Translating caring theory into practice

N U R S I N G A N D H E A L T H C A R E M A N A G E M E N T A N D P O L I C Y

Adopting a personal digital assistant system: application of Lewin’s

change theory

Ting-Ting Lee PhD RN

Associate Professor of Nursing, National Taipei College of Nursing, Taipei, Taiwan

Accepted for publication 9 December 2005

Correspondence:

Ting-Ting Lee,

National Taipei College of Nursing,

No. 365, Min-Td Road,

Taipei 112,

Taiwan.

E-mail: tingting@mail1.ntcn.edu.tw

doi: 10.1111/j.1365-2648.2006.03935.x

L E E T . - T . ( 2 0 0 6 )L E E T . - T . ( 2 0 0 6 ) Journal of Advanced Nursing 55(4), 487–496

Adopting a personal digital assistant system: application of Lewin’s change theory

Aim. This paper reports a study exploring nurses’ perceptions of adopting an

information system using handheld computers (personal digital assistants) in their

daily practice.

Background. Handheld computers have recently been used in nursing information

systems for patient care, but few studies have explored their impact on users. By

understanding clinicians’ experiences of using this technology, strategies can be

implemented to smooth the change process in adopting their use, thus achieving

optimal patient outcomes.

Method. A descriptive, exploratory approach was used to study nurses’ perceptions

of using personal digital assistants as part of a hospital information system. A

purposive sample of 15 nurses participated in one-to-one, in-depth interviews from

February to March 2004. Nurses’ perceptions of the adoption process were analysed

using Lewin’s force field theory of change as a framework.

Findings. Nurses initially resisted using the personal digital assistant system

(unfreezing stage), then came around to using it (moving stage), and finally adopted

the system in their daily practice (re-freezing stage). However, an anticipatory stage

also occurred and this could serve as a feedback mechanism to improve the system

for current and future use.

Conclusion. Educational programmes should be provided and strategic planning

should be done in the early stage of implementing a policy to adopt new technology.

In addition, the adoption process and learning period could be shortened by

improving the system’s content design. During this transition stage, dual charting

should be used as a backup only for a limited time to avoid adding extra work to

nurses’ already heavy workload. Finally, the concept of confidentiality should be

reinforced and stressed early in the educational programme to protect patient data,

which can easily be accessed in computerized systems.

Keywords: empirical research report, handheld computers, Lewin’s change theory,

nurses’ perceptions, personal digital assistants, qualitative research, technology

Introduction

Wireless access handheld computers, often referred to as

personal digital assistants (PDAs), are now commonly used to

manage information, especially by healthcare providers at the

point of care (McLeod et al. 2003). ‘Wireless access’ implies

that the system is always connected and that data can be

retrieved in real time, which is appropriate and necessary in

health care (Newbold 2004). PDAs have been used to store

reference information for prescribing drugs (Johnson et al.

2002, Rothschild et al. 2002) and for laboratory testing

(Bissell 2001, Dyer et al. 2001), and to serve as memory aids

for brain-injured patients (Wright et al. 2001a, 2001b). A

survey of nurses revealed that of those who focused on

� 2006 The Author. Journal compilation � 2006 Blackwell Publishing Ltd 487

information management in health care, approximately one-

fourth used their own PDAs for clinical use (Newbold 2004).

While using information systems that interface with PDAs

has become popular in health care, few studies have explored

the impact of this technology on users. In nursing, only home

health nurses’ experiences with wireless, pen-based comput-

ers have been reported (Wilson & Fulmer 1997, 1998).

Although PDAs have been promoted as portable and easy to

use (Enger 2001, Enger & Segal-Isaacson 2001, Jenkins

2002), no study to date has applied a model or conceptual

framework to investigate the adoption process for this

technology and how its use affects clinicians’ daily practice.

Since the transition process from a manual to an automated

system is a tremendous change for nurses, change theory is an

ideal framework for understanding clinicians’ perceptions of

the impact of using a PDA system. This understanding can be

used to design and implement strategies and programmes to

smooth the technology adoption process, thereby achieving

optimal use for clinical care.

Background

The adoption of mobile technology for health care has raised

issues in three major areas: computer hardware and software,

personal perspectives, and concerns about confidentiality

(Hughes 2003). The following literature review addresses

these issues.

Hardware and software issues

Personal digital assistants have many known advantages,

such as easy data access, electronic prescribing, electronic

charge capture, on-line documentation, wireless synchron-

ization of shared data, and integrating different input and

output devices to support workflow (Barbash 2001, Goss &

Carrico 2002, Fischer et al. 2003, Lewis & Sommers 2003).

Nonetheless, the drawbacks of this technology include cost of

hardware (device and maintenance), software fees (design

and shareware license), short battery life and small screens

for viewing data (Enger 2001, Enger & Segal-Isaacson 2001,

Jenkins 2002, Gallagher 2004).

Personal usage issues

The interaction between humans and handheld computers

has been examined in many studies. In one study (McManus

2000), the use of PDAs in a healthcare institution was

expected to have benefits such as increased time with patients

and improved staff professionalism, but these goals were not

achieved due to poor system interface design. McManus

cautioned that for optimal usage outcomes, administrators

need to consider human factors such as eyesight limitations

for reading small screens and cognitive overload when

searching through many screens to obtain the desired

information.

The difficulties encountered by PDA users in clinical

settings have also been studied. Wallace and Harrington

(2003) found that for non-clinician managers in one

hospital where PDAs were used, all respondents admitted

having difficulties when they first used PDAs. Furthermore,

most of them did not know that on-line information could

be downloaded to PDAs, nor that they could ‘beam’

information via infrared transmission from one PDA to

another. Thus, while PDAs may not be hard to use, they

are often underused.

Nurses’ perceptions of using handheld computers have

been explored for documenting home care (Wilson & Fulmer

1997, 1998) and managing intravenous consultation services

(Bosma et al. 2003). Although nurses valued the PDA’s

assistance in organizing daily practice, retrieving point-of-

care information, and integrating with statistical analysis

software, these studies reported that nurses experienced

obstacles such as fear of losing PDAs or styluses, data

transmission problems, software (screen) freezes, hardware

breakage and slow responsiveness after entering a large

amount of patient data.

Confidentiality issues

The ease with which patient information can be accessed via

PDAs has raised issues about confidentiality of patient data

(Hughes 2003, Bobula et al. 2004). If a clinician loses a PDA,

the confidentiality of patient information might be put at risk.

To avoid this problem, it has been suggested that specific

patient information not be stored on PDAs (McCord 2003).

It has also been recommended that clinicians not store patient

data on their PDAs unless the institution has developed

functionality and policies to ensure confidentiality of data

and data transmission (Tooey & Mayo 2003). To protect

information on PDAs, Pancoast et al. (2003) proposed the

following precautions: keep physical control of the device,

use data encryption, use a password to turn on PDAs, disable

infrared ports except during use, and do not send infrared

transmissions in public locations.

In addition to the issues reviewed above, the adoption of

mobile technology for health care involves changes in

workflow. As technological change becomes an increasingly

common occurrence in the healthcare environment, change

theory offers one way of understanding the dynamic inter-

action by which individuals adapt to change.

T.T. Lee

488 � 2006 The Author. Journal compilation � 2006 Blackwell Publishing Ltd

Lewin’s force field or change theory

Lewin’s (1951) theory posits that change occurs in three stages:

unfreezing, moving and refreezing. Unfreezing involves moti-

vating individuals by getting them ready for change, moving

involves encouraging individuals to adopt a new perspective

that enables them to perceive that the current situation can be

improved, and refreezing involves reinforcing new patterns of

behaviour. In the unfreezing stage, the forces driving towards

and restraining individuals from adopting a change must be

identified. Strategies should be devised to strengthen the

driving forces and to weaken the restraining forces. In the

moving stage, open communication and participation in

developing the change in perspective should be encouraged.

Once individuals feel actively involved and personally com-

mitted to a project, they will be more likely to support its

successful implementation. In the refreezing stage, the change

is maintained by providing continued assistance and support to

people using the system (Lewin 1951).

Lewin’s theory has been proposed as a framework for

planning, implementing, and evaluating the acceptance and

success of a nursing information system (Bozak 2003). To

assist nurses in the transition from a paper documentation

system to an electronic one, Bozak suggested several strategies

to strengthen the driving forces and to overcome the restraining

ones. While Lewin’s change theory has been suggested as a

guideline for analysing this change process (Bozak 2003), no

study has applied this theory in clinical situations.

The study

Aim

The aim of this study was to use for exploring nurses’

perceptions of adopting a PDA system in their daily practice.

The research question was, ‘What are nurses’ perceptions of

the change process (adopting a new technology) in using

PDAs in their daily practice?’

Design

A descriptive, exploratory qualitative approach with in-depth

interviews was used to study nurses’ perceptions of adopting

a PDA system. Lewin’s force field theory was used as the

theoretical framework. The data were collected in 2004.

Study setting

The study was conducted at a 600-bed medical center in

Taiwan. This hospital implemented the PDA system in

January 2002 for electronic charge capture as the first step

in computerizing the patient record system, and it has been

available in most inpatient units ever since. At the time of this

study (see below), nurses were required to use the PDA for

charge capture and charting patient intake/output (I/O)

records. Nurses had to download patient data from the

unit’s personal computer (PC) to individual PDAs.

The designated PDAs, which were 5Æ1 · 3Æ3 · 0Æ6 in and weighed 6 oz, used the WinCE 3Æ0 (Microsoft Corporation,

USA) operating system and had a colour display. They used a

lithium battery with 14-hour capacity, 32 MB random access

memory, and 16 MB read only memory. Each unit had six to

seven PDAs (depending on unit size), which were used for

three different shifts and kept as unit property. Once the

charge or charting was complete, nurses uploaded the data

from the PDA to the unit PC. Nurses then verified the uploaded

data on the PC to complete the documentation process.

Participants

A sample of 15 nurses took part in the study. All participants

were purposively recruited from inpatient units where PDAs

were used for daily charge capture and charting of I/O

records. Potential participants volunteered in response to an

introductory letter that was posted in these units. The letter

explained the study purpose and procedures. The inclusion

criteria were that participants must be Registered Nurses who

had worked in the unit and used the PDA system for at least

3 months. It was assumed that after 3 months nurses would

understand the unit’s routine care and operations related to

PDA use, and would have developed perceptions about

integrating the technology into their work.

Of the 15 participants, five were 20–25 years old, six were

between 26 and 30 years, and the remaining four ranged from

31–40 years. Eight had a baccalaureate nursing degree, and

the rest had a vocational nursing degree. Five had less than

3 years’ nursing experience, five had more than 3 but less than

6 years’ experience, and the remaining five had 6 or more years’

experience. Ten had used computers in their previous jobs.

Data collection

Data were collected by semi-structured, in-depth interviews

undertaken from February to March, 2004. All interviews took

place in a reserved conference room at the participant’s work

unit. Each nurse was interviewed once, before or after work

hours. Interviews, which lasted between 30 and 45 minutes,

were tape recorded and transcribed verbatim, and were guided

by the following questions: ‘What do you think about using a

PDA in your practice?’, ‘What specific experiences did you

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� 2006 The Author. Journal compilation � 2006 Blackwell Publishing Ltd 489

have in the process of adjusting to PDA use?’ and ‘What would

you suggest to smooth this process in the future?’

Ethical considerations

The study was approved by the Institutional Review Board at

the medical centre where participants were employed. Signed

informed consent was obtained before interviews, and

privacy and anonymity were guaranteed. After each inter-

view, participants were asked for demographic information

(i.e. age, education, job title, computer and nursing experi-

ences). To express gratitude for nurses’ participation, they

were given a small gift after the interview.

Data analysis

Data analysis was based on procedures proposed by Miles

and Huberman (1994), including data reduction, data display

and conclusion drawing. First, the raw data (participants’

descriptions of their experiences) were open coded, line by

line. Incidents or themes were identified in each transcript

and compared with those of other transcripts. Comparison

and contrast of transcripts were based on similarities or

differences (so-called data reduction). Since the purpose of

this study was to analyse nurses’ perceptions of the change

process in adapting to PDA use, specific attention was paid to

behavioural or attitude changes. The identified representative

concepts or themes were arrayed either in tables or diagrams

to indicate patterns or relationships among themes (data

display). Finally, major concepts were abstracted and themes

were categorized from the content of these tables and

diagrams to draw conclusions about the nurses’ perceptions

(conclusion drawing).

Rigour

To ensure trustworthiness of the qualitative data, methods

were applied to increase rigour by ensuring fittingness,

credibility and auditability (Sandelowski 1986). First, all

transcripts were reviewed by participants before data analysis

(member check) to ensure data accuracy. Fittingness of the

findings was addressed by purposively recruiting nurses who

practised in inpatient units where PDAs were used and who

could articulate their perceptions. Credibility was enhanced

by including numerous quotes from participants’ verbal

descriptions in the findings of this study. Auditability was

demonstrated by having another nurse researcher with

expertise in qualitative research review the interview content,

emergent themes and categories to ensure the objectivity of

data analysis.

Findings

Central themes from participants’ perceptions of using PDAs,

their relationship to Lewin’s change stages, and supporting

interview content are summarized in Table 1.

Unfreezing stage: resistance to inconveniences or usage

difficulties

Nurses encountered many inconveniences when they first

used the PDA. For example, hospital policy required them to

chart on PDAs but to keep charting manually as backup

documentation. This dual charting added another task to the

nurses’ busy schedule. One said, ‘After charting on the PDA,

we still have to chart on the I/O sheets for doctors to read. It’s

a waste of our time and adds to our workload’ (RN1).

Nurses also complained about the training process to use

the PDA. One said,

We sent nurses to be trained [to use the PDA] and then they came

back to teach others. However, the class was so short that you had to

learn by trial and error. Thus, when you kept trying and losing data,

you didn’t want to use it anymore. (RN2)

Another commented about the inconvenience of using PDAs:

Sometimes you need to go through many screens to get what you

want. For example, it [the PDA] is only designed to chart two drain

tubes. If a third one is needed, you have to find out how to do it.

(RN3)

Furthermore, the PDA system had technical problems at first.

Some nurses described feeling panic:

We had unexpected problems, such as numbers and charting times

changing after data transmission, long response time, and finding out

after you’d been charting for awhile that the memory was so full that

what you did was not saved. (RN4)

In addition, the PDA weight and short battery life made

nurses not want to take it to the bedside:

It [the PDA] is too heavy to carry for patient care. I am afraid that I

might drop it, break it or lose it. Not to mention the battery goes out

after a short time. Although it gets fully charged in the morning, it

goes down to 30–40% by the afternoon. I am afraid of losing data

while charting due to low battery. (RN5)

Moving stage: coming around to use the system

Despite all the perceived inconveniences and difficulties

imposed by using the PDA, nurses came around to use the

system and developed strategies to adapt:

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490 � 2006 The Author. Journal compilation � 2006 Blackwell Publishing Ltd

Table 1 Themes in nurses’ perceptions of adapting to personal digital assistant (PDA) use

Stage of change: Theme Examples from participant interviews

Unfreezing: Resistance to inconvenience or usage difficulties

Dual charting adds work After charting on the PDA, we still have to chart on the I/O sheets for doctors to read. It’s a waste of our

time and adds to our workload (RN1)

Insufficient instruction We sent nurses to be trained [to use the PDA] and then they came back to teach others. However, the class

was so short that you had to learn it by trial and error. Thus, when you kept trying and losing data, you

didn’t want to use it anymore (RN2)

Inconvenience of using PDAs Sometime you need to go through many screens to get what you want. For examples, it [the PDA] only

designed to chart two drain tubes. If a third one is needed, you have to find out how to do it (RN3)

Initial technical problems We had unexpected problems, such as numbers and charting times changing after data transmission, long

response time, and finding out after you’d been charting for a while that the memory was so full that

what you did was not saved (RN4)

Device problems It [the PDA] is too heavy to carry for patient care. I am afraid that I might drop it, break it or lose it. Not

to mention the battery goes out after a short time. Although it gets full charge in the morning, it goes

down to 30–40% by the afternoon. I am afraid of losing data while charting due to low battery (RN5)

Moving: Coming around to use the system

Practice makes familiarity I think practice brings familiarity. We seldom use the [paper] I/O sheet in our unit and that’s why we

don’t think it [using the PDA] was easy to do the beginning. But if we use it all the time, it is not so hard

to chart on the PDA (RN6)

Accept change as a policy

requirement

I was hoping that the PDA would go away when everyone complained about its drawbacks. But it stayed

and became one of our required tasks. Now that I understand it’s part of our workflow, I won’t resist it

anymore (RN5)

Involvement in design process I was involved in the design process, so it was no problem for me to use it [the PDA] at all. I also

understand that the paper system will phase out, and the dual charting is temporary (RN6)

Incentives to use system The PDA usage frequency in nursing units is announced every month. I don’t want our unit to look

inferior to others by showing up at the bottom of the list, so I try my best to use it (RN4)

Use extra time to deal with

PDAs

I used to come to work early to download patient data just in case there were patients to be transferred or

discharged and they needed to be charged immediately (RN4)

Re-freezing: Working with PDAs

Time-share use We take turns transmitting PDA data to avoid rush hours, which could slow down the system response

time. But if you are busy and have no time to download, key-in, upload and verify data, we take notes

[on paper] and then chart directly to the PC. It is faster and much easier (RN7)

Change workflow It is very convenient for the system to automatically sum up the I/O. However, the cutoff point is at 8 am,

and the shift changes over at 7 am, so we count any I/O volume that occurs after 7 am on the next day.

Furthermore, since there is no column for decimals, we wait to chart small volumes of a medicine or

fluid until it reaches an integer (RN9)

Relying on the PDA Sometime you rely on the PDA so much that you don’t read all the details. You may charge a wrong item

due to similar spelling (RN8)

login/logout problems Patients’ data can be stored in different PDAs, but you can check them using the nurse’s ID from the

previous shift if she did not log out. Many nurses won’t bother to log in and log out just to check data.

However, I will log out for others and use my own login ID, but I won’t bother to log out after use

(RN4)

Saving charge for the last task I always save the charge to the last when patient care is finished. I can recall in detail what I have done for

patients so I won’t lose or miss charting and the charge capture is complete (RN4)

Anticipatory stage: wish lists

No dual charting I don’t think dual charting is needed. If you think that charges are missing on PDAs, they could be missing

on paper as well. (RN10)

More PDA functions, a PDA for

each nurse

I would like it [the PDA] to have voice recognition, to weigh less for better portability, for each nurse to

have her own PDA, and enough PCs to upload data. I also think that a brighter screen would be helpful

to read on the night shift (RN4)

More features besides charting I wish it had ditto function and could beam data [infrared transfer]. There should be more features than

just charge capture or charting I/O, such as documentation for wound assessment or clinical path

(RN11)

Concern about job security Here’s what I learned from this technology: if your eyesight or physical condition has deteriorated too

much to work with a PDA at night, you may want to consider another career (RN5)

RN, Registered Nurse; I/O, intake/output; PC, personal computer; ID, identification.

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� 2006 The Author. Journal compilation � 2006 Blackwell Publishing Ltd 491

I think practice brings familiarity. We seldom use [paper] I/O sheets

in our units and that’s why we didn’t think it [using the PDA] was

easy to do at the beginning. But if we use it all the time, it is not so

hard to chart on the PDA. (RN6)

Nurses who believed that change is inevitable and finally

accepted the system expressed a similar attitude:

I was hoping that the PDA would go away when everyone

complained about its drawbacks. But it stayed and became one of

our required tasks. Now that I understand it’s part of our workflow, I

won’t resist it anymore. (RN5)

Moreover, a positive attitude was shown by some nurses who

had been involved in the design team and had learned earlier

than the others how to take advantage of the PDA’s usage

functions:

I was involved in the design process, so it was no problem for

me to use it [the PDA] at all. I also understand that the paper

system will phase out, and the dual charting is only temporary.

(RN6)

The hospital also used some strategies to increase nurses’

incentives to use the PDA. For example, PDA usage frequen-

cies on each unit were posted as a monthly report:

The PDA usage frequency in nursing units is announced every month.

I don’t want our unit to look inferior to others by showing up at the

bottom of the list, so I try my best to use it. (RN4)

Some nurses learned to use the PDA on their own time. As the

same nurse explained:

I used to come to work early to download patient data just in case

there were patients to be transferred or discharged, and they needed

to be charged immediately. (RN4)

In talking about how she managed this change phase, this

same nurse said:

Because I am a new nurse, my first priority is to get to know the work

setting. The PDA is something I can learn after work at my own pace.

So I spent extra time on it [the PDA] during that period just to

familiarise myself with the system. (RN4)

Re-freezing stage: working with PDAs

While the system’s features were not designed for nurses’

needs, they developed ways to integrate PDA use into their

daily practice:

We take turns transmitting PDA data to avoid rush hours, which

could slow down the system response time. But if you are busy and

have no time to download, key-in, upload and verify data, we take

notes [on paper] and then chart directly to the PC. It is faster and

much easier. (RN7)

Moreover, nurses changed their workflow to adjust to

difficulties using the PDA:

It is very convenient for the system to automatically sum up the I/O.

However, the cutoff point is at 8 am, and the shift changes over at

7 am, so we count any I/O volume that occurs after 7 am on the next

day. Furthermore, since there is no column for decimals, we wait to

chart small volumes of a medicine or fluid until it reaches an integer.

(RN9)

Since the PDA system was designed to ease nurses’

workflow, some admitted relying on listed items and

tending to click on the screen (point-and-click) without

paying sufficient attention to the content. One commented:

‘Sometimes you rely on the PDA so much that you don’t

read all the details. You may charge a wrong item due to

similar spelling’ (RN8).

When asked about providing continuous care by obtaining

patient information from the PDA system, the notion of data

confidentiality seemed to be ignored:

Patients’ data can be stored in different PDAs, but you can check

them using the nurse’s ID from the previous shift if she didn’t log out.

Many nurses won’t bother to log in and log out just to check data.

However, I will log out for others and use my own login ID, but I

won’t bother to log out after use. (RN4)

Some nurses preferred to postpone documentation until the

end of the shift:

I always save the charge to the last when patient care is finished. I can

recall in detail what I have done for patients so I won’t lose or miss

charting, and charge capture is completed. (RN4)

Anticipatory stage: wish lists

Many nurses commented at this stage that using PDAs posed

no problem for them. However, when asked what they

thought would help to streamline their workload, most asked

to eliminate dual charting. One said: ‘I don’t think dual

charting is needed. If you think that charges are missing on

PDAs, they could be missing on paper as well’ (RN10).

Others had a wish list for added PDA features:

I would like it [the PDA] to have voice recognition, to weigh less for

better portability, for each nurse to have her own PDA, and enough

PCs to upload data. I also think that a brighter screen would be

helpful to read on the night shift. (RN4)

I wish it [the PDA] had ditto function and could beam data [infrared

transfer]. There should be more features than just charge capture or

T.T. Lee

492 � 2006 The Author. Journal compilation � 2006 Blackwell Publishing Ltd

charting I/O, such as documentation for wound assessment or clinical

path. (RN11)

A few nurses expressed concern that technology use might

affect their job security:

Here’s what I learned from this technology: if your eyesight or

physical condition has deteriorated too much to work with a PDA at

night, you may want to consider another career. (RN5)

Discussion

The study findings indicate that nurses went through different

change stages in adapting to PDA usage, but their resistance

to change occurred while they were using the PDA and not

when they anticipated its coming use. In addition, education

programmes on PDA use seemed insufficient, since nurses

complained about problems using PDAs and they were

unaware of the concept of data confidentiality. Finally, the

study revealed an additional stage in the change process: an

anticipatory stage to refine the PDA system for current and

future use.

In Lewin’s theory, the unfreezing stage involves perceiving

a change and deciding whether to accept or reject it.

However, in the real world of health care, employees usually

do not have much say in policy implementation. A study of

factors affecting the adoption of an electronic medical record

system found that staff was required to use the new

technology, whether or not they liked it (Lee 2000). Not

until the nurses in the present study encountered difficulties

using PDAs did resistance appear and decrease their work

efficiency. Therefore, as others have emphasized, it is

important to train and educate staff to understand how and

why to use the new technology applications (McManus 2000,

Lee et al. 2002). In addition, the design of technology

applications (such as nursing information systems) should be

user-friendly for clinicians (McAlearney et al. 2004). In the

present study, a more thorough development of PDA content

and more hands-on practice using PDAs would have helped

smooth the initial chaotic stage of the change process.

Involving staff nurses in the implementation of new

technology systems is vital in the change process, but they

might still resist due to concerns about intrusions into their

normal way of performing activities (Bozak 2003). While

resistance may be a coping mechanism to protect against the

instability brought by change, interventions could be applied

to promote acceptance of innovation (Schoolfield & Orduña

2001). In the current study, nurses did show resistance when

they encountered difficulty using the PDA system. None-

theless, after the policy to use it had been consistently

implemented throughout the organization, and users’ feed-

back was used to repair and improve the system, nurses were

willing to use the system as their voices had been heard by

administrators. Furthermore, an incentive strategy was

applied (posting usage frequency), which certainly increased

nurses’ motivation to learn to use the PDA in their spare time.

While nurses learned how to adopt the PDA system into

their daily practice (e.g. using ‘time-sharing’ to avoid slow

system response time during rush hours), other issues also

emerged. For example, nurses took shortcuts by charting

directly on the PC, counting their I/O amount at 7 am instead

of 8 am, or waiting for fluid volumes to reach an integer

before charting them. This finding reflects how nursing

practice is influenced by technology, which could sometimes

make nursing practice more demanding, time-consuming

and distracting (Barnard 2000). Therefore, others have

suggested that clinical workflow should be redesigned

when introducing an innovation such as an information

system to alleviate workload or streamline nurses’ routines

(Miranda et al. 2001, Lee et al. 2002). Although features of

the PDA system, such as data transmission time, were

improved after nurses complained, they still had to modify

their work patterns in adapting to the system. Some of these

modifications (e.g. charting directly on the PC to avoid the

data transmission process, and charting volumes as integers)

could be solved by other alternatives to improve work

efficiency. Technology is more likely to be used when

potential users perceive that its use is compatible with

established work activities and brings clear results (Hughes

2003).

Another issue raised by the findings is data confidentiality.

Nurses generally did not seem concerned about the import-

ance of using personal IDs to log into the system. They

routinely left the system without logging out, which could

jeopardize patient data by allowing access by unauthorized

persons. This finding was conveyed to managers at the study

setting before completing data collection, resulting in a

change of the educational programme to emphasize user

liability and confidentiality of patient data. Although the

system currently does not keep patient data in PDAs for more

than 24 hours, protecting patient privacy through instant

access is still a vital concept that needs to be taught and

integrated into the technology adoption process (Jenkins

2002, McCord 2003, Gallagher 2004).

Although Lewin proposed three main stages for the change

process – unfreezing, moving and re-freezing – our findings

suggest adding a fourth stage: ‘anticipatory stage’. This stage

is based on a summary of participants’ wish lists after the

third stage. In a retrospective view of this change process,

nurses wished that the next step in PDA use (most likely to

chart vital signs) would not have a dual charting requirement.

Nursing and healthcare management and policy Adopting a personal digital assistant system

� 2006 The Author. Journal compilation � 2006 Blackwell Publishing Ltd 493

Although administrators see dual charting as a backup to

save patient data during the transition from manual to

computerized documentation, nurses view this process as

time-consuming and meaningless (Miranda et al. 2001, Lee

et al. 2002). The dual charting requirement also sent a

message that administrators did not trust nurses’ charting,

which made them wonder whether adapting to the new

system was worth their effort.

In this anticipatory stage, nurses wished that PDAs had

more or better characteristics to streamline their work, such

as lighter weight, longer battery life, infrared beam data

transmission, and functions other than charting (such as

wound assessment and documentation). Some also wished

that each nurse could have their own PDA to use, as doctors

did. As computers are increasingly used in health care and the

public have more access to technology applications such as

PDAs and mobile phones, computer technology may not be

an innovation for nurses but may become a versatile tool in

alleviating and streamlining their workload.

Nonetheless, the massive adoption of technology may also

be perceived as a threat to the job security of those who are

not familiar with these products. While Robinson (2003)

emphasized that technology cannot replace compassion in

health care, the challenges of using the PDA system (e.g.

having to go through many screens to process data, dimly lit

screens) caused some nurses in this study to reconsider their

careers. A more user-friendly interface design would alleviate

this problem.

Implications for nursing

The healthcare environment is dynamic, constantly changing,

including the use of technology. The proposed ‘anticipatory

stage’ provides a feedback mechanism for improving current

and future technology use, thus enhancing both user satis-

faction and workflow efficiency. This stage takes into account

nurses’ responses to the current system and gives rise to

anticipation about its future use, thus preparing nurses for

further changes.

In this retrospective study, nurses’ overall experiences of

using a specific technology during the initial phase of

adopting a hospital information system were analysed. As

with all qualitative findings, the interpretation of these results

should take into consideration the healthcare setting, design

of the technology system, and users’ individual perceptions.

Several future studies are suggested. First, because experience

is subjective, it can change with time or as technology

evolves. Thus, a longitudinal study targeting different change

stages may be necessary to explore nurses’ responses to using

technology.

Secondly, since changes in individual behaviour occur in

the context of a particular environment (Lewin 1951),

organizational factors cannot be ignored. Factors such as

management style and organizational culture need to be

taken into consideration when interpreting individual behav-

iours. Last, Schoolfield and Orduña (2001) suggest that

Lewin’s theory explains little of the emotions and motiva-

tions of everyday performance, and that more attention

should be given to cognitive or psychological variables to

explain the change process. After all, given the beauty of PDA

technology’s portability and instant Internet accessibility,

studying its use would benefit most healthcare providers and

patients.

Conclusion

Nurses did not encounter difficulty until they first used the

PDA system, corresponding to the unfreezing change stage.

Thus, educational programmes should be provided and

strategic planning should be done in the early stage of

implementing a policy to adopt new technology. In addition,

since nurses took some time to master using the PDA system

What is already known about this topic

• Using computers has become a trend in healthcare organizations to streamline workflow and to improve

patient care quality.

• Personal digital assistants have been used to prevent prescription or medication errors, efficiently retrieve

data, and collect data.

• Lewin’s change theory has been suggested as a frame- work for explaining attitudes and reactions towards

change processes.

What this paper adds

• Educational programmes should be provided and stra- tegic planning should be done in the early stage of

implementing a policy to adopt new technology.

• The adoption process and learning period could be shortened by improving the system’s content design,

and during this transition stage dual charting should be

used as a backup only for a limited time to avoid adding

to nurses’ workload.

• The concept of confidentiality should be reinforced and stressed early in the educational programme to protect

patient data, which can easily be accessed in compu-

terized systems.

T.T. Lee

494 � 2006 The Author. Journal compilation � 2006 Blackwell Publishing Ltd

and to develop strategies for using the technology in their

daily routine, the adoption process and learning period could

be shortened by improving the system’s content design.

During this transition stage, dual charting should be used as a

backup only for a limited time to avoid adding extra work to

nurses’ already heavy workload. Finally, the concept of

confidentiality should be reinforced and stressed early in the

educational programme to protect patient data, which can

easily be accessed in computerized systems.

Acknowledgement

This study was sponsored by a grant from the National

Science Council of the R.O.C. (NSC-93-2520-S-227-001).

References

Barbash A. (2001) Mobile computing for ambulatory health care:

points of convergence. Journal of Ambulatory Care Management

24(4), 54–66.