature on the topic as best practices. By destabilising the equilibrium of the two groups of forces, it is possible to promote change and guide it through the three stages of the described change model.
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