Change Can Be Challenging

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Change Can Be Challenging

Introduction To Changes and Implementation of Computerized Technology In Health Care

Thesis for the degree of Philosophiae Doctor Trondheim, November 2010

Norwegian University of Science and Technology Faculty of Medicine

Department of Cancer Research and Molecular Medicine

Beate André

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NTNU

Norwegian University of Science and Technology Thesis for the degree of Philosophiae Doctor Faculty of Medicine

Department of Cancer Research and Molecular Medicine

ISBN 978-82-471-24-&-. (printed ver.) ISBN 978-82-471-24-'-+ (electronic ver.) ISSN 1503-8181

Doctoral theses at NTNU, 2010:2)) Printed by NTNU-trykk

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- introduksjon av endringer og implementering av computerteknologi i helsevesenet

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To you who only live in the harts of us who loves you- my sister Jannike, my father Georg and my beloved son Anders.

Knowing you have made my life richer

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Acknowledgments

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Abbreviations

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List of papers

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I. %HDWH$QGUp*HUG,5LQJGDO7RULO5DQQHVWDG-RQ+/RJH+DOOYDUG /DHUXP6WHLQ.DDVDExperiences with Implementation of Computerized Tools in Health Care Units - A review article. International Journal for Human-Computer Interaction

II. %HDWH$QGUp*HUG,5LQJGDO-RQ+/RJH7RULO5DQQHVWDG6WHLQ.DDVD Implementation of Computerized Technology in a Palliative Care Unit.

Palliative & Supportive Care

III. %HDWH$QGUp*HUG,5LQJGDO-RQ+/RJH7RULO5DQQHVWDG6WHLQ.DDVD The importance of key personnel and active management for successful implementation of computer-based technology in palliative care – Result from a qualitative study. CIN: Computer, Informatics, Nursing

IV. (QGUH6M¡YROG)URGH+HOGDO%HDWH$QGUp-DQ7RUH/LXPHow professional culture influences interdisciplinary teamwork.6XEPLWWHG

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1.0 Introduction

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2.0 Aims of the thesis

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3.0 Theoretical foundations for this thesis

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3.1 Palliative care

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A suggestion for classification

Expected survival Karnofsky Primary palliation >6 months 70-90

Early palliation 2-3 months 50-60

Late palliation B 1 month 20-40

Imminently dying B 1-2 weeks B 10

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3.6 Organizational culture as barrier to change

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4.0 Methods

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4.1 Paradigms guiding this study

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4.3 Systematic literature search

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4.6 Questionnaires

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4.6.1 The Systematizing the Person Group Relation method

This method describes the development of interactions within a social system, and analyzes interaction patterns on individual, group and organizational levels. The Systematizing the Person Group Relation (SPGR) method is based on Bales’ theory of

social interaction systems (Bales, 1999), Parsons’ functional model of group development (Parsons, 1953) and Bion’s theory of group emotionality (Bion, 1961).

The SPGR method draws from the principles of the System for the Multiple Level Observation of Groups (Symlog) instrument (Bales & Cohen, 1979); however, the three SPGR dimensions have a different orientation in the factor-analytical space. The systematic approach of the Symlog theory and methodology gives a reliable set of data for the analysis of polarization-unification concerning the behavior level.

However, the original analyses of polarization based on Symlog do not sufficiently emphasize the influence of emotions on the process of polarization. On the other hand the “Basic Assumptions” (see Figure 2) seems to act as focal points in polarization.

Since it has been proved possible to identify these “Basic Assumptions” within the Symlog-space it became possible to combine this theory and the theory on group emotionality (Sjøvold, 1995). In addition a psycho-social growth model was included for analysis of developmental aspects of group and organizational culture (Mills, 1971; Mills, 1976;). The SPGR is a balance model and this means that if there is more of something, for instance loyalty and acceptance, there is less of the opposite, creativity and task-orientation. The theoretical foundation for SPGR has been elaborated by Sjøvold (2007) and the psychometric properties have been presented (Sjøvold, 1995; Sjøvold, 2002).The validity and reliability of the scale used in this study has been confirmed in by others (Koenigs et al., 2002; Koenigs et al., 2005).

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4.6.2 The Systematizing Person-Group Relations instrument

The Systematizing Person-Group Relations (SPGR) is an instrument designed for analyzing interaction patterns of behavior within social systems and has also been used in hospital settings in several studies in Norway. The SPGR instrument is an operationalization of SPGR theory (Sjøvold, 2007). SPGR theory is a theory of group development where the group-functions are labeled: ‘Control’; ‘Nurture’;

‘Opposition’; and ‘Dependence’. The basic idea is that a group activates the function best suited to deal with the specific problem they face. If the problem at hand is instrumental, then the Control function is activated; if the problem is relational, the Nurture function is activated and so on. When the Control function is active, analytical, task-oriented or even autocratic behavior dominates; when the Nurture function is active, caring, empathic or even spontaneous behavior dominates; if the Opposition function is active, critical, assertive or even self-sufficient behavior dominates; and when Dependence is active, passive, conforming, and obedient behavior dominates. These functions represent poles in the basic dimensions of the SPGR theory: C-N (Control –Nurture) and O-D (Opposition – Dependence) (Sjøvold 2007). A group’s level of development is labeled maturity. The level of maturity in SPGR is expressed by a third dimension: S-W or Synergy to Withdrawal. Synergy appears in groups characterized by engagement and constructive goal-oriented teamwork. In a group at a lower level of maturity members commit to their initial role, and tend to restrict themselves from contributing to the common group work.

This will in turn result in passive behavior and resistance, i.e. withdrawal (Sjøvold 2006, 2007). Systematized observed behavior is therefore a good indicator on both a group’s level of maturity and its culture. The SPGR instrument is developed for this

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4.8 The Palliative Assessment Tool-Computerized project

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4.9 Ethical considerations

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5.0 Summary of papers

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5.1 Paper I - Experiences with Implementation of

Computerized Tools in Health Care Units - A review article

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5.1.1 Research question and methods

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Method Systematic literature review

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5.1.2. Main results and summary

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5.2 Paper II - Implementation of Computerized Technology in a Palliative Care Unit.

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5.2.1 Research question and methods

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Symptom registration was introduced through a handheld computer together with a special database (PMU-base) at the Palliative Medicine Unit (PMU), the Department of Oncology, Trondheim University Hospital in Norway, in 2001. The goal was to improve the symptom registration and give the patients better and more accurate symptom treatment aimed at the specific symptoms. It was also possible for health care personnel, together with the patients, to record the ten symptoms on paper instead of using the handheld computer and punching the data into the PMU-base.

The implementation had only partly been a success. A qualitative approach was used in analyzing the data. Seventeen respondents (nurses, physicians and physiotherapists) participated in a semi - structured in-depth interviews. The interviews were held over a two-month period and lasted from 30 to 50 minutes each. Two interviewers participated in each interview. One method to check the creditability of the material and the interviews is to use two persons who read the transcription (Kvale, 1996).

Table 6 shows the method used.

Table 6 Method and material in paper 2 and 3 Method In-depth interviews

Subjects Health care personnel at the PMU.

Selection A total of 17 health care personnel at the PMU participated in an in-depth interview for the purposes of this study. The sample consisted of 13 nurses, two physicians and two physiotherapists all working full-time or part time (< 75%).

Inclusion criteria

The health care personnel had to been a part of the implementation process.

Comment The interview guide was used as a guideline and the respondents were requested to speak freely about the themes they were introduced to. Both notes and tape were used.

Analysis We used a qualitative approach to obtain data to understand why the tool was not used to its full potential. Categories emerged from the data. We examined data that both could explain and lead to an understanding of this phenomenon.

Change Can Be Challenging