by Sarah Payne, BN, RN
Masters of Nursing Student,
Memorial University of Newfoundland and Labrador
The healthcare environment is continuously changing and evolving. Nurses are making great strides to adapt to these changes in an attempt to meet complex health care demands. The transition to electronic documentation is one technological change that has significant implications for the nursing profession and the overall health care system. This method of documentation can assist nurses in addressing problems that occur as a result of paper-based documentation. It can also improve the accuracy and comprehensiveness of patient information and enhance the provision of quality nursing care. Although electronic documentation can be very beneficial, many barriers exist that impede the implementation of computerized documentation systems. In order to successfully implement this project, the nurse informaticist must be able to identify and address these challenges. Kurt Lewin’s Change Management Theory offers a strategic approach that can assist nurses in planning, implementing, and evaluating the proposed change. The purpose of this paper is to describe electronic clinical documentation and explore how the implementation of this project can address problems commonly experienced by nurses. This paper also presents an overview of Kurt Lewin’s Force Field Analysis Model and discusses how it can be applied in the practice setting to successfully implement the hypothetical nursing informatics project.
change theory, electronic documentation, field theory, nursing informatics, Lewin’s theory
Advancements in computers and information technology have significantly contributed to changes within the nursing profession and the overall health care system. In today’s health care environment, it is imperative for nurses to adapt to technological advancements in order to address complex health care issues and deliver optimal nursing care (Ross-Kerr, 2003). Quality of care is greatly influenced by a nurse’s ability to access accurate and comprehensive health information. The transition from paper to electronic charting can facilitate this process and greatly improve the quality of nursing documentation (Curtis, 2011; McDowell, Dillon & Lending, 2008; Oroviogoicoechea, Watson, Beortegui, & Remirez, 2012; Pfortmiller, Mustain, Lowry, & Wilhoit, 2011; Pynn, 2010; Smith, Smith, Krugman, & Oman, 2005; Wolf & Nellis, 2011). This technological change can also address system inefficiencies that result from paper-based charting. Evidently, the implementation of electronic clinical documentation is essential to enhance the provision of safe, ethical, and effective nursing care.
The computerization of nursing documentation systems necessitates both structural and behavioral change (Kelley, Brandon, & Docherty, 2011). Since nurses are often resistant to change, the implementation of electronic documentation can be a very challenging endeavor (Bozak, 2003). Kurt Lewin’s theoretical framework demonstrates the complexities that occur as a result of the change process and offers a strategic approach to support the implementation of this technological advancement (Bozak, 2003).
The purpose of this paper is to define electronic clinical documentation and provide a description of my hypothetical nursing informatics project. Throughout the paper, I will provide an extensive review of the literature to explore how the implementation of electronic documentation can address problems experienced by nurses. I will also identify barriers that can potentially impede the implementation of this project. Additionally, I will describe Lewin’s Change Management Theory and discuss how it can be utilized to facilitate the successful transition from paper to electronic documentation in the practice setting.
Electronic clinical documentation, also known as computerized documentation or computer-based documentation is an electronic information system used by nurses and other health care professionals to systematically document clinical information that pertains to the health of an individual. In the practice setting, this collection of information is usually referred to as the patient’s electronic health or medical record. Information contained in this file includes, but is not limited to, assessment data, medication orders, clinical interventions, care plans, consults, nursing histories, laboratory data, and client outcomes. This record is also used to facilitate structured communication between nurses and other members of the health care team, and to promote the delivery of quality care. According to the Association of Registered Nurses of Newfoundland and Labrador (2010), both electronic and paper-based documentation are integral components of nursing care. However, a vast amount of literature indicates that the transition from paper to electronic documentation can have significant implications for clients, nurses, and the overall health care system. The implementation of this electronic documentation project can address many problems experienced by nurses in practice settings and greatly assist them in meeting professional goals and organizational standards (Oroviogoicoechea et al., 2010; Pfortmiller et al., 2011).
Based on a review of the literature, it is quite evident that today’s nurses are facing many problems that hinder their ability to provide quality care for their patients. Although nurses experience many challenges within their areas of practice, I will focus on some issues that can be addressed with the adoption of electronic clinical documentation.
One major concern for nurses in clinical settings is the amount of time spent documenting or recording patient information (Banner, & Olney, 2009; Banner & Olney, 2007; McDowell et al., 2008; Menke, Broner, Campbell, McKissick, & Edwards-Beckett, 2001; Pabst, Scherubel, & Minnick, 1996; Poissant, Pereira, Tamblyn, & Kawasumi, 2005; PricewaterhouseCoopers, 2001; Smith, Rogers, Hood, & Phillips, 1998; Yee, Needleman, Pearson, Parkerton, Parkerton, & Wolstein, 2012). PricewaterhouseCoopers (2001) reported that nurses spend approximately 30 to 60 minutes completing paperwork for every hour they spend providing patient care. Another study indicated that a nurse spends at least two to three hours of their shift completing forms and manually documenting clinical information (Poissant et al., 2005). Although clinical documentation is essential to promote safe and high-quality care, many studies have shown that the transition from paper to electronic documentation reduces the overall time that nurses spend documenting patient information; thus allowing more time to provide direct patient care (Banner & Olney, 2009; Banner & Olney, 2007; McDowell et al., 2008; Pabst et al., 1996; Smith et al., 1998; Spencer & Lunsford, 2012; Yee et al., 2012). Conversely, two studies showed that there were no significant changes in charting time following the transition to computerized documentation (Menke et al., 2001; Smith et al., 2005). Menke et al. (2001) also posited that the introduction of computerized clinical systems did not create more time for nurses to deliver patient care. However, their study did reveal other benefits of computerized documentation.
Incomplete and illegible documentation are significant issues that interfere with a nurse’s ability to access and accurately interpret clinical findings in paper charts (McDowell et al., 2008; Menke et al., 2001; Turisco & Rhoads, 2008). According to Menke et al. (2001), computerized systems eliminate the need for handwriting; thus providing more legible and comprehensive patient records. Electronic systems also minimize the potential of lost or damaged information that occurs with paper-based charting (Curtis, 2011). Additionally, these systems improve the accuracy of patient information (Mahler et al., 2006; McDowell et al., 2008; Smith et al., 2005), which assist nurses in meeting regulatory and legal documentation requirements (Mahler et al., 2006; Turisco & Rhoads, 2008). It also facilitates better communication between nurses and other health care professionals (Curtis, 2011; Saranto & Kinnunen, 2008). Specifically, Menke et al. noted that computerized documentation enhances the exchange of information between nurses during their change of shift. The benefits of timely and accurate communication cannot be underestimated as it greatly promotes the continuity, and overall quality, of nursing care (Menke et al.; Saranto & Kinneunen, 2008). The exchange of comprehensive patient information can be further enhanced through the use of well-designed computerized systems (Spencer & Lunsford, 2010). For example, standardized templates, customized computers screens, and drop down menus guide the documentation process and prompt nurses to enter all pertinent patient information (Curtis, 2011; Smith et al., 2005; Turisco & Rhoads, 2008).
Electronic documentation can also address workflow issues. According to Turisco & Rhoads (2008) new computerized documentation systems generate work lists and alerts features that offer nurses an “electronic helping hand,” and assist them in prioritizing and managing their care (p. 19). Electronic documentation systems also reduce documentation redundancies and promote quicker retrieval of clinical data (Curtis, 2011; Turisco & Rhoads). Furthermore, these systems allow multiple healthcare providers to simultaneously access patient records. This enhances collaboration among health care providers and strengthens interdisciplinary care.
As you can see the successful implementation of electronic patient records can greatly improve nursing documentation and enhance the safety and quality of patient outcomes. As a result, nurses report higher levels of job satisfaction, which can have a positive influence on nurse productivity, patient satisfaction, and overall success of health care institutions (McHugh, 2004). Despite existing evidence that supports the benefits of electronic documentation, the transition from paper-based to electronic documentation present major challenges within health care organizations.
The literature reveals many barriers that prevent or impede the successful implementation of electronic documentation in practice settings. Many studies focus on nurses’ perceptions or attitudes towards the integration of clinical information systems (Alquraini, Alhashem, Shah, & Chowdhury, 2006; Lacey, 1993; Moody, Slocumb, Berg, & Jackson, 2004; Pfortmiller et al., 2011). Lacey (1993) noted that nurses’ attitudes greatly influence their willingness to accept and adapt to electronic documentation. According to Pfortmiller et al. (2011), the implementation of computerized systems has a much greater chance to succeed if nurses believe that they can accept the change and that the change will have positive implications for patient care. In a study conducted by Moody et al. (2004), demographics such as age and experience with computers were studied to determine if a relationship exists between these characteristics and associated attitudes towards electronic documentation. Moody et al. discovered that younger nurses and experienced computers users had a more positive attitude towards electronic documentation than older nurses and nurses with less computer experience. A study conducted by Alquraini et al., (2007) also showed a positive correlation between previous computer experience and positive attitudes toward computerized information systems.
Technological changes, in general, can also influence nurses’ attitudes and perceptions. Nurses regularly resist new technological advancements based on the assumption that it will disrupt their normal way of performing routine activities (Bozak, 2003). The introduction of electronic documentation in practice settings will inevitably create changes that may cause nurses to experience a variety of feelings including fear, anxiety, anger, resentment, confusion, exhaustion, and irritability (Bozak, 2003). These feeling and behaviors can cause nurses to resist the transition to computerized documentation (Maher et al., 2006; Whittaker et al., 2009).
Several other barriers that may impede the successful implementation of my hypothetical nursing informatics project have been identified throughout the literature. These include: the cost of selecting and implementing electronic systems (Curtis, 2007; Kulhanek, 2011; Moody et al., 2004; Wolf & Nellis, 2011; Zandich, Yoon-Flannery, Kuperman, Langsam, Hyman, & Kaushal, 2008), lack of infrastructure to support computerized documentation (Pfortmiller et al., 2011), acceptance of new technology (Whittaker, Aufdenkamp, & Tinley, 2009), time to adequately train and provide ongoing technical support for employees (Whittaker et al., 2009; Zandieh et al., 2008), and problems with computer equipment (Whittaker et al., 2009). Lewin’s theoretical framework can assist nursing informaticists in addressing these barriers.
Kurt Lewin’s model of change offers a structured approach that can help nurses identify the need for change, navigate through the change process, and achieve a desired goal or outcome (Bozak, 2003). Lewin’s approach to change management can be very useful for health care organizations that strategically plan changes in an attempt to meet ongoing health care demands. Lewin’s Force Field Analysis Model can also assist nurses in analyzing the change process and in identifying forces that support or resist the change (Bozak, 2003). Lewin identified these forces as driving forces and restraining forces, respectively (Kaminski, 2011). According to Kaminski (2011), driving forces initiate change and assist organizations in reaching their desired goals. Restraining forces, on the other hand, are static forces that counteract the driving force and prevent the change from occurring (Sassen, 2009). When the driving forces and restraining forces are equivalent, a state of equilibrium is reached. In order for change to transpire, this state of equilibrium must be disrupted (Bozak, 2003; Kaminski, 2011). This occurs when the driving force is more powerful than the restraining force, or conversely, when the restraining force is weaker than the driving force (Bozak, 2003; Kaminski, 2011; Sassen, 2009).
Lewin’s theory of change consists of three stages: unfreezing, moving, and refreezing (Bozak, 2003; Kaminski, 2011; Sassen, 2009). Unfreezing is the initial stage of the change management process. In this stage, individuals recognize the need for change and prepare for the change to occur. This step often evokes a change in the behaviors among individuals. Bozak (2003) stated that feelings of discomfort, apprehension, and distress might be experienced during this period. In order to progress to the next phase. Nurse informaticists must recognize and adequately address these behaviors, as well as other resistive forces. Additionally, the nurse informaticist needs to analyze the driving forces to determine if they are more powerful than the restraining forces. Educating individuals regarding the motives for change can enhance the strength of driving forces and facilitate the transition from the first to second stage of Lewin’s model (Bozak, 2003; Kaminski, 2011; Sassen, 2009).
The second step of the change process is known as moving (Bozak, 2003; Kaminski, 2011). At this point, change management strategies must be geared towards strengthening driving forces or weakening restraining forces that are encountered by the organization. Additionally, initiatives need to be implemented to encourage individuals that the desired state will bring about positive organizational change. Individuals who understand these benefits are more likely to support the proposed change and actively engage in activities that drive the change forward and actually cause the change to occur (Bozak 2003).
The third, and final, step of Lewin’s process is refreezing (Bozak, 2003; Kaminski, 2011). In this step, equilibrium has been successfully reached. As a result, change is incorporated into routine procedures and practices within the organization. To prevent individuals from regressing to their previous state, it is vital to continuously maintain and reevaluate the change that has been established (Bozak, 2003). This can be accomplished through the use of supportive mechanisms such as policies, rewards, education sessions, and champion leadership (Kaminski, 2011).
Throughout this paper, I have clearly identified the need to transition from paper to electronic documentation. In the ensuing discussion, I will utilize Lewin’s Force Field Analysis model to hypothetically plan and implement my nursing informatics project.
Adhering to Lewin’s model, the first step of the change process involves “unfreezing” the change. To accomplish this step it is necessary for the nurse informaticist to identify and prioritize driving and restraining forces in the practice setting (Bozak, 2003). The nurse informaticist can generate this information by brainstorming and collaborating with administrative staff and nursing colleagues. Additionally, input should be obtained from other health care professionals, since all disciplines will be affected by the transition from paper to electronic documentation. Examples of driving forces that relate to the implementation of electronic documentation include: the desire to improve the method of documentation, the belief that electronic documentation will facilitate access to accurate and comprehensive clinical information, previous experience with computers, and positive attitudes towards computerization. Other potential driving forces include: adequate training, supportive management, desire to expand personal knowledge, sufficient financial resources, and positive organizational culture (Bozak, 2003).
Bozak (2003) also identified possible restraining forces such as inadequate training, unsupportive management, reluctance to learn something new, insufficient financial resources, and negative organizational culture. Other restraining forces include: the desire to continue to use paper-based documentation, lack of computer experience, and negative attitudes towards computers. Once all these forces have been identified, the nurse informaticist should proceed to develop a plan to strengthen the driving forces and weaken or eliminate the restraining forces. It is crucial for the nurse informaticist to maintain open communication with the nursing staff and involve them in all stages of the planning process (Bozak, 2003; Noah, 2011; Sassen, 2009).
The second step of Lewin’s model involves perusing the plan that was proposed in step one, and actually implementing the change (Bozak, 2003; Kaminski, 2011; Sassen, 2009). As with the previous step, the nurse informaticist should continue to communicate with the nursing staff and acknowledge their suggestions and opinions. The nurse informaticist should also help the staff to recognize the benefits of electronic documentation. According to Bozak (2003), employees are more likely to support the change if they understand the benefits of electronic documentation and are actively involved during the planning and implementation process. The nurse informaticist should also continue to closely monitor for changes in staff attitudes and behaviors throughout this step (Bozak, 2003; Pfortmiller et al., 201l). Undoubtedly, the implementation of the electronic documentation will disrupt normal changes in workflow, which may evoke negative feeling or behaviors among staff. If this occurs, the nurse informaticist must return to strategies used during the unfreezing stage (Bozak, 2003; Kaminski, 2011). Once the staff has accepted and successful transitioned from paper to electronic documentation, the organization can proceed to the final stage of Lewin’s model.
At this point of the process, the organization will be using computerized systems to electronically document patient information. The refreezing stage is a time for stabilizing and reevaluating the change to electronic documentation (Bozak, 2003). The nurse informaticist can maintain this change by providing staff with ongoing education and support. Additionally, the nurse informaticist must ensure that resources are put in place to support the staff once they have withdrawn from the project. For this particular project, it is important to have information technologists available around the clock to address general concerns and issues regarding the computerized systems. Clinical educators should also be available to support staff and provide comprehensive training for new employees. Additionally, policies should be available to assist staff in the documentation process (Kaminski, 2011). Ongoing evaluation is also essential to determine if this system of documentation meets personal, professional, and organizational standards, or if additional changes need to be made to further improve this method of clinical documentation.
Change commonly occurs within the healthcare environment. Technological advancements significantly contribute to these changes and assists nurses in meeting professional and organizational goals. The transition from paper to electronic documentation, in particular, can address some of the issues that nurses are currently experiencing, and help nurses to meet complex health care demands. Although this change is necessary, the implementation of electronic documentation can be challenging for nurses. The application of Kurt Lewin’s Change Management Theory provides a structured approach that can help nurses to overcome these challenges, as well as other barriers that impede the transition to electronic documentation. Throughout this paper I have examined Lewin’s Force Field Analysis Model and demonstrated how it could be used to plan, implement, and evaluate the transition from paper to electronic documentation. I believe that the implementation of electronic clinical documentation is essential to enhance the quality of nursing care. Lewin’s theoretical framework can be used to help nurse informaticists manage this change and successfully implement electronic documentation in practice settings.
Alquraini, H., Alhashem, A. M., Shah, M. A., & Chowdhury, R. I. (2007). Factors influencing nurses’ attitudes towards the use of computerized health information systems in Kuwaiti hospitals. Journal of Advanced Nursing, 57(4), 375-381. doi:10.1111/j.1365-2648.2007.04113.x
Association of Registered Nurses of Newfoundland and Labrador. (2010). Documentation standards for registered nurses. St. John’s: Author.
Banner, L., & Olney, C. M. (2007). A step in the right direction: Electronic clinical documentation improves nurse charting, efficiency, and satisfaction. CIN: Computers, Informatics, Nursing, 25(5), 312. doi:10.1097/01.NCN.00002891981.01767.bb
Banner, L., & Olney, C. M. (2009). Automated clinical documentation: Does it allow nurses more time for patient care? CIN: Computers, Informatics, Nursing, 27(2), 75-81.
Bozak, M. G. (2003). Using Lewin’s force field analysis in implementing a nursing information system. CIN: Computers, Informatics, Nursing, 21(2), 80-85.
Curtis, C. (2007). Nursing evaluation of electronic documentation systems. Retrieved from http://healthfieldmedicare.suite101.com/article.cfm/electronic_health_records
Kaminski, J. (2011). Theory applied to informatics – Lewin’s change theory. CJNI: Canadian Journal of Nursing Informatics, 6(1), 1-4. Retrieved from http://cjni.net/journal/?p=1210
Kelley, T., F., Brandon, D., H., & Docherty, S., L. (2011). Electronic nursing documentation as a strategy to improve quality of patient care. Journal of Nursing Scholarship, 43(2), 154-162. doi:10.1111/j.1547-5069.2011.01397.x
Kulhanek, B. (2011). Creating effective electronic medical record change management processes. CIN: Computers, Informatics, Nursing, 29(8), 431-435. doi://10.1097/ncn.0b13e3182293726
Lacey, D. G. (1993). Nurses’ attitudes towards computerization: A review of the literature. Journal of Nursing Management, 1(5), 239-243.
Mahler, C., Ammenwerth, E., Wagner, A., Tautz, A., Happek, T., Hoppe, B., & Eichstädter, R. (2007). Effects of a computer-based nursing documentation system on the quality of nursing documentation. Journal of Medical Systems, 31(4), 274-282.
McDowell, D. E., Dillon, T. W., & Lending, D. (2008). Perceived quality benefits influenced by usefulness and documentation accuracy of information. CIN: Computers, Informatics, Nursing, 26(6), 350-357. doi:10.1097/01.NCN.0000336463.72069.7c
Menke, J. A., Broner, C. W., Campbell, D. Y., McKissick, M. Y., & Edwards-Beckett, J. A. (2001). Computerized clinical documentation system in the pediatric intensive care unit. BMC Medical Informatics and Decision Making, 1, 3-9. doi: 10.1186/1472-6947-1-3
MuHugh, N. (2004). Improving staff member satisfaction and productivity through technology. AORN, 80(3), 523-526. doi:10.1016/S0001-2092(06)60542-5
Moody, L. E., Slocumb, E., Berg, B., & Jackson, D. (2004). Electronic health records documentation in nursing: Nurses’ perceptions, attitudes, and preferences. CIN: Computers, Informatics, Nursing, 22(6), 337-344.
Noah, P. (2011). Implementing electronic documentation. Critical Care Nursing Quarterly, 34(3), 208-212.
Oroviogoicoechea, C., Watson, R., Beortegui, E., & Remirez, S. (2010). Nurses’ perception of the use of computerised information systems in practice: Questionnaire development. Journal of Clinical Nursing, 19(1-2), 240-248. doi:10.1111/j.1365-2702.2009.03003.x
Pabst, M. K., Scherubel, J. C., & Minnick, A. F. (1996). The impact of computerized documentation on nurses’ use of time. Computers in Nursing, 14(1), 25-30.
Pfortmiller, D., T., Mustain, J., M., Lowry, L., W., & Wilhoit, K., W. (2011). Preparing for organizational change: Project: SAFETYfirst. CIN: Computers, Informatics, Nursing, 29, TC68-74. doi:10.1097/NCN.0b013e31821ef5b7
Poissant, L., Pereira, J., Tamblyn, R., & Kawasumi, Y. (2005). The impact of electronic health records on time efficiency of physicians and nurses: A systematic review. JAMIA: Journal of the American Medical Informatics Association, 12(5), 505-516. doi: 10.1197/jamia.M1700
PricewaterhouseCoopers. (2001). Patients or paperwork: The regulatory burden facing America’s hospitals. Retrieved from http://www.aha.org
Pynn, D. ABC’s of transitioning from paper to electronic documentation. CJNI: Canadian Journal of Nursing Informatics, 5(2), 3-15. Retrieved from http://cjni.net/journal/?p=897
Ross-Kerr, J. C. (2003). Computer technology in nursing practice and research. In J. C. Ross-Kerr, & M. J. Wood (Eds.), Canadian nursing: Issues and perspectives (pp. 269-279). Toronto, ON: Mosby.
Saranto, K., & Kinnunen, U. Evaluating nursing documentation – research designs and methods: Systematic review. Journal of Advanced Nursing, 65(3), 464-476. doi:10.1111/j.1365-2648.2008.04914.x
Sassen, E. J. (2009). Love, hate, or indifference: How nurses really feel about the electronic health record system. CIN: Computers, Informatics, Nursing, 27(5), 281-287. doi:10.1097/NCN.0b013e3181b2162a
Smith, D. S., Rogers, S. H., Hood, E. R., Phillips, D. M. (1998). Overtime reduction with the press of a button. An unexpected outcome of computerized documentation. Nurs Case Management, 3(6):266-70.
Smith, K., Smith, V., Krugman, M., & Oman, K. Evaluating the impact of computerized clinical documentation. CIN: Computers, Informatics, Nursing, 23(3), 132-138.
Spencer, J. A., & Lunsford, V. (2010). Electronic documentation and the caring nurse-patient relationship. International Journal for Human Caring, 14(2), 30-35.
Turisco, F., & Rhoads, J. (2008). Equipped for efficiency: Improving nursing care through technology. Retrieved from http://www.chcf.org.
Whittaker, A. A., Aufdenkamp, M., & Tinley, S. (2009). Barriers and facilitators to electronic documentation in a rural hospital. Journal of Nursing Scholarship, 41(3), 293-300. doi:10.1111/j.1547-5069.2009.01278.x
Wolf, D., M., & Nellis, D., L. (2011). Informatics: Helping the LNC adjust to electronic records Journal of Legal Nurse Consulting, 22(1), 9-13.
Yee, T., Needleman, J., Pearson, M., Parkerton, P., Parkerton, M., & Wolstein, J. (2012). The influence of integrated electronic medical records and computerized nursing notes on nurses’ time spent in documentation. CIN: Computers, Informatics, Nursing, 30(6), 287-292. doi:10.1097/NXN.0b013e31824af835
Zandich, S. O., Yoon-Flannery, K., Kuperman, G. J., Langsam, D. J., Hyman, D., & Kaushal, R. (2008). Challenges to EHR implementation in electronic-versus paper-based office practices. Journal of General Internal Medicine, 23(6), 755-761. doi: 10.1007/s11606-008-0573-5.
Sarah Payne received her Bachelor of Nursing from the Centre for Nursing Studies in 2008. She is currently a student in the Master’s of Nursing Program at Memorial University of Newfoundland. She also works fulltime on a pediatric surgical unit. Her research interest relate to the pediatric population. She is also has a keen interest in nursing informatics.