The Importance of Medical and Nursing Sub-cultures in the Implementation of Clinical Information Systems

Summary

Objective: To measure doctors’ and nurses’ perceptions of organisational culture and relate this to their attitudes to, and satisfaction with, a hospital-wide mandatory computerised provider order entry (CPOE) system in order to illuminate cultural compositions in CPOE use.

Methods: A cross-sectional survey design was employed. Data were collected by administering an organisational culture survey (Organisational Culture Inventory, OCI) along with a user-satisfaction survey to a population of 103 doctors and nurses from two clinical units in an Australian metropolitan teaching hospital. Clinicians from the hospital had used the CPOE system since 1991 to order and view clinical laboratory and radiology tests electronically for all patients. The OCI provides a measure of culture in terms of three general styles which distinguish between: constructive; passive/defensive, and aggressive/defensive cultures. The cluster which best describes the overall culture is the one that has the highest percentile score when the percentile scores of the four cultural norms included in the cluster are averaged. The user satisfaction survey asked questions relating to satisfaction with, and attitudes to, the system.

Results: We found identifiable sub-cultures based on professional divisions where doctors perceived an aggressive-defensive culture (mean percentile score = 43.8) while nurses perceived a constructive culture (mean percentile score = 61.5). There were significant differences between doctors and nurses on three of the attitude variables with nurses expressing more positive views towards CPOE than doctors.

Conclusion: The manifestation of sub-cultures within hospitals and the impact this has on attitudes towards clinical information systems should be recognized and addressed when planning for system implementation. Identification and management of the cultural characteristics of different groups of health professionals may facilitate the successful implementation and use of clinical information systems.

Keywords

Organisational culture - sub-cultures - IT implementation - hospital information systems - clinical information systems - computerised provider order entry systems (CPOE) - health professionals

• References

• 1 Ash JS, Gorman PN, Seshadri V, Hersh WR. Perspectives on CPOE and patient care. J Am Med Inform Assoc 2004; 11: 95-99.
• 2 Ash JS, Bates DW. Factors and forces affecting EHR system adoption: Report of a 2004 ACMI discussion. J Am Med Inform Assoc 2005; 12: 18-20.
• 3 Massaro TA. Introducing physician order entry at a major academic medical center: impact on organizational culture and behavior. Acad Med 1993; 68: 20-5.
• 4 Lorenzi NM, Riley RT, Blyth AJC, Southon G, Dixon BJ. Antecedents of the people and organizational aspects of medical informatics: A review of the literature. J Am Med Inform Assoc 1997; 4: 79-93.
• 5 Kaplan B. Addressing organizational issues into the evaluation of medical systems. J Am Med Inform Assoc 1997; 4: 94-101.
• 6 Berg M. Medical work and the computer-based patient record: a sociological perspective. Methods Inf Med 1998; 37: 294-301.
• 7 Ahmad A, Teater P, Bentley TD, Kuehn L, Kumar RR, Thomas A, Mekhjian HS. Key attributes of a successful physician order entry system implementation in a multi-hospital environment. J Am Med Inform Assoc 2002; 9: 16-24.
• 8 Callen JL, Braithwaite J, Westbrook JI. Cultures in hospitals and their influence on attitudes to, and satisfaction with, the use of clinical information systems. Soc Sci Med 2007; 65: 635-639.
• 9 Gosling AS, Westbrook JI, Coiera EW. Variation in the use of online clinical evidence: a qualitative analysis. Int J Med Inf 2003; 69: 1-16.
• 10 Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order entry: The importance of special people. Int J Med Inf 2003; 69: 235-250.
• 11 Ash JS, Gorman PN, Lavelle M, Stavri PZ, Lyman J, Fournier L, Carpenter J. Perceptions of physician order entry: results of a cross-site qualitative study. Methods Inf Med 2003; 42: 313-323.
• 12 Aarts J, Doorewaard H, Berg M. Understanding implementation: the case of a computerized physician order entry system in a large Dutch university medical center. J Am Med Inform Assoc 2004; 11: 207-216.
• 13 Schein EH. Organisational culture and leadership. San Francisco: Jossey-Bass; 1985
• 14 Degeling P, Sage D, Kennedy J, Perkins R, Zhang K. A comparison of the impact of hospital reform on medical subcultures in some Australian and New Zealand hospitals. Aust Health Rev 1999; 22: 172-188.
• 15 Greenberg J, Baron RA. Organizational culture, creativity and innovation. In: Greenberg J. (ed.). Behaviour in organisations: Understanding and managing the human side of work. Upper Saddle River, NJ: Prentice Hall; 2003. pp 513-546.
• 16 Scott T, Mannion R, Davies H, Marshall M. Implementing culture change in health care: Theory and practice. Int J Qual Health Care 2003; 15: 111-118.
• 17 Braithwaite J. Analysing structural and cultural change in acute settings using a Giddens-Weick paradigmatic approach. Health Care Anal 2006; 14: 91-102.
• 18 Braithwaite J. An empirical assessment of social structural and cultural change in clinical directorates. Health Care Analysis 2006; 14: 185-193.
• 19 Martin J. Organizational culture: Mapping the terrain. Thousand Oakes, CA: Sage Publications; 2002
• 20 Davies HTO. Understanding organizational culture in reforming the National Health Service. J R Soc Med 2002; 95: 140-142.
• 21 Friedman CP. Information technology leadership in academic medical centers: A tale of four cultures. Acad Med 1999; 74: 795-799.
• 22 Cooke RA, Lafferty JC. Organizational Culture Inventory. Plymonth, MI: Human Synergistics; 1989
• 23 Szumal JL. Organisational culture inventory. Interpretation and development guide. Australia: Human Synergistics; 1998
• 24 Scott T, Mannion R, Davies H, Marshall M. The quantitative measurement of organisational culture in health care: A review of available instruments. Health Serv Res 2003; 38: 923-945.
• 25 Xenikou A, Furnham A. A correlational and factor analytic study of four questionnaire measures of organisational culture. Hum Relat 1996; 49: 349-370.
• 26 Seago JA. Organisational culture in hospitals: Issues in measurement. J Nurs Meas 1997; 5: 165-178.
• 27 Seago JA. Registered nurses, unlicensed assistive personnel, and organizational culture in hospitals. J Nurs Admin 2000; 30: 278-286.
• 28 Cooke RA, Rousseau DM. Behavioural norms and expectations: A quantitative approach to the assessment of organizational culture. Group & Organization Studies 1988; 13: 245-273.
• 29 Cooke RA, Szumal JL. Measuring normative beliefs and shared behavioural expectations in organizations: The reliability and validity of the Organizational Culture Inventory. Psychol Rep 1993 pp 1299-1330.
• 30 Tierney WM, Overhage JM, McDonald CJ, Wolinsky FD. Medical students’ and housestaff’s opinions of computerized order-writing. Acad Med 1994; 69: 386-389.
• 31 Weiner M, Gress T, Thiemann DR, Jenckes M, Reel SL, Mandell SF, Bass EB. Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system. J Am Med Inform Assoc 1999; 6: 234-244.
• 32 Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly. 1989; September: 319-340.
• 33 Lee F, Teich JM, Spurr CD, Bates DW. Implementation of physician order entry: User satisfaction and self-reported usage patterns. J Am Med Inform Assoc 1996; 3: 42-55.
• 34 Anderson JG, Aydin CE, Jay SJ. (eds). Evaluating health care information systems: Methods and applications. London: Sage Publications; 1994
• 35 SPSS Version 11.5 for Windows. SPSS Inc.; Chicago USA: http://www.spss.com
• 36 Scott T, Mannion R, Marshall M, Davies H. Does organisational culture influence health care performance? A review of the evidence. J Health Serv Res Policy 2003; 8: 105-117.
• 37 Braithwaite J, Westbrook MT, Iedema R, Mallock NA, Forsyth R, Zhang K. A tale of two hospitals: Assessing cultural landscapes and compositions. Soc Sci Med 2005; 60: 1149-1162.
• 38 Ash J. Organizational factors that influence information technology diffusion in academic health sciences centers. J Am Med Inform Assoc 1997; 4: 102-111.