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Bringing social worlds together: Information systems as catalysts for new interactions in health care organizations

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Bringing social worlds together: Information systems as catalysts for new interactions in health care organizations

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Content I BRINGING SOCIAL WORLDS TOGETHER: INFORMATION SYSTEMS AS CATALYSTS FOR NEW INTERACTIONS IN HEALTH CARE ORGANIZATIONS by Carolyn Elizabeth Aydin A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Communication Theory and Research) March 1989 \ Copyright 1989 Carolyn Elizabeth Aydin UM I Number: DP22437 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete m anuscript and there are missing pages, th e se will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI DP22437 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United S tates Code ProQ uest LLC. 789 E ast Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 4 8 1 0 6 -1 3 4 6 UNIVERSITY OF SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES, CAUFORNIA 90089 Pfi.IX CM ’ 89 A97S h ?/ This dissertation, w ritten by Carolyn_E1iz ab e t h _ Ay d i n........ under the direction of h&x. Dissertation Committee, and approved by all its members, has been presented to and accepted b y The Graduate School, in partial fulfillm ent of re quirem ents for the degree of D O C TO R OF PHILOSOPH Y D ean o f G ra d u a te S tu d ie s D a te Ap.r.i.L.U.,...1.989. DISSERTATION COMMITTEE C2. CT" fr~— C h a irp erso n ii TABLE OF CONTENTS ABSTRACT vii PREFACE ix 1 INTRODUCTION 1 2 THEORETICAL FRAMEWORK AND HYPOTHESES 9 Medical Information Systems 13 The Symbolic Interactionist Perspective 16 Social Structure of Medical Care 2 0 The Influence of Social Worlds on Attitudes: Professions and Departments 25 Influence of Individual Differences on Attitudes 39 Influence of Computer System Implementation and Use on Attitudes 44 New Opportunities for Interaction 54 Summary 6 6 3 METHODOLOGY 72 The Setting 74 Study Design 92 The Sample 97 Measurement 99 Analysis Methods 119 4 RESULTS FOR ATTTIUDE CHANGE MODEL 127 Occupations and Departments as Attitude Predictors 127 Individual Differences as Attitude Predictors 155 Participation in Implementation and Computer Use as Attitude Predictors 158 Summary 174 5 RESULTS FOR CHANGES IN DEPARTMENT BOUNDARIES 177 Employee Perceptions of Boundary Changes 178 Summary 210 6 DISCUSSION 212 Theoretical Implications 212 Implications for Practice 230 REFERENCES 236 APPENDIX 248 Ill LIST OF TABLES Table 3.1 Timeline for the Present Research 81 Table 3.2 Survey Response Rates for the Three Time Periods 98 Table 3.3 Demographic Information for Time 1-Time 3 Respondents 100 Table 3.4 Variables Analyzed in this Study 102 Table 3.5 Attitude Change Model: Correlation Matrix Among Variables for Time 1/Time 3 Respondents 105 Table 3.6 Factor Matrix and Descriptive Statistics for Time 3 Combined Attitude Scale Toward Computer 107 Table 3.7 Factor Matrix and Descriptive Statistics for Relations with Computer Staff and Knowledge/Involvement 113 Table 3.8 Factor Matrix and Descriptive Statistics for Work Group Communication and Organizational Policies 115 Table 3.9 Changes in Openness of Department Boundaries: Correlation Matrix Among Variables— Time 1/Time 3 Respondents 118 Table 3.10 Attitude Change Model: Hypotheses and Methods of Analysis 12 0 Table 3.11 Changes in Openness of Department Boundaries: Hypotheses and Methods of Analysis 122 Table 4.1 Attitude Toward Computer System by Occupation: Time 1/Time 3 129 Table 4.2 Attitude Toward Computer System by Department: Time 1/Time 3 134 Table 4.3 Time 3 Combined Attitude Scale Toward Computer by Occupation 138 Table 4.4 Time 3 Combined Attitude Scale Toward Computer by Department 140 iv Table 4.5 Regression Analysis to Predict Time 1 Attitude Toward Computer System from Individual Difference Variables Table 4.6 Regression Analysis to Predict Time 3 Combined Attitude Scale Toward Computer from Participation in Implementation Process and Computer Use Table 4.7 Level of Computer Use by Occupation Table 5.1 Regression Analysis to Predict Change in Information Exchange Between Departments from Participation in Implementation Process and Computer Use Table 5.2 Regression Analysis to Predict Change in Understanding Work of Other Departments from Participation in Implementation Process and Computer Use Table 5.3 Regression Analysis to Predict Change in Average of Information Exchange/Understanding Work from Participation in Implementation Process and Computer Use 185 Table 5.4 Changes in Exchange of Information with Target SHS Departments by Computer Use Category 186 Table 5.5 Changes in Exchange of Information with Target SHS Departments by Occupational Category 187 Table 5.6 Changes in Understanding the Work of Target SHS Departments by Computer Use Category 191 Table 5.7 Changes in Understanding the Work of Target SHS Departments by Occupational Category 192 Table 5.8 Average Change in Information Exchange/Understanding Work of All Other SHS Departments by Occupation 196 Table 5.9 Average Change in Information Exchange/Understanding Work of All Other SHS Departments by Department 199 157 160 164 181 183 V LIST OF FIGURES i Figure 2.1 Overlapping Occupational and . Departmental Social Worlds 31 i Figure 2.2 Model of Attitude Change with j Study Hypotheses 67 i Figure 2.3 Model of Change in Openness of Department Boundaries with Study Hypotheses 70 Figure 3.1 Student Health Service Organization Chart 76 Figure 3.2 Sample Encounter Form 84 Figure 3.3 Typical Patient Visit 85 Figure 3.4 Sample Laboratory Report Form 88 Figure 3.5 Detail Error Report 90 Figure 3.6 Monthly Follow-Up Report 91 i Figure 4.1 Attitude Change by Occupation 13 0 i Figure 4.2 Attitude Change by Medical/Non-Medical , Category 132 Figure 4.3 Attitude Change by Department 136 J I Figure 4.4 Time 3 Combined Attitude Scale I toward Computer by Occupation 139 j Figure 4.5 Time 3 Combined Attitude Scale toward Computer by Department 141 Figure 4.6 Time 3 Combined Attitude Scale toward Computer by Level of Use 162 Figure 5.1 Change Information Exchange with Target Departments by Computer Use Category 189 Figure 5.2 Change Information Exchange with Target Departments by Occupational Category 190 Figure 5.3 Change in Understanding Work of Target Departments by Computer Use Category 193 Figure 5.4 Change in Understanding Work of Target Departments by Occupational Category Figure 5.5 Change in Information Exchange/ Understanding Work of Other SHS Departments by Occupation Figure 5.6 Change in Information Exchange/ Understanding Work of Other SHS Departments by Department Figure 6.1 Model of Change in Organizational Social Worlds Vll ABSTRACT The present project used both quantitative and qualitative research methods to follow employees of the Student Health Service of a major university as they adapted to a new integrated medical information system. Based upon the symbolic interactionist perspective, the study focused upon communication both within and between the occupational and departmental social worlds of the organization. Study findings confirmed the proposed model of organizational change. As predicted, both occupational and departmental social worlds shaped individual attitudes, with non-medical employees reporting more positive attitudes than medical employees toward the new computer system. These social worlds were, themselves, changed by the increased interaction between departments accompanying computerization. Thus existing occupations, task arrangements, and organizational structures shaped the attitudes of individuals and the interactions that occurred. These interactions, in turn, created new task arrangements and interdependencies with the potential to reshape the organization and the occupations of employees working within it. While study findings are particularly applicable to the interdependent social worlds of medical care viii organizations, findings also have implications for managing the implementation of integrated information systems in other settings. The computer system provided new information, but also created additional work for organization employees. In addition, employees created new patterns of interdepartmental communication surrounding the computer system. These new interpersonal contacts resulted in increased openness of boundaries between departments. While some of the observed changes were predictable, based upon system functions, pre-existing relationships between departments, and new tasks, others were created by the employees themselves. I Managers of integrated information systems must learn to expect and facilitate these changes if integrated information systems are to improve communication between | departments and the functioning of the organization as a j whole. i i i I i i i _ j ix PREFACE The purpose of the present study is (1) to examine the influence of an organization's competing, but interdependent social worlds on individual attitudes toward a new medical information system, and (2) to explore impacts of information system implementation and use on these social worlds and on the relationships between them. Social worlds have always fascinated me. How important is the influence of one's group, or social world, membership in determining an individual's interpretation of events? Do people react differently because they are older or younger, or have different psychological profiles or different backgrounds or different life experiences? Or is identification with a particular group more important than individual differences in influencing interpretations of events? In the sphere of work, how important and enduring is socialization into one's occupational social world? How influential are the views of co-workers and friends in interpreting work experiences? The questions are old ones and many factors undoubtedly play a part. The present project has offered me the unique opportunity both to satisfy my own curiosity and to explore a phenomenon that X may have important impacts on the functioning of health ( care organizations. I used the concept of social worlds to focus on the reactions of health care employees to the implementation of a new medical information system. My interest in computerization in health care first developed while I was Program Analyst for the California State University's Statewide Nursing Program. The functioning of any health care organization depends upon effective communication between the different occupational groups and departments (i.e., social worlds) in the organization. Medical information systems are being implemented, at least in part, to improve this communication. Research has shown, | i however, that computer systems may have both intended and ( unintended consequences. Employee reactions help determine the consequences for the organization. The present project focused on both (1) the importance of occupational and departmental social worlds in determining individual reactions to change, and (2) the | ways in which individuals reshaped organizational social worlds during the computer implementation process. The project involved approximately 125 university Student Health Service (SHS) employees over a 2 1/2 year time period as they encountered, interpreted, and j accomodated to the changes in their jobs accompanying xi computer system. For some people the changes were overwhelming, while others noted little change in their daily work. Everyone, however, was gracious and helpful. SHS employees somehow found the time in their busy work schedules to respond to lengthy questionnaires before, during, and after the implementation of their new medical information system. As we became more familiar to them, they also talked to us at length about the new computer, showing us how they did their work both before and after the computer system was implemented, and shared their views of the organization with us. I would particularly like to thank the SHS administrators who gave us access to the organization, j arranged our interviews, and were supportive of the project throughout the 2 1/2 year study period. Edward Wiesmeier, Albert Setton, Deborah Shlian, and especially Michele Pearson made our time at SHS both informative and enjoyable. In addition to SHS personnel, however, this dissertation would not have been possible without the help and support of mentors, colleagues, friends, and family. M. Lynne Markus and Ronald E. Rice conceived the ! SHS project as a joint venture involving researchers at ! two universities. Dr. Markus, principal investigator for I i the project at the university where SHS was located, made t xii the first contacts with SHS, guided her own students in the initial SHS interviews, and contributed her own considerable expertise on computer system implementation. Ron Rice invited me to participate in the project in I Fall 1986, during the initial negotiations with SHS administrators. In addition to providing me with this research opportunity, Ron has been a most helpful and understanding mentor throughout my time at USC. The t overall project has been very much a joint effort, | | I j encompassing a number of different research objectives. I ] ! i thank Ron for his understanding, tolerance, and i willingness to entertain new ideas. I have often proven j to be a stubborn student, bent on following my own course j ! without heeding good advice. ■ The theoretical framework for this dissertation was begun under the guidance of Sandra Ball-Rokeach during my second year at USC. Sandra introduced me to the symbolic interactionist perspective, emphasizing both its strengths and shortcomings. As both mentor and friend, she helped me apply these ideas to health care settings i and was always willing to discuss my concerns. Her I experience with health care organizations was invaluable j as we debated the possible effects of new communication patterns in health care environments. xiii t Eric Eisenberg helped me extend the work begun with j Sandra as I began to explore communication within ; organizations. I was particularly intrigued by recent I communication research focusing on how individual members of organizations negotiate and interpret their social j worlds. Under Eric's guidance, I conducted interview j studies at two hospitals, exploring interactions between j the departments of pharmacy and nursing as they adapted j to new computer systems. These interviews guided and j informed my thinking for the SHS project. Finally, Everett Rogers was the first faculty member I met upon coming to USC and has been a supportive mentor and friend ever since. Ev was particularly helpful as I negotiated the initial stages of the graduate program, struggling to define my area of research and make my way over the hurdles encountered by all graduate students. i His guidance and support has continued throughout my years at USC. I t In addition to the guidance of my committee members, 1 ! many colleagues have both influenced my thinking and j i provided valuable help in accomplishing my research ' i objectives. My colleagues at the Statewide Nursing | Program at California State University, Dominguez Hills j i first brought the issues of computers in nursing to my : I attention before I arrived at USC. When I decided to I xiv pursue this area of research, the nursing department at the University of California, Irvine Medical Center (UCIMC) graciously contributed time and expertise as a research site for my projects. Nell Mitchell, Associate Director of Nursing, in particular, shared her insights concerning encounters between different hospital departments and professions as the UCIMC computerization project progressed. As I continued my research into medical information systems, I had the good fortune to encounter Rosemary I Ischar, Assistant Director of Nursing at Cedars-Sinai Medical Center and a fellow student at the Annenberg School. In 1986, Rosemary and I conducted the first of what I hope will be a series of fruitful projects on | computerization in a hospital setting. The work done with Rosemary, as well as her insights into computerization in health care, provided invaluable background for the SHS project. None of this would have been possible, however, without the support of my family. There are both advantages and disadvantages to having a mother who is a doctoral student. She may not cook dinner very often, but, as my 12-year old daughter once told her teacher, "I always know where my mother is— at the computer writing.” XV The tolerance and support of my husband and children have have truly made this dissertation a reality. Carolyn E. Aydin Los Angeles 1 Chapter 1 INTRODUCTION j The present dissertation examines the experience of one medical care organization implementing a computerized medical information system. Designed as a case study, the project follows employees of the Student Health Service (SHS) of a large university over a 2 1/2 year time period as they react and adapt to a new computer system. The research focuses on (1) the influence of competing occupational and departmental social worlds on individual reactions to the computer system, and (2) the ways in which employees reshape their social worlds during the computer implementation process. Like most health care organizations, SHS is composed of a number of interdependent departments and professions, each of which constitutes a distinct and separate social world. The quality of medical care i i depends, in large part, on the effectiveness of , communication between these social worlds. Computerized medical information systems provide communication networks between departments as well as storage and I retrieval of medical information. The medical information j system at SHS was adopted in an effort both to improve j communication and to control costs and regulate the j activities of employees. I 2 Knowing the potential effects of an information system, however, does not allow the analyst "to predict what forms of social organization will develop to surround it..." (Van Maanan & Barley, 1984, p. 346). Computers are "occasions that trigger social dynamics which, in turn modify or maintain an organization's contours" (Barley, 1986, p. 81). Computerized information systems have the potential to change the work flow among jobs and departments and affect the structure and function of communication in the organization as a whole (Markus, 1984; Zuboff, 1982). Little research has been conducted on systems that change organizational work flows (Markus, 1984), and virtually no research has been conducted on the organizational impacts of computerized medical information systems. The present study breaks new ground in its use of the concept of social worlds to investigate and explain phenomena accompanying the implementation of an integrated information system. Social worlds are defined as subsets of an organization's members who: interact regularly with one another, identify themselves as a distinct group within the organization, share a set of problems commonly defined to be the problems of all, and routinely take action on the basis of collective understandings unique to the group. (Van Maanen & Barley, 1985, p. 38) 3 In the present study, both occupations and departments are defined as social worlds. These occupational and departmental social worlds (1) predict individual attitudes toward the computer system and, (2) are, themselves, subject to reshaping as organization members implement the information system. Models of change in both individual attitudes and boundaries between departments in the organization are proposed. The relationships hypothesized in each of these models have the potential to affect the structure of the organization and the delivery of medical care. The conceptualization of social worlds as both predictors of employee attitudes and interacting social systems subject to reshaping during the computer implementation process highlights the importance of communication during system implementation. The individual's social world is first introduced as an influence on employee attitudes toward the computer system, a predictor largely ignored by previous research on information system attitudes. Communication with others in one's occupational and departmental social worlds provides individuals with the opportunity to create a common perspective on the organization. In the present case, the perspective in question is an individual's attitude toward the new computer system. 4 This attitude represents a meaningful "surrogate" for the "critical but unmeasurable result of an information system, namely, changes in organizational effectiveness" (Ives, Olson, & Baroudi, 1983, p. 785). In addition to the influence of social worlds, the proposed attitude change model also includes the personal frame of reference of the individual worker, participation in the computer implementation process, and use of the computer system as predictors of individual attitudes. Analyses compare the relative importance of the individual•s personal frame of reference with that of membership in occupational and departmental social worlds. In addition, participation in the computer implementation process and actual use of the computer system introduce new interactions between members of different social worlds, influencing individual attitudes toward the computer system. Second, the study focuses on the impacts of an integrated information system on relationships between the social worlds themselves. Again, the emphasis is on communication. While interactions between departments are important to the functioning of any organization, interdepartmental communication is the very foundation of health care delivery. No research to date has addressd the changes in interdepartmental relations that may 5 accompany the introduction of an integrated information system. A number of researchers, however, have taken the position that computer communication will supplant face-to-face and voice communication, leading to greater social isolation (Hirschheim, 1985). The present dissertation challenges this ’ •pessimist" position by proposing that computerization will be accompanied by increased interaction between departments. Participation in the implementation process and use of the computer system introduce new interactions between members of different social worlds. Increases in information exchange and understanding the work of different departments represent changes in the openness of boundaries between departments.1 More open boundaries allow increased communication while less open boundaries restrict interactions and exchange of information. The implementation process is conceptualized as a process of negotiation between employees in different social worlds. Hypothesized changes in interaction patterns have the potential to change departmental relations by creating more open boundaries between departments, in effect reshaping the social worlds of the organization. The present project is designed as a case study, or "comprehensive description and explanation of the many components of a given social situation" (Babbie, 1973, p. 6 37). The strength of case studies lies in the ability to explain the "how" and "why” of observed changes (Yin, 1984). The present research also takes advantage of the strengths of both quantitative and qualitative methodology, including findings from surveys, interviews, archival data, and observation of SHS employees at work. As with other case studies, the results are generalizable to theoretical propositions, although not to populations or universes (Yin, 1984). Results of the present study have both theoretical and practical implications. From a theoretical perspective, the research tests the usefulness of the concept of social worlds in predicting individual reactions to and interpretations of organizational events. Furthermore, the study documents the role of organizational employees in negotiating changes in the work environment and initiating new interactions with members of different departments. These new interactions reshape the social worlds of the organization. The present study's findings are no less important from a practical perspective. As noted above, the delivery of medical care hinges upon effective communication between departments in the organization. A successful information system will improve communication, while an ineffective system may well hinder communication 7 between departments. Employee attitudes, and the determinants of those attitudes, are important considerations in the success of any computer system. System planners also face the issue of employee involvement in the implementation process, and the effects of such involvement on both attitudes and relationships between departments. Finally, system managers and implementers must learn to expect and facilitate changes in communication patterns surrounding a new computer system. All of these factors, addressed in detail in this project, may either hinder or facilitate daily work and affect the quality of medical care. The present dissertation is organized as follows: Chapter 2 outlines the theoretical framework of the study, reviews relevant literature, and proposes specific hypotheses. Chapter 3 details the organizational setting, study design, sample, measurement strategies, and statistical procedures. Chapter 4 presents the results for the proposed attitude change model, using both quantitative and qualitative data. Chapter 5 details changes in departmental boundaries, also including both quantitative and qualitative data. Finally, Chapter 6 provides a discussion of the issues raised, including both theoretical and practical implications of the study findings. 8 Notes 1. The concept of openness is frequently used in research that views organizations as open systems and focuses specifically on the relationships of organizations with their environments. Scott (1987, p. 23) offers the following open system definition: "organizations are coalitions of shifting interest groups that develop goals by negotiation; the structure of the coalition, its activities, and its outcomes are strongly influenced by environmental factors." The focus of the present project, however, is on interdepartmental relationships within the organization, rather than on the relationship between the organization and its environment. Specifically, the present project explores changes in the openness of departmental boundaries within the organization accompanying the implementation of the computer system. 9 Chapter 2 THEORETICAL FRAMEWORK AND HYPOTHESES Little research has been conducted on the impacts of computerized medical information systems, although there is a substantial body of research on computer use in other organizational settings and in public life. According to Kling's (1980, p. 100) review of empirical studies: The first thing we learn is that computers by themselves 'do1 nothing to anybody... computing is selectively adopted in a given social world and organized to fit the interests of the dominant parties. There is sufficient evidence that computing use is purposive and varies between social settings; little causal power can be attributed to computers themselves. Kling's (1980) perspective emphasized the opportunities available for choice in the design, implementation, and management of computers in the work setting. Zuboff (1982, p. 150) also noted that the "flexibility, memory, and remote access capabilities of information systems create new management possibilities and, therefore, choices, in the design of an application." Zuboff (1982), however, also added that the flexibility of the technology does not imply neutrality. Rather, according to Zuboff (1982, p. 150), information technology has "attributes that are unique in the world 10 view they impose and the experience of work to which they give shape." Hirschheim (1985, p. 196) summarized three alternative positions on computer impacts: optimism, pessimism, and pluralism. The optimist position (e.g., Giuliano, 1982? Hodge, 1977; Schmitz, 1979) emphasizes increased productivity and organizational effectiveness, new jobs, and enhanced communication and quality of work life. Research has provided support for the optimist view that communication will be enhanced, a result which, according to optimists, will also lead to greater community feeling among individuals communicating via computers. The pessimist position, on the other hand, views information technology "as the latest in an unending stream of tools and techniques which are used to maintain— indeed improve— control over the working class" (Hirschheim, 1985, p. 220). Individuals are robbed of their expertise by machines, and employees will become j more isolated from other workers, with the computer ! terminal becoming the primary focus of interaction (Braverman, 1974? Hirschheim, 1985? Van Maanaen & Barley, 1985). Increased communication is not necessarily seen as j desirable and computer communication has the potential to i supplant face-to-face and voice communication, leading to j 11 greater social isolation. Research has also supported this view in certain industries, organizations, and occupations (Van Maanen & Barley, 1985). Finally, the pluralist focuses on a different set of issues. The pluralist is neither optimistic nor pessimistic, but assumes that automation may be either positive or negative, depending on the way in which the technology is managed and put to use. Thus the pluralist is concerned with how the technology is used and emphasizes the participation of all affected parties as a necessary (but not sufficient) condition for acceptable automation (Johnson & Rice, 1987). The pluralist approach focuses on the development of "criteria for social and technological acceptance and the application of 'acceptable' technologies in appropriate circumstances" (Hirschheim, 1985, p. 196). The symbolic interactionist perspective described below is often adopted by the pluralist as a way of identifying and understanding alternatives to the outcomes predicted by the strict optimist and pessimist views. The present study resembles the pluralist approach in its use of a symbolic interactionist perspective and its emphasis on the importance of participation in the implementation process. The symbolic interactionist framework is used in the present study to understand the 12 impacts of a computerized information system on two levels: individual and departmental. At the individual level, study hypotheses predict that employee responses to computerization will be determined by (1) membership in a specific department or work group (i.e., social world), (2) professional training and identification, and (3) personal frames of reference. At the departmental level, hypotheses predict that participation in the implementation process and use of the information system will result in changes in the boundaries between departments, or social worlds. This prediction echoes the pluralist emphasis on the importance of participation in the computer implementation process, as well as Hirschheim*s (1985, p. 268) own emphasis on "negotiating and conflict resolving rather than the traditional planning approach" to participation. The arguments upon which these predictions are based follow from two specific contingencies: (1) the integrating capabilities of a medical information system, and (2) the interdependence between departments in medical care settings. The following sections present a description of medical information systems, followed by a detailed analysis of the kinds of social structure found in many medical care organizations. The symbolic interactionist perspective provides a general framework 13 for understanding the occupational and departmental social worlds often found in medical care. Detailed hypotheses are introduced throughout the chapter, following the theoretical argument supporting each hypothesis. These hypotheses predict both individual reactions to computerization and changes in departmental relations as a result of computer system implementation and use. Medical Information Systems Computerized medical information systems are defined as "formal arrangements by which the facts concerning the health or health care of patients are stored and processed in computers" (Lindberg, 1979, p. 9). In some organizations a comprehensive system coordinates patient care activities by using computer terminals to link units in patient care areas to all departments through a central or integrated information system. Other organizations have smaller separate systems which link patient care areas to only one department such as the laboratory, radiology, or the pharmacy. Order entry systems, for example, require that physician orders for a patient be entered in the computer by either the physician, nurse, or unit clerk in the department in which the order originates and be communicated by computer to other departments such as the laboratory or 14 pharmacy. These systems provide communications networks between departments as well as storage and retrieval of medical information. Medical information systems have recently begun to be adopted by a substantial number of hospitals and clinics (Packer, 1985). In addition to providing communications networks and storage and retrieval of information, however, medical information systems have the potential to change work procedures and affect the ways in which hospital or clinic departments relate to one another. Prior to system implementation, for example, each department (e.g., pharmacy, nursing) customarily maintains separate records ; i (computer files, card files, etc.) for its own use. These | records are often supplementary to the information | i recorded on the patient's medical record. The design of most medical information systems, however, requires all departments to share in the use and maintainance of a common database. Information such as physician precriptions for medications is entered by one department and available to qualified workers in departments throughout the organization. These systems help to create a "virtual office" (Guiliano, 1982), with boundaries related to task and information flow rather than to traditional functional departments. 15 Computerized information systems, however, have had "more than their fair share of difficulties in implementation in health facilities" (Smith & Kaluzny, 1986, p. 212). Implementation of medical information systems has "frequently resulted in system rejection and organizational upheaval" (Dowling, 1980, p. 23). A survey of 40 randomly selected hospitals indicated that staff interference had occurred in nearly half of the hospitals installing administrative or clinical information systems (Dowling, 1980). Brenner and Logan (1980, p. 109) attributed "the lack of acceptance of computerized patient and medical records systems by the medical community," to attitudes and social relationships within the hospital as well as to physician norms and national health policies. In addition to these factors, Kaplan (1987) noted that decentralized computer applications serving individual departments parallel the departmental structure of medical institutions. Thus, departmental applications are more likely to be adopted than integrated medical information systems that require coordination and cooperation between departments throughout the institution. The integrated nature of the medical information systems described above has the potential to change both 16 the distribution of tasks and the patterns of communication between departments. Departmental relationships may change when one group assumes responsibility for entry or maintenance of information upon which all groups depend. Communication between departments may become more or less frequent, as well as use different media (i.e., computer rather than telephone or written reports), after the computer system is implemented. In order to understand the significance of these potential changes in relationships between departments, however, it is essential to understand the interdependent social worlds typical of many hospitals, the traditional relationships between these social worlds, and the current rapid changes taking place in the context of medical care. The symbolic interactionist perspective provides a useful approach to understanding a hospital or clinic's interdependent social worlds and the negotiated order between them. The Symbolic Interactionist Perspective The concept of "social worlds" is central to the symbolic interactionist perspective, a sociological point of view that focuses on the communication of symbols through interaction (Babbie, 1980). The symbolic interactionist perspective traces its origins from the Scottish moral philosophers, through the American 17 pragmatists, and especially to George Herbert Mead (Mead, 1964; Stryker, 1981). According to this perspective, society "is viewed as a network of interpersonal communication, connecting persons organically" (Stryker, 1981, p. 5). Individual actions stem from perceptions of reality socially constructed through interaction with others. Through this process, society is continuously being created and re-created. Social life is "constructed from the interaction of people and groups as they create and respond to socially defined meanings" (Kling, 1980, p. 66-67). The symbolic interactionist perspective, however, has frequently been criticized for neglecting the importance of social structure and large-scale features of society (Stryker, 1981). While symbolic interactionists may have considered these matters, there is criticism over their lack of a formal theory of social structure (Maines, 1977). Wentworth (1980, p. 4), for example, pointed out symbolic interactionism1s "unexplained gap" between intentional acts of individuals and the "structural aspects of the situation." In looking at the interplay between agency and constraint, Wentworth (1980, p. 5) noted that "historical social structures are not reproduced by accident or by intention 18 i i only, although this is what the concept of emergence is often taken to imply.1 ' In response to these concerns, recent theorists have extended the symbolic interactionist perspective to include the relationship of individual interactions to the social structure. According to Stryker (1981, p. 22) , "Structural concepts like group, organization, community refer to patterns of social life tying particular subsets of persons together and separating others." Social structure shapes the interaction between individuals. Thus, while individuals create their reality through interaction with others, it is the social structure that shapes the opportunities, criteria for, and circumstances of, social relationships (Stryker, 1981). According to Shibutani (1978, p. 112), modern mass societies "are made up of a bewildering variety of social worlds." "Groups of friends, interaction partners, and co-workers may be important loci for the establishment of i social reality...leading different groups to have different interpretations of events" (Moch, Feather, & Fitzgibbons, 1983, p. 218). Each social world is characterized by its own sense of identity, definition of purpose, and a system of formal and informal communications. Each may develop a jargon or code 19 language of its own (Croog & Ver Steeg, 1972; Runcie, 1974). An individual employee may be a member of more than one such world in the organization. An individual's opportunities for interactions, and the realities he or she is able to construct, will depend upon the particular groups or social worlds to which he or she belongs. Social worlds are "fluid, as negotiating, as interacting systems, with the actors continuously moving between these worlds and processes depending on what kind of role they are taking" (Mauksch, 1972b, p. 192). Both shared tasks and communication patterns have been suggested as determinants of the boundaries of definable social worlds. Studies of occupational communities have often i i i focused on social worlds defined by the specific tasks shared by community members (e.g., Becker, 1982, 1986? Van Maanen & Barley, 1984). This approach defines a social world as "the joint production of specific actions and services" (Kling & Gerson, 1977, p. 132). "Workers of various kinds develop a traditional 'bundle of tasks'" (Becker, 1982, p. 9; Hughes, 1971). Kronus (1976, p. 5) focused on task boundaries and occupational power, noting that one aspect of occupational power is "the relative ability of the occupation to protect its task domain from encroachment," and/or the ability to encroach upon 20 others. An example of a power conflict between | I occupational communities in health care is the current ) j debate concerning which professions should prescribe ! medications, with both pharmacists and nurses are i l attempting to encroach upon the domain of physicians in this area. Social Structure of Medical Care The social structure typical of many American hospitals and clinics is made up of numerous interdependent occupations1 and departments, each of which can be defined as a social world (Mauksch, 1972a). The main objective of any hospital or clinic is "professional individualized care and treatment rendered directly to the client by medical, nursing, and other specialists, according to the needs and requirements of each case..." (Georgopoulos, 1972, p. 17). Modern American hospitals and clinics are highly complex organizations "based on the mutual cooperation of a large and heterogeneous number of interdependent professional, semiprofessional, and nonprofessional members" (Georgopoulos, 1972, p. 3). These members work in close proximity, but possess different education, skills, values, and orientations. Medical specialists work interdependently. Their "inputs and outputs are highly interrelated and the 21 performance of each is always contingent on the performance of others" (Georgopoulos, 1972, p. 19) . Consequently, the hospital or clinic's requirements for cooperation between groups are far greater than those of most other organizations of similar size. Communication is essential to the maintenance of these relationships and to the delivery of medical care. The following sections describe the social worlds typical of most medical care settings. The first section deals with the hospital's dual system of authority, encompassing both the medical and administrative aspects of the organization (Kimberly & Evanisko, 1981). The next section provides an overview of the the paramedical professions, each of which constitutes its own unique social world. The social structure of medical care described in these sections can be attributed to a combination of (1) technological imperatives, and (2) institutionalized myths that delegate specific tasks to the appropriate occupations, often regardless of any concern for efficiency (Meyer & Scott, 1983). The potential conflict between these two sources of structuring makes detailed descriptive studies of the ways in which individuals in the various health care occupations relate to one another particularly valuable (Scott, 1982). 22 Administrators and Physicians The typical modern general hospital or clinic is organized on a dual system of administrative and professional lines of authority (Croog & Ver Steeg, 1972; Young & Saltman, 1985). The administrative line runs from the trustees down to hospital workers, while the physician is the primary power figure in the professional line of authority. Inevitably the two systems of authority overlap and conflict, since "each system is oriented to a different set of values, one emphasizing the maintenance of the operation of the organization, the other emphasizing the provision of service" (Croog & Ver Steeg, 1972, p. 290). Complications also arise from directions from multiple superiors, inconsistent orders, and inadequate coordination of activities. Research on organizational innovations has underscored differences between the medical and non-medical (or administrative) social worlds in hospitals, with different variables found to influence the adoption of medical and non-medical innovations (Kimberly & Evanisko, 1981). According to Kimberly and Evanisko (1981, p. 706), the hospital's dual authority structure presumably implies a high potential for bargaining over resource allocations along with the "kind 23 of negotiation and bargaining required when potentially conflicting interests are at stake." Recent developments, however, are changing the dual power structure. Physicians are beseiged by the demands of government regulation, changes in reimbursement, ethical concerns, and rapidly changing technologies. On the other hand, administrators are expanding their power due to the greater importance of functions such as accounting and computer control systems. According to Scott (1982, p. 185), "the power position of administrators has now been consolidated by their crucial role in mediating between internal and external constituencies." It is within this context of increased administrative authority that medical information systems are being adopted. Paramedical Professions Occupations such as nurse, pharmacist, laboratory technician, and physical therapist are classified as paramedical because their work is organized around the work of the physician and performed under physicians1 orders (Cockerham, 1978). These technical professions were developed expressly to provide physicians with hospital and laboratory support that would be competent and professionally trained and yet not "challenge the authority or economic position of the doctor" (Starr, 24 1982, p. 221). In recent years, however, there has been a move for increased professional status on the part of so-called emergent professions such as paramedicals (Cockerham, 1978). In addition, various occupational groups (e.g., nurses) may have little formal authority, but possess considerable power, based on knowledge and experience upon which physicians and other professionals, especially interns and residents, depend (Blau, 1979). Thus, the organization as a whole includes individual departments and professional groups that compete with one another for recognition, privileges and a more advantageous position (Ver Steeg & Croog, 1979). Each group of professionals or employees has a fairly well defined group strategy (Young & Saltman, 1985). The purpose of the present study is (1) to examine the influence of the organization's competing but interdependent social worlds on individual attitudes toward the medical information system, and (2) to explore impacts of information system implementation and use on the social worlds and on the relationships between them. The following section outlines the influence of social worlds on individual attitudes and describes mechanisms such as the social information processing approach through which social worlds exercise this influence. 25 The Influence of Social Worlds on Attitudes: I i Professions and Departments An important issue in considering hospital or clinic social worlds is the debate over the relative influence of profession vs. department in determining an individual's view of the organization. As noted by Guy (1985), organizational theorists and health care personnel alike make the assumption that occupation is instrumental in distinguishing individual values and perspectives. "Professionalization brings together employees with occupational identities and ideologies that set them apart from other employees " (Van Maanen & Barley, 1985, p. 40). March and Simon (1958), for example, noted that the specific formal training of professionals also results in homogeneity of background. "Since there is a need to be like other members of the profession in a number of attributes, there is a tendency to extend this need to other attributes and thus to identify with the group" (March & Simon, 1958, p. 71). In fact, the classic professional model posits that "the function of professional training is to instill long-lasting values that direct and guide the practitioner after he leaves school" (Kronus, 1976; Merton, Reader & Kendall, 1957). 26 Discrepancies in the classic professional model, however, have been noted both by theorists within this tradition and by those who challenge the model. Training even within a single occupation, for example, is by no means homogeneous. Various types of training programs produce graduates with different conceptions of their work roles (Kronus, 1976; Light, 1983). Each formal training program is affected by the outside community, the formal organization to which it is linked, professional organizations, as well as the professional ideology of particular staff members and the structure of the training program itself (Bucher & Stelling, 1977). Thus, even before occupational members enter the working world they are subject to a variety of different expectations and learning situations. Challenges to the model itself stem from studies of professional organizations such as hospitals or universities in which the "primary or core tasks are performed by professional participants" (Haddock, 1987, p. 297). Guy (1985, p. 180), for example, maintained that an organization which is divided according to profession gives "rise to barriers among members of different professions and predispose staff to parochialism...." In her view, much of the dissention that has been noted between professional groups in 27 organizations arises not from differences in norms or attitudes, but from what she describes as unnecessary insulation and lack of communication between groups. This emphasis on communication points to an important weakness in the professional model, i.e., its failure to consider the importance of ongoing communication in maintaining social worlds. In addition to shared tasks, communication is an essential determinant of social world membership (Shibutani, 1978). Individuals create their reality through interaction with others; communication provides the opportunity to create a common perspective among individuals. "The most important vehicle of reality-maintenance is conversation" (Berger & Luckmann, 1966, p. 152). Van Maanen and Barley's (1985) definition of organizational "subcultures," which includes regular interaction (i.e., communication) between members, will be used in the present project to define organizational social worlds. Thus, a social world is defined as a; "subset of an organization's members who interact regularly with one another, identify themselves as a distinct group within the organization, share a set of problems commonly defined to be the problems of all, and routinely take action on the basis of collective understandings unique to the group. (Van Maanen & Barley, 1985, p. 38) 28 This definition provides a rigorous description of a social world, emcompassing both shared tasks and communication patterns as determinants of social world boundaries. A group of individuals who are simply members of the same occupation, however, will not necessarily fulfill all of these criteria for a social world. While they may share common tasks and values, they may or may not interact regularly with each other in the work setting. Physicians in different departments in the same hospital, for example, all treat patients and identify themselves as physicians. Their perspective on the hospital as a whole, as well as their actions, however, may differ depending on the particular problems of the department in which they work. Physicians who work within the same department, however, are more likely to communicate and act according to collective understandings as they perform agreed upon departmental tasks. Thus while the actual level of shared understanding or interpretation of agreed upon actions is always open to question, communication, at the very least, has the potential to forge agreements concerning individual actions needed to attain departmental goals (Donnellon, Gray, & Bougon, 1986). 29 Thus, physicians working in different departments in the same hospital may be defined as members of different social worlds. They perform similar patient care tasks, but may have different perspectives based on unique departmental problems. In this view, shared or common tasks (e.g., treating patients), without communication, are not sufficient to predict a common or shared perspective, despite a common occupational identification. Shared tasks are a necessary, but not sufficient, condition to define a social world. Using Van Maanen and Barley's (1985) definition of organization subcultures or social worlds (see above), it becomes obvious that the departmental structure of an organization is an important determinant of social world membership. In cases where departments are composed of members of only one occupational group (e.g., the pharmacy or laboratory), both occupation and department will define the same social world. Members will then both (1) share departmental tasks and (2) communicate with each other about departmental concerns. Other types of departments, however, may include personnel from various occupations working interdependently (e.g., women's health). In a department with different occupational groups, each group may share a general departmental perspective, but also hold 30 specific viewpoints related to their own occupational concerns. The social world of a nurse, for example, includes other nurses with whom she communicates and shares common tasks and values. The nurse may also define her world, however, to include specific members of other professions such as physicians or clerks working in the same department. While her perspective may have more in common with other nurses in her department than with physicians in her department, the physician may also be part of her social world because they work together and communicate with each other concerning the specific issues of the department in which they both work. Thus, the perspective of an individual worker may stem from both tasks shared with others in the same job or profession, and from the more general tasks defined as belonging to the particular department in which he or she works (see Figure 2.1). A clerk or a nurse in a clinic, for example, may be concerned with those tasks (e.g., typing, patient care) that are defined as part of clerical or nursing work throughout the organization or profession. On the other hand, the worker may also be concerned with the more general tasks assigned to the department as a whole (e.g., scheduling of appointments, treating patients, and scheduling follow-up care). It is likely, in fact, that nurses in the department of women's 31 Figure 2.1 Overlapping Occupational and Departmental Social Worlds Hospital or Clinic Boundary Women's Health Clerks Neurology Departments Occupations 32 health will communicate more frequently with clerks in the same department than with nurses working in other departments. Both nurse and clerk will share a concern !with the effective performance of general tasks related to women's health. In addition to conversation alone, departments "control many of the stimuli to which an individual is exposed in the course of his organizational activities" (Hackman, 1983, p. 1457). These stimuli include written materials, objects, the physical surroundings, and so on. Furthermore, "groups minimize internal conflict and focus on issues that maximize consensus" (Van de Ven, 1986, p. 596). Nurses working in different groups without contact with one another may share similar tasks, but interpret those tasks differently. Their interpretations will be based upon communication with others within their own departments regarding specific departmental problems and concerns. Recent research on professional identification supports this emphasis on the importance of communication in defining an individual's group identification. Kronus (1976, p. 304) studied pharmacists to investigate the "fate of occupational identities after the socialization process is over." Results showed that the structural characteristics of the daily work setting, especially 33 day-to-day contacts, possess "far more explanatory power than the professional model in accounting for different reference groups" (Kronus, 1976, p. 324). In fact, occupational identification was only important for neighborhood pharmacists who lacked a powerful organizational framework. These results were corroborated in an investigation of professional identification among professionals in two psychiatric hospitals. Guy (1985, p. 175) concluded that "socialization to a stable unit overrides professional or hierarchical differences among staff." Furthermore, long-term membership in an organizational unit had a significant impact on the amount of agreement. The more idiosyncratic preferences of respective professions were traced not to their discipline, but to limited communication with other professions. It is the structures "we create within organizations...that make them appear different" (Guy, p. 180). Recent research on computing in health care settings has also focused on the importance of social influence in predicting physicians' attitudes toward medical information systems (Anderson et al., 1986). Individual physician attitudes and computer use were found to be significantly influenced by the level of interaction with their peers, as measured by physician participation in a 34 consultation network (Anderson et al., 1986). These results further emphasize the importance of communication in addition to professional identification in determining perspectives on organizational innovations. In summary, social world membership is determined by shared tasks (professional identity) and communication patterns. While departmental membership typically provides both of these conditions, professional identification is predicated upon shared tasks alone. Under some conditions, communication may be devisive rather than unifying, and the frequency, nature, and content of communication are also important variables. Despite these caveats, however, individuals who communicate with one another in addition to sharing tasks (professional identity) are more likely to share a common perspective on the organization than those who only share tasks. The social information processing model of job design explores some of the mechanisms through which social worlds, especially departments, influence the attitudes of individuals. This approach maintains that job or task characteristics are not an objective reality, but are defined by primarily by information received from others (Salancik & Pfeffer, 1978). Although this model does not deal with the issue of professional 35 identification, it has contributed additional evidence on the importance of interactions between individuals in shaping shared perspectives in organizations. Specifically, the model addresses the importance of subgroup or departmental influence in testing the "relative effects of social influences on attitudes against the effects of individual traits, such as needs or personality dimensions" (Pfeffer, 1982, p. 116). It is often difficult, however, to determine whether attitude differences between members of different subunits are due to social influence alone, or to differences between the jobs performed in those subunits, or both. The social information processing model was initially tested using laboratory experiments (Thomas & Griffin, 1983). These experiments manipulated both artificial information cues and objective task characteristics and investigated the influence of both manipulations on subjects' perceptions of a task. Results largely supported an overlapping view, with both the information cues and objective changes in task characteristics affecting subjects' perceptions of the task. Recent research using the social information processing model has extended the perspective to new communication media. These researchers view the formation 36 of attitudes toward computer use as "analogous to the formation of task attitudes and behaviors" (Steinfield & Fulk, 1987, p. 484). The social information processing approach to computer use predicts "different patterns across groups due to differences in social norms and interaction patterns, even though communication tasks...are comparable" (Fulk, Steinfield, Schmitz, & Power, 1987, p. 543). Research findings have been mixed. According to Fulk et al. (1987), some studies have uncovered differences in attitudes or patterns of use between departments or subgroups. Other research, however, has found no significant differences independently attributable to social information, once influences of task characteristics and other variables have been taken into account (e.g., Rice, Grant, Schmitz, & Torobin, 1988). Furthermore, objective information on task requirements or information system characteristics is often unavailable, making conclusive explanations for any differences between subgroups impossible. Two studies undertaken with nurses in hospital settings did, however, control for differences in task requirements between different units (Aydin, 1987; Ischar & Aydin, 1988). In hospitals, nurses are particularly important users of computer systems because of their 37 central role in the coordination and communication of patient-related data (Romano & McNeely, 1985). Results of both studies showed perceived attitudes of others in the same social world to be highly predictive of respondent attitudes. Attitudes of workplace friends were most predictive, followed by those of co-workers and supervisors. Significant differences in nurses' actual attitudes were also found between different units in the same specialty and performing the same information system tasks, underscoring the importance of an individual1s social world in predicting attitudes. The foregoing theoretical arguments, supported by recent research, lead to the following predictions. Beginning with the situation of greatest similarity, the strongest shared perspectives (i.e., common attitudes toward the computerized information system) should be expected where individuals share both tasks specific to an occupation and also communicate with one another to perform those tasks. Such homogeneous social worlds may be either departments composed of a single occupational group (e.g., pharmacy) or several members of the same profession working within a larger department (e.g., obstetrical nurses). These specific circumstances may not even occur, however, in smaller health care organizations such as clinics where departments may be 38 small and/or composed of members of a variety of occupational groups. Departmental membership, regardless of constituent occupations, however, should also predict a shared perspective (i.e., attitude toward the computer system), albeit with less agreement than departments composed of one occupational group. This prediction is based upon the importance of communication in creating a common perspective and contingent upon the expectation that department members will, in general, communicate more frequently with other department members than with other individuals in the organization. Finally, members of the same profession throughout the organization (e.g., clerks, nurses) should share some similarities in perspective (i.e., attitudes toward the computer system) based upon common tasks professional training, norms and values. Without ongoing communication, however, these commonalities should be less predictive of a shared perspective than departmental membership. The following hypotheses concerning attitudes toward the computer system are predicted by the theoretical arguments detailed above. Hypotheses will be introduced throughout the text following each theoretical argument. 39 Hypothesis 1: Membership in the same social world will predict similar attitudes toward the computer system. Hypothesis la: Respondents in the same occupational social worlds will have similar attitudes toward the computer system. Hypothesis lb: Respondents in the same departmental social worlds will have similar attitudes toward the computer system. Influence of Individual Differences on Attitudes As we have seen, both professional and departmental social worlds are hypothesized to determine individual reactions to computerization. Multiple influences on individual members of the same social world, however, affect the level of agreement or homogeneity of their shared perspective. Individual perceptions of reality, including assessments of job characteristics and organizational innovations such as computerization, may vary according to an individual's unique frame of reference (Dean & Brass, 1985; O'Reilly, Parlette, & Bloom, 1980). These individual differences should operate independently of social world membership. Each element in an individual's frame of reference affects reactions to the organization and events that occur within it. Previous research on computerization has 40 shown that cognitive style, previous computer experience, and age affect attitudes toward information systems. The following section briefly reviews the literature and states specific hypotheses concerning the effects of these three individual difference variables on attitudes toward the computer system. Each of the specific hypotheses stated later follows from the following general hypothesis: Hypothesis 2: Individual differences (cognitive style, prior computer experience, age) will predict attitudes toward the computer system. Cognitive Style The concept of cognitive style has been useful in research on the ways in which individuals react to information systems (Keen & Morton, 1978; Kilmann & Mitroff, 1976; Mason & Mitroff, 1973). "Cognitive styles represent characteristic modes of functioning shown by individuals in their perceptual and thinking behavior" (Zmud, 1979, p. 967). The relationship between cognitive style and information system use has been addressed by many investigators (Bariff & Lusk, 1977; Benbasat & Taylor, 1978; Huber, 1983; Keen & Morton, 1978; Mason & Mitroff, 1973; Robey & Taggart, 1981; Zmud, 1979). Most models distinguish between an individual's analytic, systematic approach to problem solving and a more 41 intuitive, global approach as the two main types of cognitive style. The Myers-Briggs Type Indicator (MBTI) is a reliable multiple-item instrument that measures behavior in terms of the Jungian typology, classifying individuals' modes of evaluation as either thinking or feeling (Myers & McCaulley, 1985). A thinking type relies primarily on cognitive processes and formal systems of reasoning. A feeling type, on the other hand, is not an emotional individual, but someone who relies primarily on affective processes in problem solving. Thinking types have been shown to "prefer more objective, quantitative data than feeling types" (Kerin & Slocum, 1981, p. 132). While most research on the relationship of cognitive style and information systems has been done in the context of management information systems, the construct is equally applicable to health care workers in a hospital or clinic setting. According to Andreoli and Musser (1985, p. 19), for example, "it is often difficult for nurses to span the chasm of the 'real' world of patient care and patient records and the computer's world, where data are not physically tangible." The use of computers requires a more analytic approach while many of the tasks related to patient care require a more global personal strategy. Those individuals who rely on 42 logical structures to clarify a situation (thinking types in Jungian terminology) should have less difficulty adapting to computer tasks and consequently a more positive attitude toward a new medical information system (Keen & Morton, 1978). Recent research on nurses' adaptation to medical information systems showed mixed results on the effect of cognitive style. During the first months after the implementation of a medication information system, cognitive style was shown to predict self-reported computer use by nurses (Aydin, 1987). A replication study of a similar system in a different hospital eight years after implementation, however, showed that cognitive style had no effect on nurses' self-reported computer use (Ischar & Aydin, 1988). While it is not possible to generalize from two cases, cognitive style may be a more important predictor when individuals first encounter computers, and the importance of this variable may disappear as individuals become accustomed to using the computer. Hypothesis 2a: Individuals with a stronger "thinking type” cognitive style will have more positive attitudes toward the computer system than individuals with a stronger "feeling type" cognitive stvle. 43 Computer Experience Research findings on previous computer experience and acceptance of information systems are mixed. Kerr & Hiltz (1982) concluded that previous computer experience might contribute to acceptance for some groups and not for others. The lack of standardization between systems may make it difficult for experienced computer users to adapt to a new system, resulting in "too much" experience being negatively related to acceptance (Kerr & Hiltz, 1982). Experienced computer users may also have higher performance standards, leading to more negative attitudes toward a new system that does not measure up to their expectations. Researchers studying medical systems, however, have shown experience to result in greater acceptance of computer systems (Hodge, 1977? Startsman & Robinson, 1972; and Svenning, Ruchinskas, & Pease, 1984). Familiarity with the "culture" of computing (Sproull, Kiesler, & Zubrow, 1984), as well as actual technical skill and understanding of computers, are likely contributors to this result. Hypothesis 2b: Individuals with more computer experience will have more positive attitudes toward the computer system. 44 Age Age has been shown to be both positively (Ball & Hannah, 1984? Hicks, 1984; Reznikoff, Holland, & Stroebel, 1967; Schmitz, 1979; Startsman & Robinson, 1972; Stevens, 1983) and negatively (Fowler & Glorfeld, 1981? Kerr & Hiltz, 1982? Zmud, 1979) related to attitudes toward a variety of computer applications. Several of the studies showing positive relationships (i.e., older workers reacting more positively to computers than younger workers) involved nurses. It is possible that younger nurses were more idealistic about their role and saw computers as lessening their commitment to patient care, rather than as aiding in record keeping and reducing paper work. On the other hand, younger people and people with fewer years at an organization may be less resistant to changes in job tasks, or to innovations in general (Dickson & Simmons, 1970). Hypothesis 2c: Younger employees will have more positive attitudes toward the computer system than older employees. Influence of Computer System Implementation and Use on Attitudes The hypotheses detailed above argue that the influences of occupation, departmental membership, and 45 selected individual difference variables will determine attitudes toward the computer system. Researchers who focus on the beliefs and attitudes of individuals in organizations, however, often overlook how those attitudes are formed (Sproull, 1981). Attitudes are not static, even within departments or occupational groups. Rather, they evolve as individuals interact with one another and share experiences and interpretations of events. Participation in the computer implementation process and use of the computer system have the potential to influence attitudes toward the computer system through increased opportunities for interaction and communication. The following sections review these processes and present detailed hypotheses concerning the effects of the implementation process and system use on individual attitudes toward the computer system. Negotiation. Implementation, and System Use The implementation stage in the innovation process includes all of the events, actions, and decisions involved in putting the innovation into use (Rogers, 1983) . "Implementation focuses on issues of system management, bureaucratic processes, organizational development, user resistance, and conflict and bargaining" (Johnson & Rice, 1987, p. 42). An underlying theme in all discussions of the implementation process is 46 the importance of user participation for successful system implementation (e.g., Franz & Robey, 1986; Ives & Olson, 1984; Lucas, 1981; Markus, 1984; Zmud & Cox, 1979) . User involvement in the implementation of an integrated information system that links different departments within an organization involves employees from a number of different social worlds. It is precisely this involvement of individuals from different social worlds that is of interest here. The negotiations that take place between departments as part of the implementation process will be examined using the symbolic interactionist notion of social worlds, coupled with Strauss et al’s (1963) perspective on the negotiated order within an organization. Negotiated order. The notion of negotiated order emphasizes the process of internal change in the organization and the "importance of negotiation— the processes of give-and-take, of diplomacy, of bargaining— which characterizes organizational life” (Strauss et al., 1963, p. 148). The model pictures the hospital or clinic as a "locale where personnel... are enmeshed in a complex negotiative process in order both to accomplish their individual purposes and to work— in 47 an established division of labor— toward...institutional objectives" (Strauss et al (1963, p. 167). The concept of negotiated order links the ongoing interactions between individuals with the social structure, or context, of the negotiation. In this view, the rules that govern behavior and interactions between groups are continuously under negotiation (Strauss et al., 1963; Stryker, 1981). Van de Ven makes a similar point in describing transactions within an organization as "deals" or exchanges which "tie people together within an institutional framework" (Van de Ven, 1986, p. 597). In a hospital or clinic, negotiations (or transactions) take place both within and between departments as medical tasks and procedures are coordinated and carried out. The implementation of an information system, including the assignment of different information system tasks to specific departments, is an example of just such a negotiation process. The "development of an innovation might be viewed as a bundle of proliferating transactions over time" (Van de Ven, 1986, p. 598). Negotiations, however, can vary tremendously. Each set of negotiations takes place within a negotiative context or structural unit that defines "what is to be negotiatied, by whom, in what manner, and for what 48 purposes" (Maines, 1977, p. 253). Two important aspects of the negotiative context warrant attention here: (1) the scope of the negotiations (i.e., who is included), and (2) the subject of negotiations (i.e., new task boundaries between and roles of departments). First we will consider the scope of the negotiations. Scope of negotiations. Recent models of the implementation process focus on the interaction between users and system implementers (Ginzberg, 1981; Kling & Scacchi, 1980; Lucas, 1981; Markus, 1984). Markus (1984, p. 10) argued that "users' behaviors and system design features are tightly linked and that effective system design and implementation strategies must take this into account." Lucas (1981, p. 100) also noted, however, that "involvement must mean influence or it is meaningless." Kling and Scacchi (1980, p. 261) broadened the potential for interactions still further by maintaining that each phase of the information system life cycle is "shaped predominantly by social interactions between computing promoters, developers, users, maintainers, and their organizations." Many aspects of daily work in an organization, however, may not be subject to negotiation. According to Day and Day (1977, p. 139), the specific negotiations taking place on the lower and middle levels of complex 49 organizations are "highly restricted, shallow, and at times very superficial or temporal in nature and in terms of their ultimate outcome." The negotiating process may exclude many members of the affected groups and the most important issues may not be negotiated, but traditionally decided by the more powerful groups in the organization. Decisions to implement information systems in health care settings are often authority decisions (Rogers, 1983) . While representatives of departments or professional groups may be involved, most employees are not. Thus the level of user involvement often becomes an issue in the implementation process. One reason for this limitation on user involvement, at least in the early stages of the implementation process, is practical. The implementation of an integrated information system affects the entire organization. Most health care organizations range in size from 100 employees (in the clase of a clinic) to many thousand employees (in the case of a large hospital). Thus involvement of a large percentage of organization employees is seldom undertaken. Markus (1984) described the difficulties involved in user participation in detail. In general, however, she concurred with Lucas (1981), noting that participation can be harmful if it is designed primarily for political 50 purposes with no intention to accept or consider seriously the recommendations of participants. The implementation of many information systems "affects both formal and informal relationships among personnel as well as their particular relationships with and attitudes toward the organization" (Zmud & Cox, 1979, p. 42). The process of implementation is critical. "Extensive participation approaches require lots of time but build self-renewing organizations" (Markus, 1984, p. 209). In the current context, the choice of a computerized information system may be an authority decision and the implementation process may involve a limited number of representatives from individual departments. The scope of involvement is important, however, in the formation of attitudes toward the computer system. User involvement can, among other outcomes, lead to a more accurate knowledge of user needs while "encouraging users to develop commitment to and ownership of the change" (Johnson & Rice, 1987, p. 106). In fact, rationales for participation are, in a general sense, "derived from theories of democracy, socialism, human growth, and organizational efficiency" (Johnson & Rice, 1987, p. 107). These arguments for participation lead to the following hypothesis: 51 Hypothesis 3: Participation in the implementation process will result in more positive attitudes toward the computer system. Negotiating new tasks and computer use. The effective implementation of a medical information system requires recognition of the large changes which must take place in organizational procedures, roles, responsibilities, and ways of carrying out work (Gerdin-Jelger & Peterson, 1985; Peterson, 1985). A variety of role and task changes for different occupational groups may accompany the introduction of a computerized system. A change in task boundaries is defined as the shifting of specific tasks from one department or group to another. Implementation negotiations in the hospital or clinic generally center on specific information tasks crucial to the work of all departments. In the past, each department may have been responsible for its own information storage procedures. Now, however, responsibility for data entry and accuracy of information must be allocated between departments. Milner (1985, p. 4), for example, examined computer implementation in a hospital, noting that: one of the greatest role changes has occurred at the Unit Clerk level. The Clerk previously spent time booking diagnostic procedures, 52 receiving and forwarding phone messages, writing lists and completing laboratory requisitions. As a result of the computer, these tasks have been either reduced or eliminated. New tasks may include entering physician orders in the computer, as well as retrieving and filing patient care print-outs and ensuring that new medical orders are immediately brought to the attention of the charge nurse. Studies have been conducted on the reactions of physicians, nurses, and other paramedical personnel toward the changes accompanying computerized medical information systems. Nurses and pharmacists, for example, were enthusiastic about a system called PROMIS because it expanded their expertise and professional roles. Physicians, on the other hand, were less enthusiastic about the system because it infringed upon their accustomed use of information by requiring them to read parts of the medical record they were accustomed to skipping over (Fischer, Stratmann, Lundsgaarde, & Steele, 1987). Aydin (1989) also noted both increased friction and cooperation between pharmacy and nursing departments in two hospitals as new information system roles were introduced. Mixed reactions, however, can also occur within the same occupational group. Kaplan (1986) noted substantial differences between technologists in different clinical 53 laboratories in the same medical center in their reactions to the computer, depending on the particular laboratory's definition of the role of the technologist. Technologists in general, however, "felt more accountable for their work and reported that the computer could 'catch their mistakes' and make their errors 'more obvious.• Because the computer system records who enters test results, respondents felt more cautious about entering their own or others" (Kaplan, 1986, p. 1058). Barley (1986) also reported that the first use of body scanners in the radiology departments of two hospitals resulted in new boundaries between the various technological subunits within the radiology departments. In this case, "x-ray techs began to complain more frequently about their work, while sonographers and special techs deplored the privileged treatment given CT techs..." (Van Maanen & Barley, 1985, p. 49). Thus role changes brought out latent conflicts based upon the prestige of certain tasks. The following hypotheses all address ways in which computer use, and resulting task changes, either directly or indirectly affect attitudes toward the new computer system. Hypothesis 4: Computer use will influence attitudes toward the computer system. 54 Hypothesis 5: The introduction of an integrated information system will result in task changes for workers in some departments. Hypothesis 6: Workers who perform tasks formerly performed by another department will have more negative attitudes toward the computer system. New Opportunities for Interaction Examining the attitudes of individuals toward the computer system, and the determinants of those attitudes, is only the first step in exploring potential changes that may accompany the implementation of an integrated information system. Computerization creates the potential for organizational change through new opportunities for interaction among members of different organizational social worlds. The concept of negotiated order is based on a dialectical perspective encompassing both social structure and process (Maines, 1977). In this view, social structures such as departments shape the interactions that take place within an organization. Individuals, however, can also creatively alter patterns of interaction and, ultimately, the social structure can change (Stryker, 1981). Technological innovation can be seen as an occasion for the restructuring of organizations (Barley, 1986). 55 According to the arguments outlined in the previous section, occupational and departmental social worlds (along with individual differences and implementation practices) shape individual attitudes and actions. If this proposition is true, however, potential changes in the interactions between these social worlds should have important consequences for individual perspectives and for the organization as a whole. The structural shifts that accompany technological innovation can "alter interactional opportunities which, in turn, spawn the contrasting interpretive systems that characterize organizational subcultures" (Van Maanen & Barley, 1985, p. 44). The altered perspectives that result from these changes, or new ways of interacting can, in turn, lead to new interaction patterns. Thus, technological change may "lead to the demise of organizational and occupational subcultures... or or create new ones" (Van Maanen & Barley, 1985, p. 43). The following sections investigate shifts in interaction patterns and relationships between departments that may accompany both the implementation process and the initial use of a medical information system. In particular, this portion of the present study focuses on changes in the nature of the boundaries between departments, characterized by changes in 56 information exchange and understanding on the part of employees about the work of other departments. New levels of information exchange represent new opportunities for interaction while new levels of knowledge about other departments may result in an altered perspective about other departments in the organization. Boundaries between Departments "Organization boundaries do matter" (Scharpf, 1977, p. 162, cited in Minzberg, 1979). Boundaries "separate specialized subunits from each other and from external areas" (Tushman & Scanlan, 1981, p. 290). Organizational structures "serve to sort attention," focusing efforts of group members in prescribed areas and blinding people to other issues by influencing perceptions, values, and beliefs (Van de Ven, 1986, p. 596). Boundaries between departments in organizations are "associated with the evolution of local norms, values, and languages tailored to the requirements of the unit's work (Tushman & Scanlan, 1981, p. 290). Interdependence between departments gives rise to such issues as "cooperation, coordination, conflict, and struggles for power" between groups (McCann & Galbraith, 1981, p. 61). Appropriate management of departmental boundaries is essential for the successful implementation of new technologies (Johnson & Rice, 1987). 57 Interdepartmental relations are of particular interest in complex environments such as health care organizations. Social worlds in health care settings are highly interdependent. Few medical care tasks can be performed without the cooperation of one or more departments or professions. The physician cannot make a diagnosis without laboratory tests and x-rays. The nurse cannot administer medications without an order from the physician and the medication itself from the pharmacy. The laboratory must receive orders from the physician, through intermediaries, and then return the test results to the physician. Virtually no work can be done independently. This interdependence points to the importance of communication across departmental boundaries for effective organizational functioning. The relationship between any two departments includes the communication required to perform medical work (e.g., the clerk or nurse regularly telephones the laboratory to obtain results of laboratory tests). Periodic meetings, both formal and informal, may also occur between members of different departments to discuss coordination of tasks or changes in procedures. As individuals interact over time, however, and address problems cooperatively: 58 collective understandings form to support concerted action. These perspectives are likely to pertain not only to the nature of the work and to the solution of task-related problems, but also to the nature of the organization and to the individual's position within it. (Van Maanen & Barley, 1985, p. 37) Thus, effective communication across departmental boundaries creates knowledge about the work of others as well as a general perspective on other social worlds in the organization. The boundary between any two departments is characterized by a customary or accepted level of communication and knowledge between members of the respective departments. Remarks such as "they just don't know how difficult it is to do this work" or "the computer in pharmacy is down so we don't know how long it will take to get the medications" are examples of differing levels of knowledge and understanding across departmental boundaries. Departmental boundaries characterized by frequent communication and knowledge about the tasks and problems faced by the other department can be defined as more open than boundaries characterized by little communication or knowledge of the work of the other department. This section focuses on changes in departmental boundaries that accompany the implementation and use of a medical information system. The nature of these changes can affect the relationship between departments and the coordination of work within the organization as a whole. It should also be noted, however, that changes in communication and knowledge will not necessarily reduce conflict between departments. "Whether interdependence proves beneficial or dysfunctional depends upon the extent that shared appreciations of interdependencies are created and maintained....Each department has a preferred way of performing its activities" (McCann & Galbraith, 1981, pp. 67-68). Agreeing upon terminology to be shared between departments, for example, is a major task. "Each department is used to considering itself as distinct from the rest of the hospital" (Cook, 1985, p. 164). Departments have their own specialized semantics, making it "necessary to recode at boundaries between units" (Tushman & Scanlan, 1981, p. 291). With an integrated information system, employees outside of the department will communicate directly with the department. Without shared terminology, these communications may cause constant friction. Latent tensions between organizational groups may also be activated by events such as the implementation of technological change (Van Maanen & Barley, 1985). Role conflicts that have never been completely resolved may again become an issue when workers in different 60 j departments are no longer isolated from one another j (Smith & Kaluzny, 1986). "The past is not only i I continually being redefined in light of the present, I but...it has a structuring effect on what is likely to occur in the present" (Maines, 1977, p. 244). In research related directly to this issue, Aydin | (1989) focused on changes in the relationship between pharmacy and nursing in two hospitals following the implementation of a computerized medication entry system. In both hospitals, respondents claimed an improved relationship, with increased interaction between departments since sharing an integrated information system. In one hospital, however, role conflicts initially increased friction between nursing and pharmacy employees, with nurses resenting the time spent doing order entry for the pharmacy and pharmacists criticizing nursing errors in computer entry. Nurses perceived themselves as doing clerical work for the pharmacy while the pharmacist gained additional free time to join the physicians on rounds. In the other hospital, pharmacy employees complained about the amount of time spent in correcting nursing errors in order entry. The long-term result, however, was a closer working relationship between pharmacy and nursing based on the need to 61 maintain a common information resource upon which both departments depended. Barley's (1986) study of two radiology departments' implementation of body scanners also offers an "example of latent subcultural collision" (Van Maanen & Barley, 1985, p. 49). In this case, technologists made clear occupational distinctions among themselves. These distinctions, however, remained hidden until the arrival of the new technology. The body scanners, however, were accompanied by changes in task assignments which disrupted the status quo. Finally, Kaplan (1986) noted changes in the relationship between newly computerized hospital laboratories and the rest of the medical center. "Overall, negative feelings seemed to predominate over positive ones" (Kaplan, 1986, p. 1058). This was particularly noticable in the perceived change in the relationship between laboratory technologists and other employees in the medical center. Sixty-six percent of the respondents reported a negative change in how technologists were treated by others in the medical center, a change that was attributed to problems with the computer system. Thus changes in interactions between departments, including communication and knowledge about the work of 62 other departments, have the potential to change departmental relations. The results of these changes, however, may be different in different organizational contexts. Both participation in the implementation t process and actual use of the information system are hypothesized as determinants of new interaction patterns and departmental relationships. The roles of each will be discussed in detail in the following sections. Departmental Boundaries and the Implementation Process In order to maintain one's own definition of reality, one must be "very careful with whom one talks" (Berger & Luckmann, 1966, p. 159). The negotiation of plans for computer implementation, however, may result in new interactions between members of different social worlds when members of different departments are included in implementation planning (Lucas, 1981). The consequences of these negotiations are new, "organized patterns of interaction..." (Stryker, 1981, p. 19). Thus, regardless of the substance of the negotiation, the process itself has the potential to alter the perceived realities of the participants through exposure to the perspectives of members of other departments or social worlds. Through the implementation process itself, and the new interactions that occur, the boundaries between 63 departments or social worlds themselves may become more open. That is, members of different social worlds will communicate with and, consequently, be influenced by, the socially constructed realities of members of other social worlds. They may become more knowledgable about the work | procedures and problems faced by other departments. These influences, in turn, have the potential to change employee perceptions of other departments as well as their actions as members of both departments communicate and coordinate their work to deliver medical care. The negotiation process for computer implementation is similar to Ackoff's (1970, 1974) concept of interactive planning across departments. Interactive planning "emphasizes interdependencies and thus creates a I felt need for coordination; and it can encourage conflict resolution by creating a shared vocabulary and basis for communication" (McCann & Galbraith, 1981, p. 71). Implementation planning across departments has the potential to create collective understandings and shared perspectives among members of different departments who participate. The level of involvement in the implementation process, however, is important in determining how widespread these collective understandings and shared perspectives become. The following hypotheses address the general proposition that 64 participation in the implementation process will result in increased openness in the boundaries between departments in the organization. Hypothesis 7: Participation in the implementation process will increase the openness of boundaries between departments. Hypothesis 7a: Employees who participate in the implementation process will perceive increased exchange of information between departments. Hypothesis 7b: Employees who participate in the implementation process will perceive increased understanding of the work of other departments. Departmental Boundaries and System Use Finally, actual use of the information system, regardless of participation in the implementation process, also has the potential to increase the openness of boundaries between departments. An integrated medical information system requires departments to work cooperatively to maintain a common database upon which all departments depend. Data entered into the computer by one department is essential to the work of many other departments. Hospital or clinic departments no longer carry out their work using separate patient records and databases, but depend upon each other for the information needed to do their work. In addition, the use of an 65 integrated information system requires departments to agree upon common forms, terminology, and increased standardization of information (Cook, 1985). Thus, as workers share responsibility for the maintenance of a common information resource, increased information exchange and understanding of the work of each department should result. Similar reactions were noted by Zuboff (1988) in her study of computerization in a global bank. The author observed that there was a: growing recognition that as the new technology integrated data from across all banking functions, a new quality of communication and collaboration would become necessary. Many managers questioned the current functional organization of the bank, which separated people into areas of special expertise with little cross-fertilization. (Zuboff, 1988, pp. 201-202) Thus, as individuals in different departments begin to use the information system, the increased dependence upon each other for shared information should result in increased communication between departments concerning allocation of tasks and quality control. This effect will be even more pronounced in instances where task boundaries between departments have shifted. Members of the department that has lost control of a specific task will need reassurances that they can depend on the same information they themselves controlled in the past. The 66 department newly charged with the task may also need to exchange information more frequently in order to learn and adapt to the new tasks. This increased exchange of information should have the same effect as participation in the implementation process— an increase in knowledge of the work of other departments. Both increased information exchange and knowledge of others' work can be conceptualized as increased openness in the boundaries between departments. Hypothesis 8: Use of the computer system will increase the openness of boundaries between departments. Hypothesis 8a: Employees who use the computer system will perceive increased exchange of information between departments. Hypothesis 8b: Employees who use the computer system will perceive increased understanding of the work of other departments. Summary The perspectives outlined in this chapter are illustrated using two models of organizational change. The first model includes both determinants of an individual's initial (Time 1) attitudes toward the computer system and the formation of post-implementation (Time 3) attitudes through participation in the implementation process and computer use (see Figure 2.2). Figure 2.2 Model of Attitude Change with Study Hypotheses Hypothesis 1 Hypothesis 1 Hypothesis 2 Hypothesis 3 Hypothesis 4 iypothesis 6 Hypothesis 5 Task Changes (I, A ) Computer Use (Q, I) Participation in Implementation (Q. I, A ) Time 3 Attitude: Combined Scale (Q) Time 1 Attitude: System Worth Time/Effort (Q) Individual variables: Cognitive style, computer experience, age (Q) Membership In Occupational and Departmental Social Worlds (Q, A) Time 1 Data Gathering System Implementation Time 3 Data Gathering Before System Implementation After System Implementation Data Sources: Q=Questionnaire ^Interview A=Archival. 68 Attitudes concerning the computer are influenced by both ,(1) membership in departmental or professional social ) jworlds within the organization (Hypothesis 1), and (2) i the individual's own personal frame of reference (Hypothesis 2). As proposed by Hypothesis 1, interactions with others, particularly within the same idepartment or occupation, help shape an individual's [ r perceptions of organizational reality on an ongoing basis. Furthermore, initial (Time 1) attitudes toward ithe computer system should strongly influence attitudes i toward the computer at Time 3. The computer implementation process, however, may disrupt accepted reality by introducing new interactions between members of different departments in order to discuss new ways of accomplishing the work. These negotiations also affect an individual's perceptions of the computer system itself (Hypothesis 3). Subsequently, actual use of the information system may create additional changes in how departments perform their work using newly agreed upon divisions of labor. These changes are "newly negotiated role arrangements" that may be met j ,with initial uneasiness if they conflict with cultural expectations (Stryker S t Statham, 1985, p. 353) (Hypotheses 4-6). Thus, social world membership, participation in implementation, and system use all jcontribute to an individual's attitude (Time 3) toward ;the computer system. | The second model concerns changes in interaction patterns between departments accompanying the implementation of the computer system (see Figure 2.3). This model specifically predicts changes in the openness j jof departmental boundaries as a result of participation |in the implementation process and system use (Hypotheses \ l and 8). In this view, members of different social ^worlds interact with each other as they participate in system implementation and use. As they negotiate new system tasks and role changes they exchange information and become more knowledgable about the work of other departments. These changes can be conceived of as i t increased openness of the boundaries between occupational and departmental social worlds in the organization. Figure 2.3 Model of Change i n Openness of Department Boundaries with Study Hypotheses Departmental Social Worlds Before Computer Implementation Departmental Social Worlds After Computer Implementation Women's Health Medical Records Lab Women's Health / / Medical Records Lab \ / i / \ \ \ Hypothesis 7 Hypothesis 8 Computer Use (Q, I) Participation in Implementation ( Q , I , A) Increases in Information Exchange/ Knowledge of Work (Q) Data Sources: Q=Questionnaire ^Interview A=Archival. 71 Notes 1. The terms occupation and profession are used interchangeably. The concern in the present study is not with defining the characteristics of an occupation that categorize it as a profession. In fact, current research in the sociology of occupations has moved beyond the definition of professions to the issue of occcupational power and how it is used with regard to other occupations (Hall, 19 83). The present study is concerned particularly with individual identification with specific social worlds of work and the negotiation of the work experience. Both topics apply to all identifiable occupational groups, rather than only to those that can be specifically classified as professions. 72 Chapter 3 METHODOLOGY "Social phenomena are complex phenomena.... The basic question facing us is how to capture the complexity of reality...and how to make convincing sense of it" (Strauss, 1987, p. 6, p. 10). The present study is no exception. This study investigates the predictors of individual attitudes, as well as the changes brought about by interactions between technological innovation, existing departmental relations, and individual perceptions of reality. In a effort to avoid the weaknesses and capitalize on the strengths of different research approaches, the study used both quantitative and qualitative methods. Furthermore, data collection spanned more than two years, before, during and after implementation of the system, in order to provide a better picture of the change process. The project was designed as a case study, taking advantage of the case study's strength in explaining "how" and "why" certain phenomena occur. As noted by Yin (1984, p.18), case studies focus on tracing operational links over time, rather than "mere frequency or incidence." They may include both quantitative and qualitative research methods and, like experiments, are generalizable to theoretical propositions, although not 73 to populations or universes. "The investigator’s goal is to expand and generalize theories..." rather than simply to enumerate frequencies (Yin, 1984, p. 21). Case studies, however, also present some disadvantages which must be acknowledged. According to Campbell (1975, p. 179), an observer conducting a case study who "notes a single striking characteristic...then has available all of the other differences on all other variables to search through in finding an explanation....That he will find an explanation that seems to fit perfectly becomes inevitable..." However, Campbell (1975) later discounted this potential danger by observing that, in practice, the social scientist undertaking a case study usually finds out that his prior beliefs and theories were wrong. In addition, any hypothesis will be true in some context, but a series of case studies can enable the researcher to make the limiting assumptions of a theory explicit across a number of different contexts (McGuire, 1983). This chapter presents the methodology for the present study, beginning with a description of the organizational setting and its employees, as well as details of the medical information system being implemented. It then continues with the study design, including both quantitative and qualitative techniques. 74 Finally, the sample, measurement strategies and analysis methods are described in detail. The Setting The present case study focused on the Student Health Service (SHS) of a large urban university. SHS offers outpatient medical care to the over 25,000 students attending the university, operating from a labyrinth of corridors and makeshift cubicles on two levels of the medical center basement. Colorful red and blue and yellow lines on the floor lead students from station to station, around corners and up and down stairs. The setting appears brightly lit, busy, and well-organized but somewhat comfusing. Organizational Structure SHS employs between 100 and 125 full- and part-time employees as well as numerous student workers. The maximum number of personnel are employed during the school year. Many of these, however, do not work during the summer months. Some return each fall, while others are temporary employees for a single school year. The employees include the typical range of medical occupations: staff physicians, nurses and nurse practitioners, laboratory and x-ray technologists, medical assistants, clerks, pharmacists, dentists, etc. In addition, medical center physicians from a variety of 75 specialties serve as consultants and see patients at SHS a few hours each week. SHS follows the traditional model of medical care organization described in Chapter 2 (see Figure 3.1). The director of SHS is a physician, while the executive director (who is responsible to the director) is an administrator, not a physician. This executive director also serves as acting assistant director for several services (laboratory, pharmacy, radiology, medical records, insurance and automation). Thus, as in many hospitals, ancillary services are directly responsible to a different administrator than the clinicians. SHS includes 13 distinct departments: Primary Care, Women's Health Service, Specialty Clinics, Athletic Medicine, Health Education, Finance/Personnel, Automation, Insurance, Laboratory, Medical Records, Pharmacy, Radiology and a Dental Clinic (not included in the study). Primary Care, under an associate director who is also a physician, comprises the largest clinic in the organization. This clinic offers treatment for a variety of both acute and chronic problems and is staffed by both physicians and nurse practitioners. Most students seeking care at SHS come to Primary Care first and are then referred to other clinics as necessary. Most are seen by appointment, although students may also request Figure 3.1 Student Health Service Organization Chart Director Executive Director Act. Assistant Director Ancillary Services -Automation (2) -Insurance (3) -Laboratory (8) -Med. Records (9) -Pharmacy (4) -Radiology (4) medicine (2) -Women's Health Service (15) Assoc. Director Primary Care -Primary Care Operations (31) Assoc. Director Nursing Affairs -Nursing Affairs -Specialty Clinic Operations ( 11) Associate Co-Directors Health Ed. -Health Education (10) Assist. Director Finance/Personnel -Accounting -Budgeting -Personnel -Purchasing ( 12) -Athletic Note: Numbers in parentheses indicate the number of employees employed in each department at Time 3. .j 0 \ 77 immediate care on a walk-in basis. In addition, Primary Care includes "Rapid-Care," staffed by two or three nurse practitioners, and reserved for walk-ins only. Appointments in Rapid-Care are scheduled every five minutes, compared with every 2 0 minutes for other Primary Care clinicians.1 Scheduling of most Primary Care appointments is done by telephone or in person, with the scheduling clerk selecting the appropriate physician based upon the symptoms described. Appointments are often available on the same day. Prior to 1983, all appointments were on a walk-in basis, with waiting times of up to four hours. Currently, walk-in patients are seen by a triage nurse who then assigns the student to the appropriate physician or nurse practitioner. The other clinics include the Women’s Health Service (under the SHS director himself) and Specialty Clinics (under the associate director for nursing affairs). Students may come directly to Women's Health without a referral from Primary Care. A nurse practitioner screens calls for appointments. Acute gynecological problems are given priority, with waits up to one month for annual or new visits. Treatment for patients in the Specialty Clinics, however, requires an appointment, since the physicians working in each specialty are consulting 78 physicians from the medical center and are only available for a few hours each week. Students are referred to the Specialty Clinics by a Primary Care clinician. In addition to these departments, SHS also includes Finance and Personnel, under an assistant director. The Dental Clinic, Health Education, and Athletic Medicine comprise the remaining departments of the Student Health Service. While most SHS employees (including physicians) are women, both the director and executive director are men. Informants described SHS as a hierarchical organization and noted that communication was "not a priority" for managers, some of whom were described as having poor "people skills." Prior to the implementation of the computer system, SHS management was generally wary of change, although some informants suggested that the computer system implementation might "open the minds" of employees at all levels to the benefits of change. In fact, administrators used the computer system as an opportunity to make other organizational changes that might have otherwise been perceived by employees as punitive. The Information System A medical information system for a clinic such as SHS can be designed to perform tasks such as scheduling patient visits; recording procedures, lab tests, 79 physician orders, medications, etc.; communicating orders, as well as test results, between departments; providing administrative tracking and information; and storing the patient's entire medical record. Prior to system implementation, SHS personnel had varying expectations for the information system and its benefits. At Time 1, SHS administrators described both short-term and long-term goals for the system. The transition from a paper-and-pencil to a computerized information system was to be a gradual change, with the most immediate and pressing problem being patient scheduling. System planners designed the computerized system to approximate the paper-and-pencil system previously used in each clinic. Minor changes, however, were to include an on-line expert system for appointment clerks in Primary Care to evaluate the patient's symptoms and assign the appropriate appointment. Long-term goals for the system, however, were more ambitious. In particular, staff members looked forward to using the computer system to retrieve laboratory test results for patients, eliminating the need for physical transportation of the hard copy. Furthermore, managerial expectations for the system included determining staffing needs, collecting epidemiological information, assessing community needs, substantiating SHS budget allocations 80 and identifying ways to improve the quality of service. Retrieval of scheduling information was expected to make accurate information available concerning the peak busy periods and the incidences of specific illnesses/needs. There were no immediate plans, however, to replace paper medical records with computerized records. In addition to patient scheduling and record keeping functions, long-term plans for the information system included a pharmacy dispensing and purchasing subsystem. This part of the information system was not, however, implemented during the study period and, thus, was not included in the analysis. Table 3.1 details a timeline of the actual implementation of the computer system in each department. In addition, research data collection and interview/observation time periods are also indicated on the timeline and described in the Design section below. At the time the present study was completed, most SHS departments were using the computer system for a number of functions. Numerous delays had been encountered during the implementation process, however, most of which were attributable to the system vendor. As the targeted implementation date approached, SHS system implementors discovered that the system itself was under development, rather than being the finished product promised by the vendor. Documentation accompanying the 81 Table 3.1 Timeline for the Present Research SHS Research Proiect Time Period System Implementation Surveys Interviews Summer 1986 -System selection and planning Fall 1986 -Planning Time 1 Survey Interviews Winter 1987 -Planning Spring 1987 -Primary Care Scheduling (Patient check-in/out, triage) Summer 1987 -Women's Health/ Time 2 Specialty Clinics Survey -Scheduling -Medical Records -Diagnostic Data Entry Interviews Fall 1987 -Ongoing system revisions Winter 1988 -Lab Spring 1988 -Ongoing system Time 3 revisions Survey -Lab Data Entry Summer 1988 -Radiology Data Entry -Clinics Data Entry Fall 1988 Interviews Archival Data 82 system was minimal, and most end-user documentation was developed by SHS staff rather than provided by the vendor. Many of the functions either did not operate as designed or did not fit the flow of work at SHS well. A central feature of the new system, the encounter form described below, was redesigned numerous times. By the end of the study period, however, many system functions were operating, including the scheduling of patient visits and entering the visit, along with a diagnosis and procedures performed, into the computer. SHS personnel were also beginning to use the information to generate a variety of reports. There were, however, no plans for entering results of lab tests in the computer and the on-line expert system designed to assign the appropriate physician for each student visit had been abandoned. Instead, scheduling clerks selected the clinician as they had always done. SHS's own implementation strategy included the hiring of a system analyst and assigning the medical records administrator (also a credentialed teacher) as system coordinator/trainer. While a committee composed of representatives of different groups met initially, most decisions related to system implementation were made by the executive director, system analyst, and the coordinator/trainer . 83 Many of the procedures accompanying the computerized system center around the "encounter form" developed by SHS. This form is printed for each appointment and includes the patient's updated registration and address information from the university's student database (see Figure 3.2). The encounter form (printed in quadruplicate) is used by physicians to indicate required laboratory tests as well as to update patient demographic information. It is also used to create an ongoing database of SHS patients. The following steps describe a typical patient visit and use of the encounter form. Figure 3.3 also illustrates the process, beginning with the student's first contact as an appointment is made. Step 1; The student schedules an appointment ahead (by telephone or in person) or walks in and fills out a request for appointment. For appointments scheduled ahead, a scheduling clerk uses the computer to find an available Figure appointment with an appropriate clinician according to the student's complaint. Walk-ins see the triage nurse for assignment to a clincian. Step 2: The medical records clerk pulls the student's medical record and the computer generates an encounter form. Encounter forms are DIAGNOSIS: . . 09/14/88 111 ii m 5 wwc-»noro~.-»S. if? 25 S I D ? S 3 B - *■8 ? > 3 nnz* inXftdt 0 — > 5 — n _ o 2 ® * * O 3 # - r t 5 ^*< < 0 * f l i* n jo 9 0 O « 0 g > I M I 2 i « * g € s l r- so 5 3SS sS" 3 c I I 2 f t f t f t • o o o o — 3 S 5 g £ £ C •• j* v* a -* £55 3 n’ S ; O O 0 O I I O ', I l l / s _ ° rail 8 I sis * ~ n n $ ii 1 I II II ° I I I I I ■ " § §j § ® 2iSw22 n o a > > » b * o c 0 0 B O . 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S ^ sriUtf * ■ • « 0 — “ oil M — jCx»»t3'ot)oxon t o r t m c cr m 0 ru9t£»uirvr«j<00 nQQnnnnnnnQ - r - -— *'Wf\j-sChO'rowr'-*w |3 3 S S ||i |i |§ g |K ^S??SSSC;2SJ22 = 3 Figure 3.3 Typical Patient Visit Student Actions Student calls or walks in to clinic Student sees clinician Student gets lab tests, x-rays, etc. Student leaves with instructions, etc. SHS Employee Actions Reports generated Appointment Scheduled Clinical procedures entered in computer Lab report forms generated by computer Activity codes for lab tests, x-rays, etc. entered in computer Lab and other results sent back to clinician Encounter form generated and delivered to clinician Orders written and marked on encounter form Finance/Personnel collects encounter forms and reconciles with computer entries 86 generated in batches each evening for the next day's appointments (or the same morning in Women's Health). For walk-ins, the encounter form is generated as soon as the record is pulled and the patient sees the triage nurse and is assigned an appointment. Step 3: The medical record, with the encounter form attached to the front, is delivered to the clinician before the patient arrives. Walk-ins may carry their medical record and encounter form to the clinician. Step 4: The clinician (a physician or nurse practitioner) sees the patient and then marks the type of visit, any procedures performed (e.g., injections), orders for lab tests, x-ray, etc., and follow-up instructions on the encounter form. The diagnosis is noted in the medical record, but should be marked on the encounter form as well. Step 5: The clinician separates the copies of the encounter form. If the patient needs laboratory tests or x-rays, he/she takes the third (green) copy to the lab or x-ray. The original (top) copy stays with the medical record, which is returned to the Medical Records 87 department, and the last copy belongs to the student. Step 6; The pink (second) copy of the encounter form stays in the clinic and it is the clinic's responsibility to enter codes from the "injectables," "procedures," and "summary" sections on the encounter form into the computer. Clerks enter this information (termed "activity codes") from the encounter forms in batches and initial the forms to indicate who is responsible for any errors in data entry. Step 7: Green copies of the encounter forms are used by the lab or radiology to enter codes for any lab tests or x-rays into the computer. The lab also generates a new form— a lab report form— for each lab test (see Figure 3.4). This form is used to report test results back to the clinic. The top portion of the form includes the same computer-printed information as the encounter form. 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O U O ■ > - — a v < a a*g « « — w S t . o a o < < a u u u O o ^ in o in r r - l O f N r l A ' O ' O ’O 'O l T l o o o o o o I I ' « ■ ? 2 -2 b b U C k 4 — & a o q «> -■! c 8 « c-25 « -j — o ac — z at i I 8a “ O OC 6) b < a 89 reconcile the handwritten information on the forms with the activity codes entered in the computer by these same departments. Errors are brought to the attention of the department involved for correction (see Figure 3.5). Copies of the encounter forms are later returned to the departments for filing. Step 9: The accounting department also generates reports. These include: edit reports indicating the number of errors ("follow-ups1 ') in each department, monthly reports including records of all visits, and follow-up reports showing monthly average errors for each clinic and for SHS as a whole (see Figure 3.6). Step 10: Medical records clerks enter diagnostic data from the charts and/or the encounter form into the computer and generate reports such as census information and studies of treatment of selected diagnoses. In summary, SHS employees perform several distinct tasks related to the computer system: (1) scheduling of appointments and generating encounter forms, (2) entry of activity codes into the computer, (3) reconciliation between encounter form and data entered in the computer, and (4) generation of reports. In addition, the Lab now 90 Figure 3.5 Detail Error Report AMS A/R DATA ENTRY DETAIL ERROR REPORT PC J WHS SPEC LAB X-RAY WORK OF _ PAGE / OF [ INCIDENT T T ERROR / DISCREPANCY |CORRECTED| DATE I BY | n ........ rr I ' M * ? r m v mm. \* t\ ~ 4 i< j/> (muifc— jf' U L 5 b t m J p K Z f c T A b M b ' t x . M $ r \ ( h i k L > TkT 4 0 O f m i t i L i X H h M h J b - ( V > j j f u t - d m j - y f ¥ |Total number of incidents entered = |Number with errors/discrepancies = i |Percent with errors/ discrepancies = Min I Prepared by Corrected by A U L m m w u \ Date Returned 91 Figure 3.6 Monthly Follow-up Report AMS A/R DATA ENTRY TOT ENT = Total number of incidents entered| FOLLOW-UP REPORT # F/U = Number needing follow-up | % F/U = Percent needing follow-up | JUL 1 THROUGH JUL 29 jPRIMARYCARE | WOMEN'SHEALTH I I SPECIALTY 1 ALL CLINICS | | D A Y ( D A T E | TOT 1 " % 1 TO7 1 t | * I I TOT 1 o 1 ---1 % 1 T O T | A | * I 1 | E N T | F / U F/U 1 fnt |F/U | F /U | | E NT 1 F / U | F/U | ENT I F/U | F /U | | F R I | JUL1 1 * 5 “1--- j 1 3 in 1 3 0 | 0 | 0 % | | 4 9| 1 1 | ---1 2 2 % | 1 5 4| 2 4 | 1 6 % | | HOLIDAY | JULA 1 i 1 1 1 I I 1 1 1 | TUE i JUL5 1 8 1 i 1 n 1 4 8 1 1 2 % | | 8 9 1 < 1 % | 2 1 8I 3 | 1 % | | WED | JUL6 | 8 4 i 9 in 1 6 8 | 0 i 0 % | | 4 9 1 7 1 1 4 % | 1 9 1 I < 5 I 8 % | | THU j JUL7 | 1 0 0 i n in 1 5 1 | 8 0 % | | 2 1 7 3 3% | 1 1 8 I I s 1 1 0 % | | F R I | JUL8 I 1 0 2 i 7 n 1 4 2 1 1 j 2% j | 4 8 1 8 1 0 % | 1 9 2 I 8 1 n | j MON t JUL1 1 | 1 0 9 I 1 3 1 2 1 1 5 3 | 4 1 8 % | | 2 0I 3 j 1 5 % | 1 B21 2 0 | 1 1 % 1 | TUE | JUL1 2 I 7 8 1 7 9 % I 3 4 j 1 3 % | | 5 2 1 6 3 1% | 1 6 21 2 4 | 1 5 % | | WED | JUL1 3 I 9 1 1 4 4% 1 4 5 j 2 | 4 % | | 6 5 1 2 1 3 % | 2 0 1 i 8 1 4 % | | THU 1 JUL1 4 j 9 8 j 2 2 2 2% 1 5 1 j 1 j 2 % | | 1 9I 2 j 1 1 % | 1 6 81 2 5 I 1 5 % | | F R I | JUL1 5 | 8 9 | 1 n I 3 6 | 3 j 1 2 % | | 4 5 1 8 0 % | 1 6 0 1 4 1 3 % | | MON | JUL1 8 | 9 1 1 9 9% I 5 2 | 2 I 4% | | 1 5 1 8 I 0 % | 1 6 4 1 ' I 1 7 % | | TUE f JUL1 9 I 7 6 1 4 5% i 4 4 I 3 8 | 8 6% | | 5 21 5 | 1 0 % | 1 7 2 1 4 7 i 2 7% | | WED | JUL2 0 j 6 4 1 7 3 % | 4 7 | 8 I 0 % | | 7 21 2 | 3 % | 1 8 3 1 4 I 2 % | | THU j JUL2 1 j 9 2 j 1 n I 3 5 | 2 I 6 % | | 5 1 1 1 2 2 4% | 1 7 8 1 1 5 I 8 % | | F R I | JUL2 2 j 8 9 I o 0% I 3 2 | 0 | 0 % | | 3 2 1 8 1 0 % | 1 5 3| 0 | 0% | j MON j J U L2 5 j 1 1 0 I 3 2 2 0% I 3 6 | 1 j 3 % | | 4 81 3 | 6 % | 1 9 4I 2 6 | 1 3 % | | TUE | J U L2 6 [ 7 3 ! 3 4% I 5 1 j 8 I 0 % | | 7 0 1 8 0 % | 1 9 4I 3 | 2 % | | WED | JUL2 1 | 8 2 I 1 6 2 0% I 2 5 | 2 1 8 % | | 3 5j 7 | 2 0% | 1 4 2I 2 5 | 1 8 % | j THU | J U L2 8 I 7 1 I 3 3 3 2% 1 4 7 1 2 1 5 % | | 3 5 1 I D 1 2 9% | 1 4 8 I 3 5 I 2 4 % | | F R I j JUL 1 2 9 | 9 4 1 | 3 0 I 3 2% 1 3 7 | 1 1 3 j 1 8% | | I I 3 9 1 ’ 1 1 1 3% | I no | 3 4 | I I 2 0% | AVERAGE PERCENT ERROR 10.38% FOR THE MONTH OF JULY 92 must generate lab report forms, rather than simply returning lab results on the lab order forms that were formerly filled out by clinical assistants. With the exception of the scheduling of student appointments, none of these tasks has a paper-and-pencil counterpart. Rather, they are new tasks accompanying the computer system, necessary to create the information provided by the computer. This study focused on employee reactions to these changes in their jobs, the ways in which they negotiated the new work arrangements, and the possible outcomes for the organization as a whole. Study Design Both quantitative and qualitative methods contributed important information to this study. In addition, archival data provided by SHS administrators supplied data in several areas. Research strategies for each method are outlined below. The quantitative variables collected on the questionnaires are also described in detail in the Measurement section later in this chapter. Quantitative Methods The research design included three waves of questionnaires distributed to all organization employees. The first questionnaire was completed several months before the new information system was implemented. The 93 second wave took place during the implementation process, several months after implementation had begun; not all departments had used the system at this point in time. The third wave of questionnaires was administered approximately nine months later. At that time, although the computer system had not been implemented in all departments, a number of departments had been using the system for up to one year. Questionnaires were distributed at staff meetings to all employees (including administrators), with the exception of the Dental Clinic, part-time student workers, and consulting physicians from the medical center. Respondents were requested to put their name on their response to allow matching of responses for each employee across time periods. Employees sealed and mailed completed questionnaires to a university department outside of the medical center. Confidentiality of responses was guaranteed and SHS administrators and personnel had no access to completed questionnaires. Researchers followed up non-respondents by letter or personal telephone call over a period of approximately 2 to 4 months following the distribution of the questionnaires to ensure a high response rate. 94 Qualitative Methods Qualitative research methods also provided essential information to supplement and extend the analysis of the questionnaire responses. As noted by Blumer (1969, p. 38), the empirical social world consists of ongoing group I life, and "one has to get close to this life to know what is going on in it." A small number of participants who are acute observers "is more valuable many times over than any representative sample" (Blumer, 1969, p. 41). Thus, in addition to the questionnaires, researchers interviewed employees in different occupations and departments, questioning them about their own and their co-workers’ responses to the new computer system. The first set of interviews took place prior to system implementation; the second set several months after implementation had begun; the third set following completion of the last questionnaire, at a time when several departments were experienced in the use of the computer system. Researchers also observed individuals using both the previous paper and pencil system and the computer system in the course of their daily work. Both the interviews and observation of daily work helped validate and interpret the quantitative analyses of questionnaire data. 95 Graduate students participating in the research project conducted the first series of interviews during the months immediately preceeding implementation of the computer system. SHS personnel were planning for actual implementation and discussed specific expectations regarding the system. The interviewers met with all SHS administrators and supervisors, the computer consultant, and a number of employees in different SHS departments. The interviewers' goals included (1) learning about current SHS operations, (2) identifying employee expectations— both positive and negative— for the computer system, (3) noting changes that might be required by the computer system, and (4) making recommendations concerning potential problems in implementation. The interviewers also observed the ongoing operations of SHS. A second series of interviews took place during the implementation process. Computerization of Primary Care scheduling had been implemented about two months prior to the interviews. Women's Health and Specialty Clinics, on the other hand, had just begun to use the computer 1-2 weeks before the interviews were conducted. The Laboratory was anticipating computerization, while other departments were not yet involved in the process. 96 The second set of interviews addressed the following questions: (1) actual job content, (2) involvement with the information system, (3) job changes related to the system, and (4) opinions regarding the implementation process. The interviews were open-ended and lasted approximately 1/2 to 1 hour for each participant. Respondents discussed both positive and negative impacts of the system, general job changes, attitudes about the system, how easy it was to learn, and the implementation process in general. The third set of interviews, conducted approximately 18 months after the second set, addressed similar questions. At that time, the researchers also observed SHS operations as employees used the computer system, and questioned them regarding how their jobs had changed since implementation. In addition, these interviews focused on both individual and departmental reactions to the system— especially the relationships between departments. The interviews involved members of all occupational groups and departments and approximately three days were spent observing SHS operations and talking to respondents. Archival Data To supplement the information collected through questionnaires and interviews, archival data was also 97 available. Data included rosters of SHS employees for each time period showing department assignment and job title. The computer system coordinator/trainer also coded her perceptions of the amount of involvement she had with each employee concerning the computer system. In addition, SHS personnel provided statistics related to the impacts of the computer system on SHS work. The Sample As described above, researchers collected questionnaires from SHS employees three times during the study period. Table 3.2 details the response rate for each questionnaire. At Time 1, questionnaires were distributed to 111 employees. One hundred and four of these employees returned the questionnaire, for a response rate of 94 percent. At Time 2, 81 percent of the 116 eligible employees returned the questionnaire, for a total sample of 94 responses. At Time 3, 106 of 119 employees responded, for a response rate of 89 percent. Eighty-eight of the original 111 employees were still employed at SHS at Time 3. Seventy-four of these employees (84%) completed both the Time 1 and Time 3 questionnaires. All results reported in the present study, unless otherwise indicated, are based upon these 74 respondents. 98 Table 3.2 Survev Response Rates for the Three Time Periods Total Time Period Employees Total Number Responses Percent Time 1 111 104 94 % Time 2 116 94 81 %a Time 3 119 106 89 % Lonaitudinal Analvsis (Respondents employed at SHS throughout study period) Time 1/Time 2/Time 3 S5*3 (Received all three questionnaires) 63 74 %a Time 1/Time 3 88 (Received first and third questionnaires) 74 84 % a Time 2 questionnaires were administered during the summer quarter, making follow-up of respondents more difficult and resulting in a lower response rate. k Three employees on leave when the Time were administered are not included. 2 questionnaires 99 Measurement Data for the quantitative analyses were collected using the self-administered questionnaires described above, supplemented by archival information. Table 3.3 details the demographic information for the sample. Table 3.4 lists the questionnaire items and archival information as well as the time period when each was collected and the measurement scale used. Each of these measures is described in greater detail below. The present study is part of a larger research project investigating additional impacts of computer implementation. Thus, in addition to the items listed on Table 3.4, items designed for other parts of the research project were included on the questionnaires. None of the items on the Time 2 questionnaire was used in the present study. The Time 1 and Time 3 measures used in the present study are described in detail below. Sample copies of each questionnaire are provided in the Appendix. Measures of Individual Attitudes toward Computer System SHS employees responded to a series of questions designed to predict their attitudes toward the computer system at both Time 1 and Time 3. The next sections describe the attitude variables as well as the measures used as independent variables predicting computer 100 Table 3.3 Democrraohic Information for rime 1-Time 3 Respondents3 Respondents at Variable Time 1 and Time 3 (N=74) Mean Age 39.9 years Sex Male: 9 % Female: 91 Full or Part-time Full-time: 87 % Part-time: 13 Highest Level of Education High School: 11 % Some College: 30 College Grad: 19 Grad School: 11 Master's: 16 Ph.D. or M.D. 14 Mean Years in Health Field 12.6 years Mean Years at SHS 7.1 years Level of Computer Experience • • l=None 34 % 2=Using reports or information produced by computer 12 3=Entering data by using a terminal 19 4=Doing word processing on a terminal or computer 24 5=Using other applications (databases, statistics , etc.) 8 6=Programming/repairing 3 Continued 101 Table 3.3 continued Demographic Information for Time 1-Time 3 Respondentsa Variable Respondents at Time 1 and Time 3 Occupation Number Percent Administrators 6 8 % MDs 7 10 RNs 14 19 Pharmacists*3 2 3 Other Medical 20 27 Office/Clerical 25 34 Department Director’s Office 3 4 % Finance/Personnel 8 11 Insurance 3 4 Primary Care 18 24 Women’s Health 9 12 Specialty Clinics 5 7 Medical Records 8 11 Laboratory 6 8 Health Education 5 7 Radiology 2 3 Otherc 7 9 a Data from Time 1 survey. k Pharmacists were excluded from analyses because (1) there were too few pharmacists to aggregate, and (2) the pharmacy computer applications had not yet been implemented by Time 3. c Includes Immunization/Allergy (2), Pharmacy (2), Social Services (2), Athletic Medicine (1) , and Automation (0). 102 Table 3.4 Variables Analyzed in this Study Variable Attitudes toward the Computer System Scale System Worth Time/Effort to Use (Q) (Tl) System Worth Time/Effort to Use (Q) (T3) Time 3 Combined Attitude Scale Toward Computer (T3) 7-point scale: l=strongly disagree, 7=strongly agree 7-point scale: l=*strongly disagree, 7=strongly agree Factor Scores See Table 3.6 for items Predictors of Individual Attitudes 4 Occupation (Q) (Tl) (T3) (Job Title, Education) Admin, MD, RN, Other Medical, Office/Clerical 5 , 6 Department (Q) (A) (Tl) (T3) SHS Departments MBTI Cognitive Style (Q) (Tl) Computer Experience (Q) (Tl) (T3) 8. Age (Q) (Tl) (T3) 4-point scale: l=strong thinking type 4=strong feeling type Level of experience (Table 3.3) x years Age in years Participation in Implementation Process 9. Interaction with Trainer (A) (T3) 10. Relations with Computer Staff (Q) (T3) 11. Knowledge/Involvement (Q) (T3) 12. Work Group Communication (Q) (T3) 13. Organizational Policies (Q) (T3) 3-point scale: 0=no involvement l=initial training only 2 - ongoing interaction Additive Scale See Table 3.7 for items Additive Scale See Table 3.7 for items Factor Scores See Table 3.8 for items Factor Scores See Table 3.8 for items Continued 103 Table 3.4 Continued Variable Scale Use of Computer System 14. Expected/Actual Use*5 (Q) (Tl) (T3) 6-point scale: 0=no use l=never use terminals 2=use terminals once a week 3=use terminals once a day 4=use terminals several times a day 5=use terminals most of the day Changes in Departmental Boundaries Perceived Changes in: 15. Information Exchange Between Departments (Q) (T3) 16. Understanding Work of Other Departments (Q) (T3) 7-point scale: l=significantly increased 7=significantly decreased (Reversed for analysis) 7-point scale: l=significantly increased 7=significantly decreased (Reversed for analysis) a Time 2 questionnaire items included Attitude toward Computer System and Expected/Actual Computer Use. k Actual use measured at Time 3. Sources of Information: Q=Questionnaire, A=Archival. Tl=Time 1, T3=Time 3 104 attitudes. Table 3.5 presents the zero-order correlations among the quantitative variables used to predict attitudes, as well as the mean and standard deviation for each variable. The following sections and tables contain additional detailed information for each of the measures. System Worth Time/Effort. One purpose of this study was to address the issue of change in individual beliefs or attitudes. Attitudes toward the computer system were measured at all three time periods by asking respondents to indicate their level of agreement (on a 7-point scale ranging from "l=strongly disagree" to "7=strongly agree") i with the following question: "The new SHS information system is worth the time and effort required to use it" (Aydin, 1987; Ischar & Aydin, 1988; Schultz & Slevin, 1975). This attitude item will be referred to as "System Worth Time/Effort" (Variable 1^. Time 3 Combined Attitude Scale. Survey participants indicated their attitude toward the computer system on the same single variable ("System Worth Time/Effort" above) at all three time periods. Responses at Time 3 (Variable 2 ) were regressed on responses to the same item at Time 1. Results indicated that Time 1 attitudes accounted for 21 percent of the variance in Time 3 attitudes (F (1, 65) = 17.27, p = .0001). The residuals Table 3.5 Attitude Change Model; Correlation Matrix Among Variables for Time 1/Time 3 Respondents Variable 1 2 3 6 7 8 9 10 11 12 13 14 1 Tl-System Worth — .46** .29* .01 .07 -.13 .10 .39** .45** .26* .08 .19 Time/Effort 2 T3-System Worth — .76**--.04 .07 o o • .10 .35** .25* .20 -.29* .16 Time/Effort 3 T3-Combined Attitude Scale -.12 .15 .17 .17 .20 .13 .21 -.39** .03 6 Cognitive Style — .13 -.12 .01 -.02 .01 - -.06 -.06 .17 7 Computer Experience — -.24* .20* -.04 .16 .39** .04 .15 8 Age — -.08 .11 ■ -.01 • -.16 -.28 -.10 9 Interaction with Trainer — .31** .38** .44**-.06 .63** 10 Relations with Computer Staff — .59** .10 -.15 .36** 11 Knowledge/Involvement — .38**-.27* .41** 12 Work Group Communication — .16 .37** 13 Organizational Policies — .07 14 Computer Use Scale — Mean 6.03 5.28 0.00 2.76 4.88 39.9 .88 5.11 4.06 -.08 -.05 2.35 S.D. 1.06 1.63 1.00 1.15 6.45 11.6 .86 1.27 1.69 1.01 1.02 1.84 Note: Variables 4 and 5 use nominal categories, making correlations inappropriate. n=74 *£<.05 **£<.01. 105 106 from this regression analysis represent the Time 3 attitude variance not accounted for by Time 1 attitudes. These residuals were included in a factor analysis along with two additional variables collected at Time 3: ratings of the extent the system changed the (1) "ease of performing our department’s work" and the (2) "quality of our department's work." Results for a principal components analysis indicated that the three variables constituted a single factor, termed the Time 3 Combined Attitude Scale Toward the Computer (Variable 3). Factor scores, computed via the regression method, on this single factor were used to assess respondents' perceptions of the computer system at Time 3. Table 3.6 details the results of the factor analysis and statistics for each of the three variables used to construct the Time 3 Combined Scale. Predictors of Individual Attitudes The following sections describe the variables used to predict the attitude measures detailed above. Occupational and departmental social worlds. Individuals were classified as members of both occupational and departmental social worlds. Occupational identification (Variable 4) was determined by job title and education at Time 1. The five occupational categories included administrators, physicians, nurses, 107 Table 3 .6 Factor Matrix and Descriptive Statistics for Time 3 Combined Attitude Scale Toward Computer Factor Loadings Statistics Mean S.D. Time 3 Combined Attitude Scale Toward Computer (Variable 3) System has changed: a ease of department's work quality of department work .91 .92 4.63 4.97 1.65 1.45 Agreement that system is worth time/effort required to use it: b Residuals from regression of Time 3 on Time 1 .71 .03 1.50 Eigenvalue Percent variance 2.18 73% Alpha if variables added .81 n=62. a Original scale:l=significantly increased, 2=increased, 3=slightly increased, 4=no change/no opinion, 5=slightly decreased, 6=decreased, 7=significantly decreased. Scale reversed for analysis. b Scale:l=strongly disagree, 2=disagree, 3=slightly disagree, 4=neutral, 5=slightly agree, 6=agree, 7=strongly agree. 108 other medical workers (e.g., clinical assistants, laboratory technologists), and office/clerical workers (e.g., clerks, scheduling assistants, administrative assistants). Departmental membership was determined by rosters provided by SHS administrators at the time of the survey and confirmed by respondents on the questionnaire. See Table 3.3 above for frequency distributions for both occupational and departmental categories. In addition to the five occupational categories listed above, a dichotomous variable divided employees into medical and non-medical occupations. Research has shown that medical and non-medical social worlds differ on variables related to the adoption of innovations, underscoring the importance of considering the two groups separately (Kimberly & Evanisko, 1981). The medical occupations included physicians, nurses, and other medical employees. Non-medical employees included administrators and office/clerical workers. Individual difference variables. Cognitive style, computer experience, and age were also included on the Time 1 questionnaire (computer experience and age were requested again at Time 3). The abbreviated version (Form AV) of the Myers-Briggs Type Indicator (MBTI) was attached to the Time 1 questionnaire as a measure of cognitive style (Variable 6) (Aydin, 1987, Ischar & 109 Aydin, 1988; Kilmann & Mitroff, 1976; Mason & Mitroff; 1973; Zmud, 1978). (See Myers and McCaulley (1985) for reliability and validity information.) The short form of the MBTI asks respondents a series of questions in which they select between two answers, indicating "Which Answer Comes Closer to Telling How You Usually Feel or Act." For example, respondents are asked whether they usually "value sentiment more than logic or value logic more than sentiment." They are also asked to select "Which word in each pair appeals to you more?" Sample pairs include: "convincing/touching," "analyze/sympathize," and "foresight/compassion." Form AV of the Myers-Briggs Type Indicator (MBTI) predicts best when type preferences are clear. It can be used to classify individuals into categories according to type, but use of the actual scores from the abbreviated version is not recommended (Myers & McCaulley, 1985). Thus, rather than using the scores themselves, the thinking/feeling scale of the MBTI was used to form a 4-point ordinal scale: (1) strong thinking type (thinking score higher with a difference between thinking and feeling categories of more than five points), (2) moderate thinking type (thinking score higher than feeling score, but with a difference of five points or less), (3) moderate feeling type (feeling score higher 110 than thinking score, but with a difference of five points or less), and (4) strong feeling type (feeling score higher with a difference of more than five points between thinking and feeling). Thus, a high score on this 4-point ordinal scale indicated that the individual was a strong feeling type, while a lower score indicated a strong thinking type. Respondents indicated their highest level of experience with computers by selecting among response categories ranging from "l=none" for no experience to "6=programming/repairing" for the highest level of experience. (See Table 3.3 above for a frequency distribution.) They also indicated the number of years with the highest level of experience. A computer experience scale (Variable 7) was calculated by multiplying the number of years by the code for the highest level of experience. Thus, an individual with 6 years of programming experience would receive a score of 36 (i.e., 6 years x 6) while an individual indicating one year of experience at "3=entering data by using a terminal" would receive a score of 3 (i.e., 1 year x 3). Age (Variable 8) was measured by asking respondents to indicate their age in years on the questionnaire. Ill Participation in the Implementation Process The Time 3 questionnaire included several indicators of the respondent's participation in the computer implementation process. Archival information from the system coordinator/trainer supplemented this information, as described below. Participation in the implementation process was used to predict both attitudes toward the computer system and changes in departmental boundaries (see below). Interaction with Trainer. The computer system coordinator/trainer supplied information on interaction by rating her involvement with each employee. Involvement was rated on a scale of 0 to 2 with "0=no involvement," "l=initial training only," and "2=ongoing interaction and consultation" fVariable 9^. This variable was included both as an independent indicator of involvement and to establish external validity for the subjective information on involvement supplied by respondents on the questionnaires. Relations with Computer Staff and Knowledcre/Involvement Factors. The first questionnaire items concerning the implementation process addressed relations with the computer staff and knowledge and/or j involvement in computer implementation. These items were ! t developed by Ives, Olson, and Baroudi (1983) as part of 112 their User Information Satisfaction Scale. The scale acted as a subjective measure of system success, using a semantic differential technique in which two pairs of adjectives were provided for each item. The positive and negative adjectives were at opposite ends of a 7-point scale and respondents rated each item on the resulting continuum. See Ives, Olson, & Baroudi (1983) for information on the reliability and validity of the items. | I i Factor analysis results from the larger SHS research study using the complete User Information Satisfaction scale produced five factors closely related to those proposed by Ives et al. (1983). The five factors included: Information Product, Relations with Computer Staff, Computer Services, Knowledge or Involvement, and Management/Supervisor Support. The two factors relevant to involvement in the implementation process (Relations with Computer Staff— Variable 10. and Knowledge/ Involvement— Variable 11) were included in the present study as predictors of individuals' attitudes toward the computer system. Table 3.7 lists the items along with the factor loadings, means, standard deviations, and Cronbach's alpha for the items when additive scales were computed. Additive scores were used in the analysis to allow the substitution of mean scores for missing values, 113 Table 3.7 Factor Matrix and Descriptive Statistics for Relations with Computer Staff and Knowledge/Involvement Factor Loadinosa Variables 2 4 Statistics Mean S.D. Relations with Commuter Staff (Variable 10) 5.11 1.27 Relationships w. system analysts/trainers: dissonant/harmonious .84 .07 bad/good .85 .02 5.21 5.20 1.37 1.38 Attitude of system analysts/trainers: belligerent/cooperative .84 .23 negative/positive .86 .25 5. 09 5.11 1.58 1.47 Communication with analysts/trainers: dissonant/harmonious .79 .16 destructive/productive .79 .12 5.16 5.00 1.40 1.40 Knowledae/Involvement (Variable 11) 4.06 1. 69 Understanding of the system: insufficient/sufficient .23 .88 incomplete/complete .17 .84 4.16 3 .78 1.73 1.51 Feeling of participation in implementation: negative/positive .23 .70 insufficient/sufficient .17 .76 4.12 4.12 2 . 00 1.94 Eigenvalue 4.01 2.08 Percent variance 13% 7% Alpha if variables added .95 .91 Note: Factor statistics calculated using all Time 3 respondents responding to the items (n=65). Factor analysis with Time 1/Time 3 respondents only showed similar factor loadings. Means and standard deviations based on Time 1/Time 3 respondents. Additive scales were used in the analysis. a Additional factors were not relevant to the present study. Original scale: l=most positive response, 7=most negative response. Scale reversed for analysis. 114 thus avoiding lost cases from an already reduced sample because of missing information on one or two items. Work Group Communication and Organizational Policies Factors. Employees also supplied information on two other aspects of participation in the implementation process: Work Group Communication (Variable 12) and Organizational Policies (Variable 13^. See Table 3.8. Work Group Communication items measured the extent to which the work group supported and discussed the development of new computer procedures (Rice, 1989). Organizational Policy items measured organizational approaches to learning and experimenting with new work procedures. Items measuring both concepts were developed by Taylor and Bowers (1972) as part of a standardized measure and have been used to assess responses to computerization in previous studies (Johnson & Rice, 1987; Rice, 1989). Most respondents completed all of the questions in this section, eliminating the problem of missing information. Thus, factor scores, computed via the regression method for varimax-iterated principal components, were used. Use of the Computer System Computer use was also hypothesized as a predictor of both attitudes toward the computer system and perceptions of changes in boundaries between departments. At all 115 Table 3.8 Factor Matrix and Descriptive Statistics for Work Group Communication and Organizational Policies Variables Factor 1 Loadings 2 Statistics Mean S.D. Work Grouo Communication (Variable 12) 0. 00 1.00 Praise for new procedures from supervisor .82 -.24 3.59 1.70 from co-workers .85 -.14 3.48 1. 58 Talk about new procedures with supervisor .86 -.03 3 .85 1.88 with co-workers .87 -.12 3.81 1. 82 Develop new procedures .72 -.26 3.32 1.87 Attend regular meetings .48 -.42 2.77 1. 93 Organizational Policies (Variable 13) 0.00 1. 00 Policies discourage new procedures -.12 .74 3.42 1.67 No time to learn/develop new procedures -.06 .73 4.58 1.91 Others do not encourage me to experiment -.22 .76 3.95 1.77 Eigenvalue 4.25 1.43 Percent variance 47% 16% Alpha if variables added .88 .61 Note: Factor statistics calculated using all Time 3 respondents responding to the items (n=73). Factor analysis with Time 1/Time 3 respondents only showed similar factor loadings. Factor scores used in analysis. Scale: l=strongly disagree, 2=disagree, 3=slightly disagree, 4=neutral, 5=slightly agree, 6=agree, 7=strongly agree. 116 three time periods, respondents indicated whether they expected to use (at Time 1), or had used, the information system in any way, responding either "yes'1 or "no." In addition, they specified the purposes for which they used the system, including "use the system's terminals," "provide information to it," "use information provided by it," and "use reports provided by it." Response i categories for each of the four types of use included: "l=never," "2=once a week," "3=once a day," "4=several times a day," and "5=most of the day." Since most employees were expected both to provide information for the system and to use information and reports, the level of terminal use distinguished system users from non-users for hypothesis testing. Two measures were created from the Time 3 responses on the questions described above. A dichotomous variable, "user/non-user" included all respondents who used the terminals at least "once a week" as users. Non-users never used the system in any way, or, if they did provide information or use information or reports, never used the terminals. A 6-point ordinal computer use scale (Variable 14) was also created. For this scale a "0" indicated that the respondent had never used the system in any wav. For respondents who indicated that they had used the system 117 in some way, their level of terminal use was used to indicate computer use: "l^ever,1 1 "2=once a week," "3=once a day," "4=several times a day," and "5=most of the day." Changes in Departmental Boundaries In addition to predicting attitudes toward the computer system, the present study also addresses perceived changes in the openness of boundaries between departments. The dependent variables used to measure this concepts are described below. Table 3.9 includes all variables used in the analysis of changes in the openness of departmental boundaries in the organization. Several variables predict both attitudes and perceptions of changes in departmental boundaries and are, therefore, included in both Table 3.5 and Table 3.9. Respondents indicated their perceptions of changes in the openness of departmental boundaries on the Time 3 questionnaire. Each employee reviewed a list of all SHS departments and rated the "extent to which understanding or exchanging information with each of the following SHS departments has increased or decreased" because of the system. The scale ranged from 1 to 7 ranging, indicating "significantly increased" to "significantly decreased." (Scale values were reversed for analysis so that a higher value indicated a more positive response.) Respondents 118 Table 3.9 Changes in Openness of Department Boundaries: Correlation Matrix Among Variables Time 1/Time 3 Respondents Variable 9 10 11 12 13 14 15 16 9 Interaction - .31** .38** . with Trainer 44**-.06 .63** .45** .48** 10 Relations with - .59** . Computer Staff 10 -.15 .36** .43** .40** 11 Knowledge/Involvement - 38**-.28** .41** .41** . 35** 12 Work Group Communication . 16 .37** .54** .42** 13 Organizational Policies - .07 -.13 -.14 14 Computer Use Scale .29* .33** 15 Change in Information Exchange - . 89** 16 Change in Understanding Work - Mean .88 5.11 4.06 -. S.D. .86 1.27 1.69 1. 08 -.05 01 1.02 2.35 4.54 4 1.84 .70 .51 .66 n=74. *P<.05. **E<.01. Note: Variables 1-8 used for Attitude Change Model. 119 were guided by the following definitions provided on the questionnaire: "By understanding. we mean understanding of the work each department does (including problems, procedures, decisions, information needed, etc.)* By exchanging information, we mean any type of information exchanged in any way (such as from the computer, in person, by telephone, memos, meetings, etc.)" ! These questions created two measures of change (information exchange and understanding) for each department, excluding the respondent's own department. The next step was to create two scores for each respondent: an overall (1) "average increase in information exchange" score (Variable 15), and an overall j ! (2) "average increase in knowledge of other departments' work" score (Variable 16). These scores represented each respondent's changing relationships with all SHS departments outside their own. Analysis Methods Tables 3.10 and 3.11 list the study hypotheses advanced in Chapter 2. Table 3.10 includes the hypotheses concerned with the prediction of attitudes and attitude change. Table 3.11 details the hypotheses designed to test changes in the openness of departmental i boundaries. Several of the study hypotheses predict I causal relationships between variables measured j 120 Table 3.10 Attitude Chancre Model: Hypotheses and Methods of Analysis Hypotheses/Variables Analysis Occupational Identification and Departmental Membership as Predictors of Attitudes toward Computer System Hypothesis 1: Membership in the same social world will predict similar attitudes toward the computer system. Hypothesis la: Respondents in the same occupational social worlds will have similar attitudes toward the computer system (Time 1, 3). Independent: Occupation Dependent: Tl-System Worth Time/Effort T3-Combined Attitude Scale ANOVA/ Duncan/ t-test/ Interviews Hypothesis lb: Respondents in the same departmental social worlds will have similar attitudes toward the computer system (Time 1, 3) . Independent: Department Dependent: Tl-System Worth Time/Effort T3-Combined Attitude Scale ANOVA/ Duncan/ Interviews Individual Differences as Predictors of Attitudes toward the Computer System Hypothesis 2: Individual differences will attitudes toward the computer system. predict Hypothesis 2a: Individuals with a stronaer "thinking type" cognitive style will have more positive attitudes toward the computer system than individuals with a stronger "feeling type" cognitive style (Time 1). Independent: Cognitive Style Dependent: Tl-System Worth Time/Effort Regression Continued 121 Table 3.10 continued Hypotheses/Variables Analysis Hypothesis 2b; Individuals with more computer experience will have more positive attitudes toward the computer system (Time 1). Independent: Computer Experience Regression Dependent: Tl-System Worth Time/Effort Hypothesis 2c: Younger employees will have more positive attitudes toward the computer system than older employees (Time 1). Independent: Age Regression Dependent: Tl-System Worth Time/Effort Participation in the Implementation Process as Predictor of Attitudes toward the Computer System Hypothesis 3: Participation in the implementation process will result in more positive attitudes toward the computer system (Time 3). Independent: Interaction with Trainer Relations with Computer Staff Knowledge/Invo1vement Work Group Communication Organizational Policies Dependent: T3-Combined Attitude Scale Computer Use and Task Changes as Predictors of Attitudes Toward the Computer System Hypothesis 4: Computer use will influence attitudes toward the computer system (Time 3). Independent: Computer Use Regression/ Dependent: T3-Combined Attitude Scale ANOVA/t-test Hypothesis 5: The introduction of an Archival Data/ integrated information system will result in Interviews task changes for workers in some departments. Hypothesis 6: Workers who perform tasks Archival Data/ formerly performed by another department Interviews/ will have more negative attitudes toward ANOVA the computer system (Time 3). Regression/ Interviews/ Archival Data 122 Table 3.11 Changes in Openness of Department: Boundaries: Hypotheses and Methods of Analysis Hypotheses/Variables Analysis Hypothesis 7; Participation in the implementation process will increase the openness of boundaries between departments. Hypothesis 7a: Employees who participate in the implementation process will perceive increased exchange of information between departments (Time 3). Independent: Interaction with Trainer Regression/ Relations with Computer Staff Interviews/ Knowledge/Involvement Archival Data/ Work Group Communication ANOVA Organizational Policies Dependent: Change in information exchange between departments Hypothesis 7b: Employees who participate in the implementation process will perceive increased understanding of the work of other departments (Time 3). Independent: Interaction with Trainer Regression/ Relations with Computer Staff Interviews/ Knowledge/Involvement Archival Data/ Work Group Communication ANOVA Organizational Policies Dependent: Change in understanding work of other departments Continued 123 Table 3.11 continued Hypotheses/Variables Analysis Hypothesis 8; Use of the computer system will increase the openness of boundaries between departments. Hypothesis 8a: Employees who use the computer system will perceive increased exchange of information between departments (Time 3). Independent: Computer use Regression/ Dependent: Change in information Interviews/ exchange between departments t-test Hypothesis 8b: Employees who use the computer system will perceive increased of the work of other departments (Time 3). Independent: Computer use Regression/ Dependent: Change in understanding Interviews/ work of other departments t-test 124 at different times during the study period. While the testing of causal relationships is not possible with cross-sectional data, such hypotheses are appropriate when, as in the present study, changes in attitudes or perceptions are measured over time. Both tables also indicate the independent and dependent variables used in hypothesis testing. Each of these variables has been described in detail above. The final column on the table lists the statistical procedures and/or research methods used to test each hypothesis. A probability level of p< .05 was used for all statistical tests. The statistical methods listed in the last column include analysis of variance (ANOVA), t-tests, Duncan multiple range tests, and regression analysis. 31-tests identify significant differences between the means of two groups of respondents, while ANOVA tests for differences between the means of more than two groups. A posteriori Duncan multiple range tests are performed after an ANOVA has indicated a significant difference between the means of three or more groups. Duncan a posteriori tests then show which pairs of groups have significantly different means. Finally, regression analysis indicates which independent variables are significant predictors of a specified dependent variable, as well as the proportion of variance in the dependent variable explained by the predictor (or independent) variables included in the analysis. Results of all analyses are detailed in Chapters 4 and 5. 126 Notes 1. The description of SHS operations draws upon material compiled by graduate students enrolled in a course on Office Automation and Management, advised by Dr. M. Lynne Markus. The first series of interviews was conducted by these students. The data and conclusions were compiled in a report prepared as part of course requirements and presented to SHS administrators. 127 Chapter 4 RESULTS FOR ATTITUDE CHANGE MODEL This chapter details the findings for Hypotheses 1 through 6 tracing the model of attitude formation and change (Figure 2.2). Results are based on findings from the Time 1 and Time 3 questionnaires as well as from the interviews, archival data, and observations of SHS employees at work. Chapter 6 discusses the implications of these findings. Occupations and Departments as Attitude Predictors A variety of different research methods provided information concerning the importance of both occupational identification and departmental membership as predictors of individual attitudes toward the computer system. First, several statistical techniques explored attitude change, using Time 1 and Time 3responses to the statement "the information system is worth the time and effort required to use it." Analyses were conducted by both occupation and department. To supplement this information, occupation and department were also examined as predictors of an additional variable, the Time 3 Combined Attitude Scale toward the computer described in Chapter 3. Finally, information from interviews and observation at SHS supplemented and clarified the statistical findings, suggesting answers to "how" and 128 "why" particular results occurred. The next three sections describe the results of these analyses. The following hypotheses were tested: Hypothesis la: Respondents in the same occupational social worlds will have similar attitudes toward the computer system. Hypothesis lb: Respondents in the same departmental social worlds will have similar attitudes toward the computer system. Chancres in Attitude Toward the Computer Occupation as predictor. Table 4.1 details changes in respondent attitudes toward the computer (System Worth Time/Effort) from Time 1 to Time 3. Respondents are grouped by occupational category and also by the more general categories of "medical" and "non-medical" professions. ANOVA results showed no significant differences between occupations at Time 1. Rather, members of all occupations shared very favorable expectations, agreeing or strongly agreeing that the system would be "worth the time and effort required to use it." By Time 3, however, the picture had changed. Figure 4.1 illustrates the statistical information from Table 4.1, showing changes in attitude by occupation. The sample as a whole showed a statistically significant 129 Table 4.1 Attitude Toward Computer System bv Occupation: Time 1/Time 3 Time Time 1 n Mean (S.D.) Period n Time 3 Mean (S.D.) Question: The system is worth the time and effort required to use it. Total 67 6.02 68 5.27 ** (1.09) (1.65) Occupation Administrators 6 6. 17 6 6.17 ns (0.64) (0.75) MDs 6 5.83 7 3.57 * (0.98) (2.07) RNS 13 5.77 14 4.93 ns (1.30) (1.77) Other Medical 17 5.94 16 5.31 * (1.20) (1.66) Office/Clerical 25 6.20 25 5. 68 ns (1.00) (1.28) ANOVA F (4,62) = .44 ns F (4,64) = 3.29 * Medical/Non-Medical Occupation Medical 36 5.86 37 4.84 ** (1.18) (1.85) Non-Medical 31 6.19 31 5.77 ns (.91) (1.20) t-test t (64) = 1.3 0 ns t (62) = 2.51 * Note: Includes respondents (excluding pharmacists) completing both Time 1 and Time 3 questionnaires. A posteriori Duncan multiple range tests compairing pairs of group means showed that MDs were significantly different from Other Medical, Office/Clerical, and Administrators at Time 3. * p <.05, ** p <.01. 1 =Strongly Disagree 4=Neutral 7=Strongly Agree Figure 4.1 Attitude Change by Occupation 5 - o 2 3 4 Time Period Occupation -o* Administrators -♦* MDs - a - RNs O ther Medical Office/Clerical Question: System Worth Time/Effort. 1 3 1 j attitude change (p< •01). Physicians showed the greatest decrease in attitude, while administrators continued to be enthusiastic about the system. The overall ANOVA results showed statistically significant differences between occupations at Time 3. A posteriori Duncan multiple range tests comparing pairs of group means showed that, at Time 3, physicians differed significantly from three of the other occupational categories (other medical, office/clerical, and administrators) in their attitudes toward the system. The dichotomous categories of medical/non-medical professions showed that the attitudes for medical, but not non-medical, occupations declined significantly between Time 1 and Time 3 (p< .01). (See Figure 4.2.) There was also a statistically significant difference between the Time 3 attitudes of medical and non-medical personnel, t(62)=2.51, p< .05), with the medical personnel having significantly more negative attitudes toward the computer system at Time 3. Overall, the analyses of occupation as a predictor of employee attitudes indicated more homogeneous attitudes both within and between occupational social worlds prior to computer system implementation. After experience with the computer system, differences between occupations appeared. In addition, however, the variance 1=Strongly Disagree 4=Neutral 7=Strongly Agree Figure 4.2 Attitude Change by Medical/Non-Medical Category 3 - 2 - 3 1 Time Period O ccupational Category -Q- Medical Non-Medical Question: System Worth Time/Effort. 133 within each occupational social world also increased between Time 1 and Time 3. The shared expectations for the system had given way to divergences of opinion both between and within social worlds as the computer implementation process was experienced and/or interpreted by different individuals and groups in different ways. In particular, medical and non-medical personnel reacted differently to the computer system. With the exception of administrators, attitudes of all groups toward the actual computer system were less positive than their expectations of the system before it existed. The changes were statistically significant for physicians and other medical personnel. The strongest contrast appeared between physicians, who showed the greatest decline in attitude, and administrators, the only group whose attitudes did not decline. These differences confirmed previous research findings concerning differences in adoption influences for technical (i.e., medical) and administrative (i.e., non-medical) innovations in hospitals (Kimberly & Evanisko, 1981). Department as predictor. Table 4.2 details changes in attitude toward the computer with respondents grouped by department rather than by occupation. It should be noted that, because there are more departments than 134 jTable 4.2 Attitude Toward Computer System by Department; Time 1/Time 3 i \ \ 1 j n Time Time 1 Mean (S.D.) Period l n Time 3 Mean (S.D.) i Question: The system is worth the time and effort required i to use it 1 • 1 Department3 iFinance/Personnel 8 6.00 8 6.13 ns 1 (1.07) (1.13) ■Primary Care 17 6.18 17 5.06 * i (1.19) (1.60) Women's Health 7 5.86 9 4.56 * (0.69) (2.01) Specialty Clinics 5 5.80 5 4.80 ns i (1.10) (2.39) Medical Records 8 6.25 8 5. 63 ns l 1 (1.04) (1.19) Laboratory 6 5.00 5 4.20 ns I (1.55) (2.05) Health Education 5 6. 60 5 6.40 ns j (0.55) (1.34) ANOVA F = 1.27 ns F = 1.52 ns j 1 1 (6,49) (6,50) Note: Includes departments with at least five employees j I responding to both Time 1 and Time 3 questionnaires. ! A posteriori Duncan multiple range tests comparing pairs ! of group means show the Lab significantly different , from Primary care and Health Education at Time 1. 1 | There were no significant differences between pairs j at Time 3. . i < * p <.05. j ;** p <.oi. 1 i i t 1 3 5 occupations, there is less chance that the differences between departments will be statistically significant. The results for departments resembled the results for occupations in that respondents in the different departments, for the most part, shared common positive expectations concerning the computer system at Time 1. The one exception, however, was the Lab. At Time 1, Duncan multiple range tests showed that the attitudes of Lab employees were significantly more negative than those of both Primary Care and Health Education personnel. At Time 3, decreases in employee enthusiasm for the system were evident (see Figure 4.3), and the variance between employees within each group was again greater at Time 3 than at Time 1. No individual department, however, showed a decline as extreme as that shown by physicians when respondents were grouped by occupation. Rather, the decrease was fairly similar for most departments, with statistically significant changes shown only by Primary Care and Women's Health. Only Finance/Personnel responded with a more positive evaluation of the system at Time 3 than at Time 1. Health Education, the only department in this analysis not using the computer system, showed only a slight decrease in enthusiasm for the system at Time 3. As at Time 1, the 1 =Strongly Disagree 4=Neutral 7=Strongly Agree Figure 4.3 Attitude Change by Department 7 6 5 4 3 2 1 3 1 Time Period Department -Q- Finance/Pers. Primary C are -* *■ W om en's Health -♦* Specialty Clin. Medical R ecords o Lab -a - Health Ed. Question: System Worth Time/Effort. 13 7 Lab was the most negative department, although the decrease was not as great as for other departments. Predictors of Time 3 Combined Attitude Scale As detailed in Chapter 3, the Time 3 Combined Attitude Scale was a factor score composed of (1) the residuals from a regression analysis in which attitude (System Worth Time/Effort) at Time 3 was regressed on the same attitude at Time 1, and (2) ratings of changes in "ease of performing department's work" and "quality of department's work" at Time 3. Occupation as predictor. Table 4.3 shows respondent scores on the Time 3 Combined Attitude Scale scale grouped by occupational category. ANOVA results indicated a significant difference between occupational groups on this scale. Significant differences between the medical and non-medical occupations were found as well. A posteriori Duncan tests showed significant differences (1) between physicians and office/clerical, administrators, and other medical; and (2) between nurses and administrators. Figure 4.4 illustrates these differences. Department as predictor. Table 4.4 shows the Time 3 Combined Attitude Scale results by department. ANOVA findings indicated significant differences between departments, as illustrated on Figure 4.5. A posteriori Table 4.3 Time 3 Combined Attitude Scale Toward Computer 138 Bv Occupation Time 3 Combined Attitude Scalea n Mean (S.D.) Total 61 .01 (0.91) Occupation Administrators 6 .77 (0.37) MDs 5 -1.19 (0.79) RNs 10 -.34 (1.19) Other Medical 15 -.14 (1.03) Office/Clerical 25 .25 (0.81) ANOVAb F (4,56) = 4.14 ** Medical/Non-Medical Occupation Medical 30 -.39 (1.09) Non-Medical 31 .35 (0.77) t-test t (52) = 3.05 ** a Factor scores included questions concerning system effects on ease and quality of work and Time 3-Time 1 residuals (see Table 3.6). b A posteriori Duncan multiple range tests comparing pairs of group means show that (1) MDs differed significantly from Office/Clerical and Administrators, and Other Medical, and (2) RNs differed significantly from Administrators. A ttitude Factor Score 139 Figure 4.4 Tim e 3 C om bined Attitude Scale toward Com puter by Occupation I O ccupation ■ Administrators B 3 I MDs H RNs E 3 Other Medical □ Office/Clerical 140 T a b le 4 .4 Time 3 Combined Attitude Scale Toward Computer Bv Department Time 3 Combined Attitude Scale3 n Mean (S.D.) Department*3 Finance/Personnel 8 .29 (0.80) Primary care 15 -.01 (1.12) Women's Health 7 -1.08 (0.92) Specialty Clinics 5 -.23 (1.47) Medical Records 8 .43 (0.56) Lab 5 -.52 (0.90) Health Education 5 .41 (0.44) ANOVA0 F (6,46) = 2.28 * a Factor Scores include questions concerning system effect on ease and quality of work and Time 3-Time l residuals for "System Worth Time/Effort" (see Table 3.6). b Includes departments with at least five employees responding to both Time 1 and Time 3 questionnaires. c A posteriori Duncan multiple range tests comparing pairs of group means show Women's Health to be significantly different from Primary Care, Finance/Personnel, Health Education, and Medical Records. * p <.05. ** p <-01. Attitude Factor Score Figure 4 .5 T im e 3 C om bined Attitude S cale tow ard C om puter by D ep artm e n t Department ■ F inance/P ers. E E 9 Primary Care H Women's Health E3 Specialty Clin. □ M edical R ecords ■ Lab H H ealth Ed. 142 Duncan tests showed Women's Health to be significantly different from Primary Care, Finance/Personnel, Health Education, and Medical Records. Interview Findings Interviews at all three time periods focused specifically on respondents' expectations for the computer system and, at Time 3, on their evaluation of the system in light of those expectations. The statistical analyses described above uncovered a number of statistically significant differences between occupations and departments in their reactions to the computer system. The Time 3 interviews, in particular, attempted to shed light on the "how" and "why" of these differences between groups. In addition, researchers were alert for other possible differences, as well as similarities, not indicated by the statistical analyses, but important to SHS personnel. Each of these issues is addressed below. Occupation as predictor. The most striking statistical finding based upon occupational categories was the difference between physicians' reactions to the system and those of other SHS employees in general, and administrators in particular. While physicians shared the generally high expectations for the system at Time 1, their opinions had changed dramatically by Time 3. 143 Five of the seven physicians responding to both the Time 1 and Time 3 surveys worked in Primary Care (as do almost all SHS staff physicians). One physician interviewed shed some light on her perspective and that of her colleagues in Primary Care. In her view, physician dissatisfaction with the system stemmed from the fact that physicians had originally expected clinical information to be available through the computer at the "touch of a button." Instead, the system had become primarily an administrative system, and they were just beginning to see clinical reports generated. In fact, she noted, the executive director (an administrator, not a physician) admitted to having decided to concentrate on the administrative parts of the system first. While she noted that there were positive aspects to the system, especially the computer-generated daily appointment list and the encounter form, she did not envision any change in the current emphasis on clerical/accounting tasks. The computer system was no longer a topic of discussion in SHS physician meetings, although it had been in the early stages of system implementation. i In addition to physicians' negative responses, the questionnaires also showed significant differences between medical (MDs, RNs, and other medical) and I non-medical (administrators and office/clerical) i 14 4 personnel in their reactions to the computer system. The interviews indicated, however, that the negative responses of medical personnel in general stemmed from different concerns from those of physicians. Nurses and other medical employees did not seem overly concerned that the computer system was not being used for clinical purposes. Instead, medical personnel, and nurses in particular, were more vocal about whether learning and using the computer was an appropriate use of their time, which, they felt, might be better spent in patient care. They also cited difficulties in interrupting their daily work with patients to use the computer. One radiology technologist emphasized the difficult of adding computer tasks to an already stressful day dealing with patients, x-ray technology, and physicians as well. While many office/clerical workers use the computer most of the day, medical employees either (1) use the computer on an occasional basis to look up schedules or find a student's telephone number, or (2) set aside time to help enter activity codes for their particular department on the computer. In either case, using the computer is only one of many responsibilities in a work day dominated by patient care tasks. All of these issues, however, have important 1 4 5 variations by department, as described in the next section. Department as predictor. The statistical analyses detailed above indicated that the respondent1s department was also a significant (but less powerful) predictor of attitudes toward the computer system. As noted above, statistical significance was less likely between departments than occupations because of the larger number of departments. The interview process brought to light the widely differing concerns in the different departments. Primary Care and Women's Health clinics, for example, both include clinicians as well as clerical staff and both treat patients. Opinions in the two departments about the computer system and approaches to using it in their department were, however, strikingly different. Primary Care is the largest SHS department and the one in which the student/patient is usually first seen. The triage area is particularly busy, with students waiting for scheduled appointments and walk-ins being called to see the triage nurse. A clerk enters walk-in appointments in the computer and generates encounter forms, as well as directing students and answering innumerable questions. 1 4 6 Primary Care is also, however, reminiscent of a small bureaucracy. Clinician's offices are, for the most part, located in the back, away from much of the activity. Many employees seemed concerned with performing their own jobs, and those interviewed frequently noted that a particular task was not supposed to be part of their job. Occasionally, respondents made oblique references to "political agendas" and "lack of communication" about different aspects of the computer system. In Primary Care, clinicians (especially nurse practitioners) used the computer system when it was first implemented. A combination of too much work and difficulties adapting to the computer on the part of particular nurse practitioners, however, ensued. The subsequent negotiated rearrangement of tasks (see Hypothesis 5 for a detailed description) resulted in only office/clerical staff using the computer. In fact, clinicians were subsequently instructed not to use the computer terminals. Nurse practitioners, at Time 3, were no longer even permitted to relieve the clerk generating encounter forms next to the triage office. One respondent noted that administrators thought clincians might attempt to change their schedules on the computer. 147 Another respondent, an administrator, suggested that clincians needed to learn to be "good computer citizens." Women's Health, in contrast, is a department where everyone "takes a turn at the front desk." It is a particularly busy clinic, tucked into cramped space between the Specialty Clinics and Immunization. Because of limited space, all clinicians are physically closer to each other and to the computer terminals than are personnel in Primary Care. People literally fall over each other and room dividers are used to create some of the offices. There are few physicians in Women's Health, but the nurse pracitioners not only use the computer, but enter the clinicians' schedules at the beginning of each university quarter and take an active role in decisions involving system use in their department. Respondents interviewed noted that several computer functions are essential to their operations. Clinicians in Women's Health, for example, frequently need to telephone a patient with lab results or other information. In the past, the student's record had to be retrieved from Medical Records just to get the telephone number. Now the clinician either uses the terminal herself or telephones the front desk and asks the clerk to get the telephone number from the computer for her. Daily 14 8 clinician schedules available through the computer are equally essential. Nurse practitioners in Women's Health also cited the importance of the computer for tracking students for studies related particularly to women's issues (e.g., rape, venereal disease, etc.), as well as the more commonly cited advantages such as the legibility of the encounter form. The contrast between the nurse practitioners' approach to the computer in Primary Care and in Women's Health brought up the question of whether the computer and its advantages/disadvantages were ever discussed in meetings of all SHS nurses. When asked, however, one Women's Health nurse practitioner (seeming surprised at the question) responded that nurses from Primary Care would not be interested in the same kinds of applications. Anyway, it would seem like "bragging" to share some of the ways they had begun to use the computer. Thus, in her view, departmental concerns were more important than sharing common nursing uses for the computer. Comparison of impressions gained from interviews and observation in both clinics and the responses to the questionnaires raise some intriguing questions. The survey results showed Women's Health respondents to be overwhelmingly more negative toward the computer than 149 those in Primary Care (who were essentially neutral). Women's Health, however, seemed to use the computer much more extensively, with more involvement of all employees. The computer coordinator/trainer was also surprised to learn that Women's Health personnel responded negatively to survey questions about the system. Several facts, however, may shed some light on the apparent discrepancies between the interview and questionnaire results. First, Women's Health had more difficulty than the other departments in adapting their scheduling system to the computer. The computer system was not programmed to schedule appointments at the appropriate time intervals and extensive measures were taken to adapt and work around these problems. The following comments are typical of open-ended questionnaire responses from Women's Health: There is a "terrible problem...scheduling patients in WHS...double bookings occur daily." "I feel we definitely need a different format for scheduling appointments!" In some instances, quirks of the computer system have even dictated the time of day certain types of appointments can be scheduled, a case of the computer driving clinicians' practice. Second, the nature of computer use in the two departments differs. Although both perform the same 1 5 0 scheduling, data entry, and report generation functions, the work is organized very differently. In Primary Care, only half of the respondents are computer users and no clinicians use the computer. Most computer work is performed by clerical staff. In Women’s Health, on the other hand, virtually all personnel use the computer. Thus, instead of dividing tasks into clerical and medical i categories, the computer work is, to some extent, shared by all. This may result in additional workday interruptions for all, rather than a dedicated task for a few. It is also possible, however, that the six months between the Time 3 survey and the final interviews has resulted in a change in attitude on the part of Women's Health personnel, reflected in interview results that contradict the survey responses. Although Women's Health had already been using the computer system approximately one year prior to the Time 3 survey, administrators noted that extensive use of the computer for special studies had only begun during the interval between the Time 3 questionnaires and the final interviews. This capability to conduct special studies using the computer was new for all departments since the Time 3 questionnaires. Women's Health personnel, however, placed particular importance on these studies. While other departments responded more 1 5 1 positively about the computer on the Time 3 questionnaires, the new capability for special studies may be more important to Women's Health, resulting in a change of attitude by the time the final interviews were conducted. In addition to clinics such as Primary Care and Women's Health, employees in the ancillary departments (e.g., lab, x-ray) also had varying reactions to the computer system. The survey results showed that Lab employees had negative expectations concerning the computer, expectations that did not seem to improve with computer implementation. In the interviews, Lab respondents indicated that their attitudes were directly related to the increased paperwork required of the Lab since the implementation of the computer system. Rather than simply entering lab results on a request form brought by the student from the clinics, Lab employees now both generate their own report forms and enter lab procedures (activity codes) in the computer, an increase in workload for already busy technologists and medical assistants. Medical Records, on the other hand, showed more positive responses toward the system than did many other departments. While the computer system added some tasks for Medical Records employees, the intent of the system 152 was, in the long run, to streamline medical records activities. Perhaps more importantly, however, the I computer system coordinator/trainer is also the administrator of the Medical Records department. Thus, personnel in Medical Records have more opportunity to work closely with the system and have, indeed, become informal computer "gurus" for employees in other departments. Finally, only Finance/Personnel showed increased enthusiasm for the system at Time 3. As noted by the physician informant, however, the computer system has evolved into an administrative/clerical system performing i the financial functions of the organization. Thus, while I the work in Finance/Personnel may have increased, employees in that department also perceived that their work was more effective. Before the system, "it was very difficult" to rely on the clincians for every type of data. Since system implementation, information from encounter forms is entered into the computer throughout the organization and used by Finance/Personnel to track SHS operations and produce reports. These functions give Finance/Personnel an expanded role in SHS daily operations. This new role of Finance/Personnel makes additional information available to the organization, but also 15 3 exacts costs in terms of the amount of time needed to generate this new information. The data entered by the different SHS departments from the encounter forms provides detailed information concerning all services rendered to students by SHS. This information also makes it possible to ensure that students pay for services as required. (Students pay for some services all year round. In addition, during the summer, students without the insurance program must pay for all SHS services.) Finance/Personnel's audit of this information, however, consumes nearly all of Finance/Personnel1s student work hours, as well as additional time for the full-time staff. Respondents interviewed also indicated that the system was implemented without any new staff or redesign of job descriptions. Thus the staff has absorbed the implementation in their "spare time," reaching the limits of time and energy available. SHS administrators, however, maintained that new staff had been added in Finance/Personnel, Primary Care, and Women's Health as needed. For administrators, the computer system has provided new and essential information, but there has been no decrease in operating costs. In fact, SHS administrators acknowledged that important management decisions still need to be made. The computer system has 1 54 the capability to provide an increasing amount of data, but also makes demands on SHS personnel for data entry and analysis. SHS is now faced with determining how much information is really needed and whether SHS can afford additional personnel to generate this information. The interview results clearly confirmed the statistical findings that both occupation and department are important predictors of individuals' reactions to the computer system. Interview findings, for example, indicated that, although most SHS employees had uniformly high expectations at Time 1, different groups actually expected different benefits from the computer system (e.g., clinical vs. administrative data). Time 3 reactions reflect either acceptance or disappointment with the system, based upon the advantages individual groups had hoped the system would provide. Going beyond system expectations, however, both occupation and department also determined individual experiences with the computer system and influenced attitude change. While some experiences clearly related to changes in work patterns (see additional hypotheses below), clinical departments performing similar tasks (e.g., Primary Care and Women's Health) also reported different reactions to the computer system. These differences seemed to go beyond simple task assignments 1 5 5 to "what it is like" to work in that department, i.e., to how individuals interpret and share changes in their work setting. Conclusions Quantitative and qualitative results indicated both occupations and departments to be significant predictors of individuals' attitudes toward the computer system. The findings for differences between occupations, however, were more consistent than those for departmental differences. Significant differences between occupations were demonstrated at Time 3 for both the single attitude measure ("System Worth Time/Effort) and the Time 3 Combined Attitude Scale. Interview findings confirmed these statistical results. For departmental differences, ANOVA results for the single attitude measure were not significant. Both the ANOVA results and Duncan tests did, however, indicate significant differences between departments on the Time 3 Combined Attitude Scale Toward the Computer. Furthermore, interview findings highlighted differences between departments, in particular those between Primary Care and Women's Health. Thus, Hypotheses la and lb were not rejected. Individual Differences as Attitude Predictors In addition to occupation and department as predictors, regression analyses were performed to test 1 5 6 whether the following individual difference variables were significant predictors of attitudes toward the computer system: (1) cognitive style, (2) computer experience, and (3) age. The following specific hypotheses were tested: Hypothesis 2a: Individuals with a stronger "thinking type1 1 cognitive style will have more positive attitudes toward the computer system than individuals with a stronger "feeling type" cognitive style. Hypothesis 2b: Individuals with more computer experience will have more positive attitudes toward the computer system. Hypothesis 2c: Younger employees will have more positive attitudes toward the computer system than will older employees. Regression Analysis Table 4.5 details the results of the regression analysis testing individual differences as predictors of Time 1 attitude toward the computer system (System Worth Time/Effort). None of the variables predicted respondent attitudes. Conclusions The results of the regression analysis indicated that none of the individual difference variables was a significant predictor of attitudes toward the computer 157| T a b l e 4 . 5 Regression Analysis to Predict Time 1 Attitude Toward Computer System from Individual Difference Variables Individual Difference Variables b (S.E.) t Sig. t Dependent Variable: Tl-The effort system is worth required to use the time and it. Cognitive Style -.01 -.06 (.12) .95 Computer Experience .01 .23 (. 02) .83 Age -.01 -.92 (.01) .36 Adjusted R2 = -.03 F (3,61) = .34 sig. F = .80 n = 65 -158 system. Hypotheses 2a, 2b, and 2c were all rejected. Although individual differences were not hypothesized as predictors of Time 3 attitudes, regression analyses for Time 3 were also performed, with similar results. Participation in Implementation and Computer Use as Attitude Predictors Study hypotheses predicted that both participation in the implementation process and computer use would predict attitudes (Time 3 Combined Attitude Scale) toward the computer system at Time 3. The following specific hypotheses were tested: Hypothesis 3: Participation in the implementation process will result in more positive attitudes toward the computer system. Hypothesis 4: Computer use will influence attitudes toward the computer system. Hypothesis 5: The introduction of an integrated information system will result in task chances for workers in some departments. Hypothesis 6: Workers who perform tasks formerly performed bv another department will have more negative attitudes toward the computer system. The methods used to test each of these hypotheses differed. Hypotheses 3 and 4 were included together in the same regression analysis to test the relative 159 contribution of each of the participation variables and the computer use scale in explaining variance in respondent attitudes. Hypotheses 4 also relied upon t-tests to indicate attitude differences between computer users and non-users. Hypotheses 5 and 6 were tested primarily by qualitative methods, although survey data also contributed to the results, particularly for Hypothesis 6. Statistical Analyses Table 4.6 details the results of the multiple hierarchical regression analysis predicting the Time 3 Combined Attitude Scale from implementation participation and computer use variables. The dummy-coded occupational variable was entered first to account for the variance explained by membership in non-medical/medical social worlds, followed by the implementation and computer use variables. Results showed that 25 percent of the variance in the dependent variable was explained by the independent variables entered in the final equation. The dummy-coded occupational variable had an unstandardized coefficient of .63 (p<.03) for the intercept (members of non-medical occupations). Both Work Group Communication and Organizational Policies were significant predictors of respondent attitudes. The Work Group Communication factor 160 T a b l e 4 . 6 Regression Analysis to Predict Time 3 Combined Attitude Scale Toward Computer From Participation in Implementation Process and Computer Use Variables Beta Coefficient t Dependent Variable: T3-Combined Computer Ecruation 1: (n=43) Attitude Scale Toward Occupational Dummy Code Non-Medical=0 B=. 14 .24 Medical=l -.08 -.53 Interaction with Trainer -.22 -1.20 Relations with Computer Staff .23 1.48 Knowledge/Invo1vement -.08 -.44 Work Group Communication Organizational Policies .49 2.66 ** -.39 -2.51 * Computer Use Scale Adj usted R2 = .26 F (7,35) = 3.10 ** Eouation 2: (n=45) -.31 -1.85 Occupational Dummy Code Non-Medical=0 B=. 63 2 .21 * Medical=l -.10 -.64 Work Group Communication .37 2 . 38 * Organizational Policies -.41 -2.86 ** Computer Use Scale Adjusted R2 = .25 F (4,40) = 4.59 ** -.35 -2.47 * Note: The following variables were also used in other analyses, but did not predict the dependent variable: interaction between computer use and non-medical/medical; and interaction between computer use and work group communication. * E <.05, ** p <.01. 16 1 included praise for new procedures from supervisors and co-workers, talk about new procedures with supervisor and co-workers, developing new procedures, and attending regular meetings to discuss the computer system (see Chapter 3). The regression results indicated that respondents with high scores on this factor were more likely to have positive attitudes toward the computer system. In addition, the negative influence of the Organizational Policies factor indicated that respondents who felt that the organization did not encourage learning or experimenting with new procedures had more negative attitudes toward the computer system. There was also a significant negative relationship between computer use and respondent attitudes, indicating that higher computer use leads to more negative attitudes. Additional analyses clarified the the relationship between computer use and attitudes (see Figure 4.6). The negative relationship in the regression analysis undoubtedly reflects the twenty-one respondents who use the computer "several times a day" and have relatively negative attitudes toward it. The eight respondents who use the terminals "most of the day," however, have very positive attitudes toward the computer system. ANOVA results, however, showed no significant differences between use categories overall. A ttitude Factor Score Figure 4.6 Time 3 Combined Attitude Scale toward Computer by Level of Use 1 o -1 -2 Level of Use ■ Never Never Terminals i Once/Week □ Once/Day □ Several/Day ■ Most of Day 0 4 0 4 C \ J o 1 fflm 0 4 o o T ~ o 0 0 i 0 1 i 0 4 o 163 Further breakdowns (Table 4.7) showed that the eight workers who used the computer "most of the day" were all office/clerical employees. The "several times a day" category, however, was composed of employees from all departments and occupational categories. Among these "several times a day" respondents, the nurses and other/medical employees had predominately negative attitudes toward the computer. Interview Results The implementation process at SHS did not involve a series of meetings with representatives of different departments, although it did begin with a few such meetings. In general, the process evolved into a small decision-making group coupled with an interpersonal relationship between the system coordinator/trainer and individuals in the various departments. Participation in the implementation process emerged as a significant issue in the interviews for physicians, but somewhat less so for other SHS employees. Comments from several respondents on the Time 3 questionnaire, however, indicated a desire for more input into system decision-making. For example, one Women's Health employee noted that implementers should have "allowed those on the front lines, i.e., secretaries and clinicians, input on choosing software...elegant hardware and poor software." 164 i Table 4.7 i Level of Computer Use bv Occupation Level of Computer Use Use Terminals: Occupation Never Never Once/ Week Once/ Day Several/ Day Most of Day Administrators 1 2 1 2 MDs 2 4 1 RNs 4 3 1 6 Other Medical 8 1 4 1 5 Office/Clerical 3 2 2 8 8 Total 18 (26%) 7 (10%) 10 (15%) 5 (7%) 21 (30%) 8 (12%) n=69 Scale: 0=Never Use Computer, l=Never Use Terminals, 2=Use Terminals Once/Week, 3=Use Terminals Once/Day, 4=Use Terminals Several Times/Day, 5=Use Terminals Most of the Day. Respondents who never use the terminals may use reports or provide information for the computer. 165 One employee in the Lab commented that "a system analyst or programmer should meet with all of us to get our input." At the Time 3 interviews six months later, however, involvement no longer seemed to be an issue, except for physicians. Many employees interviewed noted that coordinator/trainer was more than willing to help them solve system-related problems. They had been given the opportunity for training and several clerical workers were also given their choice of job assignments when system implementation resulted in changes in their previous jobs. Other respondents, however, pointed out insufficient training and lack of ability to use the system. Thus training, rather than actual participation in implementation decisions, seemed to be a more important ongoing issue for most employees. According to Primary Care physicians, however, there was not adequate physician input in decisions related to the system. While they noted that they were consulted early in the implementation process, their influence waned as the system, in their view, shifted to a clerical/accounting system. In addition, the Associate Director for Primary Care (also a physician) was considered by SHS administrators to represent the physicians. Other physicians, however, felt that they 166 should have had a representative who was not also an administrator. The differences between physicians and other employees may result from differing expectations. While Lab employees, for example, were unhappy with the extra paperwork generated for their department, they were resigned to the administrative decision and no longer seemed to expect additional influence in the decision-making process. Physicians, on the other hand, were dissatisfied with both their lack of influence and with the direction the computer system had taken. Although the computer system was designed to parallel the paper and pencil system, the interviews also highlighted a variety of task changes for workers in different departments. Some of these changes were common to all departments, while others were specific to a single department. Entry of activity codes into the computer, for example, involved all departments and constituted a new task with no counterpart in the pencil and paper system. Both clinics and ancillary departments have had to absorb the additional work necessary to enter codes for all student visits, procedures, lab tests performed, etc. into the computer. The tasks of scheduling assistants also changed with the implementation of the computer system. Previously, 167 scheduling assistants handled both telephone appointments and walk-ins. After computer implementation, the two functions were separated and telephone scheduling assistants were moved to a closed room where they could schedule appointments by telephone without interruption. Other schedulers register walk-ins and direct them to the triage area. Scheduling assistants were given a choice of which job they preferred and most seemed satisfied with the new arrangement. Other changes involved shifts in tasks from one department to another. Prior to system implementation, for example, clinical assistants in clinics such as Primary Care or Women's Health completed lab order forms when lab tests were ordered by the clinician. Under the computer system, however, the clinician checks off the appropriate lab tests on the encounter form which goes to the Lab. The clinical assistant no longer has a form to fill out. The Lab, on the other hand, has additional work. The Lab previously used the order form completed by the clinical assistant to report test results as well. Under the computer system, Laboratory employees must generate their own reporting form for each lab test. In addition, like all departments, they also enter activity codes into the computer for all lab tests performed. In the words of one Lab employee, "With the implementation 168 of the computer system the Laboratory has been given the work of another department. This has not only caused confusion, but increased the workload considerably." The interviews included Lab employees at all three time periods. At Time 2, before Laboratory workers began using the computer, they appeared quite apprehensive about the impending changes. They worried that they would not really know what tests the clinicians wanted and would have to telephone the clinics. They also felt that the clinical assistants, who work closely with the clinicians, should continue acting as intermediaries between the Lab and clinicians by filling out the lab order forms. At Time 3, however, Lab employees' concerns seemed mainly related to the increased paperwork, rather than to problems with the new work arrangements. In fact, one physician noted that the Lab seldom had to telephone for clarification because the encounter form was much more legible than clinician handwriting. The only discrepancies arose when the clinician did not check-off the all of the lab tests firmly enough and all ordered tests did not show through on the Lab copy of the encounter form. One of the most striking examples of new task negotiations surrounded the functions of the triage nurse 169 in Primary Care. Prior to system implementation one nurse practitioner acted as triage nurse, with others also filling in as needed on a rotating basis. (Two nurse practitioners did not feel able to perform the stressful triage role, a decision respected by their colleagues since they worked hard in other areas more suited to their abilities.) With the implementation of the computer system, however, the triage function became even more stressful. Under the original arrangement, the triage nurse was to work at a computer terminal. As she evaluated a student's complaint she was also to enter the student's information and appointment into the computer and generate the encounter form. The triage nurse, however, had difficulty with both the computer system and the combined activities, and a long line of students waiting for triage resulted. The two nurses who did not do triage also refused to use the computer at all. These issues were a major topic of concern for the computer coordinator/trainer, as well as Primary Care's nurse practitioners, during the Time 2 interviews. Several nurse practitioners objected to using the computer and the appropriate use of nursing time became a major issue. By Time 3, however, several changes had occurred, resulting in a very different configuration of tasks. The 170 original triage nurse had left and two new registered nurses (not nurse practitioners) had been hired specifically as triage nurses. In addition, one of the only new jobs created for the computer system was a clerical position located next to the triage nurse. This clerk was specifically assigned to enter data and appointments indicated by the triage nurse and to generate corresponding encounter forms. In this case, the computer system seemed to be a catalyst for an organizational change in an area where stress already existed. The new role of Finance/Personnel illustrates another type of task change related to the computer system. As the administrative/clerical aspects of the computer system evolved, Finance/Personnel began to assume a central role in system operations. Although students only pay for most SHS services during the summer quarter, the computer system now continues the analyses of SHS services all year long. Finance/Personnel is responsible for reconciling the encounter forms (600 per day) with departmental data entry in the computer, calling errors to the attention of the clerk who did the entry, and producing reports detailing all SHS activities. This is an entirely new role, and one that has "brought to light operational problems" in the 1 71 overall SHS system. This new role, undoubtedly, is one reason that Finance/Personnel was the only department whose initial positive expectations for the system actually became even more positive at Time 3. The new role of Finance/Personnel, however, also has a negative side. Maintaining the new activities and reports requires about 5 hours per day, or almost all of the time available from the department's student workers. This obligation prevents department personnel from either conducting other studies or learning more about the computer system. Furthermore, SHS has barely begun to use the information potentially available. New decisions face administrators concerning the trade-offs between the importance of the new information and the amount of employee time needed to provide it. Task changes can also require employees to learn new job skills as well as assume additional work. At SHS, while most employees noted that they all pitch in and "keep chipping away" at the work, several employees had also attempted to get their job classifications changed to reflect their new computer skills. As of Time 3, however, these attempts had been unsuccessful, with SHS administration maintaining that the tasks, for the most part, remained the same even though they now used the computer to accomplish them. Many respondents 172 interviewed, however, expressed dissatisfaction about the the additional work, which had stretched employees to the limits of their time and energy. Conclusions Hypothesis 3. Hypothesis 3 dealt specifically with the influence of participation in the implementation process on respondent attitudes. The regression analysis confirmed previous research (Johnson & Rice, 1987), indicating that the most influential type of implementation participation on attitudes was communication within the work group about new procedures and organization policies that allow time for learning and experimenting with the system. Interview results supplemented this information, for physicians as well as for other employees. In fact, the negative shift in attitudes demonstrated by physicians from Time 1 to Time 3 (Hypothesis la above) was specifically traced to dissatisfaction with physician influence on the direction of the system and lack of participation in implementation decision-making. These findings made it clear that participation was an important predictor, but that the appropriate type of participation may vary according to occupation or department. Thus, based upon both statistical and interview methods, Hypothesis 3 was not rejected. 173 Hypothesis 4. The regression results indicated that frequent computer use was a significant predictor of negative attitudes toward the system. Office/clerical workers, who use the computer terminals "most of the day," however, had very positive attitudes. Medical employees who interrupt their primary tasks to use the terminals "several times a day," on the other hand, had more negative attitudes. Thus computer use did influence attitudes, but the direction of influence depended upon the specific work context or social world. Hypothesis 4 predicted that computer use would influence attitudes, but anticipated the different effects of specific contexts and did not specify the direction of influence. (Prior research has shown both positive and negative relationships.) Thus, Hypothesis 4 was also not rej ected. Hypothesis 5. Hypothesis 5 predicted task changes for SHS workers, a prediction corroborated by interview findings. In fact, as described above, interview respondents documented several different types of task changes taking place in different departments. Thus, Hypothesis 5 was also not rejected. Hypothesis 6. Finally, Hypothesis 6 predicted that workers who take over tasks formerly performed by another department would react more negatively to the computer 174 system. At SHS, the Lab presented the most striking example of this type of change. The interviews, as well as respondent comments on the questionnaires, documented that the Lab had taken over the clinical assistant's task of generating lab report forms. In addition, both questionnaire and interview findings underscored Lab employees' initial apprehensive approach to the system and their continued discontent with the large amount of paperwork generated by the present arrangements. Thus, Hypothesis 6 was also not rejected. Summary Results for the attitude change model indicated that both occupational and departmental social worlds predicted attitudes toward the computer system (Hypothesis 1), although neither emerged as the more powerful influence. Individual differences such as cognitive style, computer experience, and age (Hypothesis 2), on the other hand, played no part in predicting reactions to the computer. Certain types of participation in the implementation process (Hypothesis 3), as well as several apects of computer use (Hypotheses 4-6), also predicted employee reactions to the computer system. Thus, the results detailed in this chapter, with the exception of Hypothesis 2, confirmed the Model of Attitude Change (see Figure 2.2 in Chapter 2). 175 Implications of these findings are discussed in further detail in Chapter 6. These results also underscore the value of using more than one research approach. Throughout the chapter, interview results and observations both extended and explained the statistical analyses of questionnaire responses. The results for social worlds at Time 1, in particular, illustrate the importance of different methodologies. At Time 1, the survey responses showed that SHS employees had, for the most part, uniformly high expectations for the computer system, with no significant differences between social worlds. The Time 1 interviews. however, indicated that while most groups expected benefits from the system, the actual benefits they expected were different. Physicians, for example, expected clinical information "at the touch of a button." Administrators, on the other hand, wanted to monitor staffing patterns and substantiate budget allocations. Clearly, the computer system was not likely to address all of these expectations simultaneously. Thus, the significant differences between social worlds at Time 3 may not indicate an actual change in the importance of social worlds as predictors of attitudes. At Time 1 employees agreed that the system would be good, not what would be good about it. Different social worlds had different expectations. The Time 3 differences between social worlds illustrate the ways in which the Time 1 expectations for the system were either met or disappointed during the course of computer implementation. This interpretation of the present findings, however, would not have been possible based upon survey results alone. 177 Chapter 5 RESULTS FOR CHANGES IN DEPARTMENT BOUNDARIES In "changing organizations...the process of developing shared beliefs about work processes may resemble negotiating as much as it does learning" (Sproull, 1981, p. 214). Chapter 4 highlighted shared beliefs or attitudes, as well as negotiations within departments concerning new work arrangements accompanying computer implementation. The findings showed that task changes influenced employee attitudes toward the computer system. In addition to shared attitudes and negotiations within departments, however, negotiations between departments concerning new work arrangements also constitute an important aspect of the implementation process. In fact, interdepartmental negotiations have the potential to affect the structure and functioning of the organization as a whole. The negotiation process itself, as well as the outcome of negotiations, constitutes a change in the accepted or customary level of communication between departments. Altered communication patterns may result in permanent changes in interdepartmental relationships. The Time 3 survey explored employee perceptions of changes in interaction patterns between their own 178 department and other departments in SHS. In addition, the interviews identified and investigated specific negotiations occurring between departments. The predicted outcome of these changes in interaction patterns was increased openness of departmental boundaries. This chapter details findings related to Hypotheses 7a, 7b, 8a, and 8b, dealing with changes in departmental boundaries (Figure 2.3). The information presented here is based on Time 3 questionnaire responses as well as interviews, archival data, and observations of SHS employees at work. Chapter 6, following, discusses the implications of these findings. Employee Perceptions of Boundary Changes Study Hypotheses 7 and 8 predicted that participation in the implementation process and system use will influence employee perceptions of increased (1) "information exchange," and (2) "understanding the work of other departments," the two variables used to measure changes in the openness of department boundaries. The hypotheses were first tested using regression analyses. In addition to these regression analyses, however, two additional statistical analyses were conducted. In the first analysis, departments played the role of targets of increased interaction. Comparisons of results for each department determined which departments were more likely 179 to be targets of changes in interaction patterns. The second analysis examined both occupations and departments as agents of increased interaction in order to determine which groups were more like to perceive (i.e., be involved in, aware of, or initiate) these changes in interaction patterns. Both analyses supplemented the regression analyses. The final section details findings from the interviews and observations of SHS employees at work. These descriptions, again, provide background information and explanation for the statistical findings. All of these analyses tested the following hypotheses: Hypothesis 7a: Employees who participate in the implementation process will perceive increased exchange of information between departments. Hypothesis 7b: Employees who participate in the implementation process will perceive increased understanding of the work of other departments. Hypothesis 8a: Employees who use the computer system will perceive increased exchange of information between departments. Hypothesis 8b: Employees who use the computer system will perceive increased understanding of the work of other departments. J 180 Regression Analyses This following sections outline the results of the regression analyses predicting changes in "information exchange" and "understanding the work of other departments." Parallel analyses were performed for both dependent variables. Correlation between these two variables, however, was .89, indicating that they measure essentially the same concept. Thus, an additional regression analysis was performed using the average of the two measures as the dependent variable. The analyses are presented in detail below. Information exchange. Table 5.1 presents the results of the multiple hierarchical regression analysis in which (1) participation in the implementation process, and (2) computer use predicted changes in information exchange between departments. Membership in either the medical or non-medical social world of SHS was taken into account by a dummy-coded variable (0=non-medical, l=medical), entered first in the analysis. Participation in the implementation process (entered next) was measured by the five variables described in Chapter 3. Computer use (entered last) was measured by a single 6-point scale ranging from "no use" to using the terminals "most of the day" (see Chapters 3 and 4). 1 81 T a b l e 5 . 1 Regression Analysis to Predict Change in Information Exchange Between Departments From Participation in Implementation Process and Computer Use Beta Variables Coefficient t Dependent Variable: Change in Information Between Departments Ecruation 1: (n=43) Exchange Occupational Dummy Code Non-Medical=0 B=3.75 9.08*** Medical=l -.11 -.77 Interaction with Trainer .12 .72 Relations with Computer Staff .32 2.19 * Knowledge/Involvement . 01 . 04 Work Group Communication .51 3.03 ** Organizational Policies -.08 -.53 Computer Use Scale Adj usted R2 = .36 F (6,35) = 4.39 ** Equation 2: (n=44) -.18 -1.17 Occupational Dummy Code Non-Medical=0 B=3.57 9.65*** Medical=l -.11 -.84 Relations with Computer Staff .35 2.92 * Work Group Communication Adjusted R2 = .39 F (3,40) = 10.20 ** .49 3 .84*** Note: Interaction between the Computer Use Scale and Work Group Communication was not significant. * p <.05. ** e <.01. *** e <-001. 182 The adjusted R2 for the final equation indicated that the independent variables entered in the equation predicted 39 percent of the variance in the dependent variable. Only the unstandardized coefficient for the dummy-coded occupational variable and two of the six variables (Relations with Computer Staff and Work Group Communication), however, were significant predictors of changes in information exchange. Neither the other participation variables nor the Computer Use Scale predicted changes in information exchange. Equation 2 shows the final results for the analysis with non-significant predictors removed. Understanding work of other departments. Table 5.2 depicts results of the regression analysis for changes in understanding the work of other departments. The same independent variables were used, with similar results (as expected). The final equation, however, only explained 22 percent of the total variance in the dependent variable, considerably less than the analysis of changes in exchanging information. General increase in openness between departments. Because of the high correlation between "information exchange" and "understanding the work of other departments," a third regression analysis was performed. The average of the two variables described above was used 183 T able 5 .2 Regression Analysis to Predict Change in Understanding Work of Other Departments From Participation in Implementation Process and Computer Use Beta Variables Coefficient t Dependent Variable: Change in Understanding Work of Other Departments Eguation 1: (n=45) Occupational Dummy Code Non-Medical=0 B=3.93 10.45*** Medical=l -.03 -.18 Interaction with Trainer .18 1.04 Relations with Computer Staff .25 1.61 Knowledge/Involvement -.08 -.42 Work Group Communication .41 2.17 * Organizational Policies -.20 -1.25 Computer Use Scale -.06 -.35 Adjusted R2 = .20 F (7,37) = 2.56 * Eauation 2: (n=46) Occupational Dummy Code Non-Medical=0 B=3.83 11.00*** Medical=l -.08 -.53 Relations with Computer Staff .29 2.17 * Work Group Communication .37 2.58 ** Adjusted R2 = .22 F (3,42) = 5.15 ** Note: Interaction between Computer Use Scale and Work Group Communication was not significant. * p <.05. ** p <.01. *** p <.001. 184 as the dependent variable in this analysis, representing a more general measure of increases in the openness of departmental boundaries. Table 5.3 presents the results of this analysis. Results for the final equation showed that the independent variables predicted 38 percent of the variance in the dependent variable. Again, the unstandardized coefficient for the dummy-coded occupational variable, Relations with Computer Staff and Work Group Communication were significant predictors of increases in the openness of departmental boundaries. Additional Statistical Analyses In addition to the regression analyses, other statistical analyses of questionnaire data explored changes in both information exchange and understanding work of other departments. The following sections describe the findings from these analyses. Departments as targets of increased interaction. Tables 5.4 and 5.5 detail changes in the exchange of information for target SHS departments. That is, a higher mean score for a particular department indicates that survey respondents perceived an increase in information exchange with that department. Table 5.4 also compares the increased information exchange with each department perceived by computer users and non-users. Table 5.5 presents the same analysis for 185 T a b l e 5 . 3 Regression Analysis to Predict Change in Average of Information Exchange/Understanding Work from Participation in implementation Process and Computer Use Beta Variables Coefficient Dependent Variable: Average of Change in Information Exchange/Understanding Work Equation 1: (n=43) Occupational Dummy Code Non-Medical=0 B=3.70 9.53*** Medical=l -.08 -.54 Interaction with Trainer .09 .54 Relations with Computer Staff .34 2.27 * Knowledge/Involvement -.00 -.02 Work Group Communication .50 2.91 ** Organizational Policies -.08 -.53 Computer Use Scale -.11 -.74 Adjusted R2 = .33 F ( 7 , 3 5 ) = 3.99 ** Eguation 2: (n=44) Occupational Dummy Code Non-Medical=0 B=3.55 10.3 6*** Medical=l -.08 -.63 Relations with Computer Staff .37 3.07 ** Work Group Communication .48 3.74*** Adjusted R2 = .38 F (3,40) = 9.85 *** * p <.05. ** p <.01. *** £ <.001. 186 Table 5.4 Changes in Exchange of Information With Target SHS Departments bv Computer Use Category All Employees3 Computer Use Category Users Non-users Target n M n M n M Department (SD) (SD) (SD) Question: Please rate the extent to which exchanging information with each of the following departments has increased or decreased because of the computer system. a Office of 59 4.49 43 4.56 16 4.31 Director (.82) (.88) (.60) Finance/ 53 4.74 36 4.78 17 4.65 Personnel (.90) (.90) (.93) Insurance 59 4.53 42 4.69 17 4.12 (1.01) (1.00) (.93) Medical 54 4.85 37 4.97 17 4.59 Records (1.10) (1.12) (1.18) Primary 48 4.77 36 4.72 12 4.92 Care (1.04) (1.03) (1.08) Women1s 53 4.64 37 4.78 16 4.31 Health (1.11) (1.11) (1.08) Specialty 57 4.67 40 4.83 17 4.29 Clinics (1.14) (1.01) (1.36) Lab 57 4.77 40 4.95 17 4.35 (1.19) (1.18) (1.22) Pharmacy 61 4.28 44 4.43 17 3.88 (.86) (.95) (.49) Radiology 62 4.16 44 4.20 18 4.06 (.64) (.76) (.24) Health 58 4.38 44 4.50 14 4.00 Education (.83) (.85) (.68) a Includes all Time 1-Time 3 employees. Results for each department exclude workers in the target department. b Exchanging information means any type of information exchanged in any way (such as from the computer, in person, by telephone, memos, meetings, etc.) Scale: l=significantly decreased, 2=decreased, 3=slightly decreased, 4=no change, 5=slightly increased, 6=increased, 7=significantly increased. Reversed scale was originally used on questionnaire. * p<.05. ** p<.01. 187 Table 5.5 Changes in Exchange of Information with Target SHS Departments bv Occupational Category Occupational Category3 Medical Non-Medical n M n M Target Department (SD) (SJD) Question: Please rate the extent to which exchanging information with each of the following departments has increased or decreased because of the Office of Director Finance/Personnel computer system.b 32 3.69 26 (.54) 31 4.45 21 3.31 (1.05) 5.10 * Insurance 32 (.62) 4.06 26 (1.09) 5.12 *** Medical Records 31 (.50) 4.58 22 (1.18) 5.23 * Primary Care 22 (.99) 4.41 25 (1.27) 5.04 * Women's Health 23 (.73) 4.09 29 (1.17) 5.03 *** Specialty Clinics 27 (.60) 4.30 29 (1.24) 4.97 * Lab 27 (1*07) 4.44 29 (1.12) 5.10 * Pharmacy 32 (1.28) 4.00 29 (1.08) 4.59 ** Radiology 32 (.62) 4.00 29 (1.02) 4.34 * Health Education 28 (.51) 4.07 29 (.77) 4.66 ** (.60) (.94) a Includes all Time 1-Time 3 employees. Results for each department exclude workers in the target department. b Exchanging information means any type of information exchanged in any way (such as from the computer, in person, by telephone, memos, meetings, etc.) Scale: l=significantly decreased, 2=decreased, 3=slightly decreased, 4=no change, 5=slightly increased, 6=increased, 7=significantly increased. Reversed scale was originally used on questionnaire. * p<.05, ** pc.01, *** p <.001. 188 medical and non-medical personnel. Figures 5.1 and 5.2 illustrate these results. The departments that were perceived as targets of the greatest increases in information exchange by all employees included Medical Records, the Lab, Primary Care, and Finance/Personnel, in that order (see Table 5.4). In most cases, computer users and non-medical personnel perceived greater increases in information exchange with these departments than did either non-users or medical personnel. As shown in Table 5.4, there were statistically significant differences between the amount of change perceived by computer users and non-users for the Insurance, Pharmacy, and Health Education departments. Differences between changes perceived by medical and non-medical personnel (Table 5.5) were found for 10 of the 11 target departments. Tables 5.6 and 5.7, as well as Figures 5.3 and 5.4, display similar results for changes in understanding the work of different departments. In this case, employees perceived greater increases in their understanding of the work of Medical Records and the Lab than of most other departments. Computer users and non-medical employees, in particular, noted that their understanding of the work of Medical Records and the Lab had increased since the 189 Figure 5.1 Change in Information Exchange with Target Departments by Computer Use Category , , , i i i i — i — i — Dir Fin Ins MR PCWH Spc Lab Rx Rad HE Target Department Use Category ■ Users E3 Non-Users 190 Figure 5.2 C hange in Information Exchange with Target Departm ents by O ccupational Category 7 O) Dir Fin Ins M R PC WH Spc Lab Rx Rad HE Target D epartm ent O ccupational C ategory ■ Medical B Non-Medical 1 9 1 Table 5.6 Changes in Understanding the Work of Target SHS Departments bv Computer Use Category All Employeesa Computer Use Category Users Non-users Target n M n M n M Department (SD) (SD) (SD) Question: Please rate the extent to which understanding the work of each of the following departments has increased or decreased because of the computer system. p Office of 60 4.43 44 4.57 16 4.06 * Director (.95) (1.02) (.58) Finance/ 55 4.63 38 4.68 17 4.53 Personnel (.80) (.84) (.72) Insurance 60 4.47 43 4.65 17 4.00 ** (.89) (.92) (.61) Medical 54 4.81 37 4.95 17 4.53 Records (1.07) (1.05) (1.07) Primary 48 4.69 36 4.67 12 4.75 Care (.93) (.96) (.87) Women’s 54 4.56 37 4.73 17 4.18 * Health (.98) (1.02) (.81) Specialty 58 4.62 40 4.75 18 4.33 Clinics (1.01) (.95) (1.08) Lab 58 4.76 41 4.88 17 4.47 (1.14) (1.19) (1.01) Pharmacy 62 4.34 45 4.47 17 4.00 * (.92) (.97) (.71) Radiology 62 4.24 44 4.32 18 4 . 06 (.76) (.88) (.24) Health 58 4 . 38 44 4.52 14 3.93 ** Education (.82) (.85) ( . 62) a Includes all Time 1-Time 3 employees. Results for each department exclude workers in the target department. k Understanding the work means understanding the work each department does (including problems, procedures, decisions, information needed, etc.). Scale: l=significantly decreased, 2=decreased, 3=slightly decreased, 4=no change, 5=slightly increased, 6=increased, 7=significantly increased. Reversed scale was originally used on questionnaire. * P<.05, * *p<.01. 192 Table 5.7 Changes in Understandincr the Work of Target SHS Departments bv Occupational Category Occupational Categorya Medical Non-Medical n M n M Target Department (SD) (SD) Question: Please rate the extent to which understanding the work of each of the following departments has increased or decreased because of the computer system.b Office of Director 32 3.78 27 3.30 (.79) (1.07) Finance/Personnel 32 4.41 22 4.91 * (.62) (.92) Insurance 32 4.09 27 4.93 *** (.53) (1.04) Medical Records 31 4.71 22 4 .95 (1.07) (1.09) Primary Care 22 4.41 25 4 .88 (.67) (1.05) Women1s Health 24 4.13 29 4.86 ** (.61) (1.09) Specialty Clinics 28 4.39 29 4.79 (.99) (.98) Lab 27 4.48 30 5. 03 (1.16) (1.10) Pharmacy 32 4.06 30 4.63 * (.72) (1.03) Radiology 32 4.03 29 4.48 * (.47) (.95) Health Education 28 4.07 29 4.69 ** (.60) (.93) a Includes all Time 1-Time 3 employees. Results for■ each department exclude workers in the target department. b Understanding the work means understanding the work each department does (including problems, procedures, decisions, information needed, etc.). Scale: Insignificantly decreased, 2=decreased, 3=slightly decreased, 4=no change, 5=slightly increased, 6=increased, 7=significantly increased. Reversed scale was originally used on questionnaire. * p<.05. ** pc.01. *** pc.001. 193 Figure 5.3 Change in Understanding Work of Target Departments by Computer Use Category S ' CD O - 6 H CO II 1 ^ cn c JZ O I I ■ > a - © c s £ £ o d> co i i 5 - 4 - 3 - 2 - Dir Fin Ins MR PC WH Spc Lab Rx Rad H E T arget D epartm ent U se Category ■ Users £9 Non-Users 1 =Sig. Decrease 4= N o Change 7=Sig. Increase Figure 5.4 Change in Understanding Work of Target Departments by Occupational Category 7 - i 6 - 5 - 4 - 3 - 2 - 1 - Dir Fin Ins MR PC WH Spc Lab Rx Rad H E Target Department Occupational Category ■ Medical E3 Non-Medical 195 computer system was implemented. Significant differences between the perceptions of changes by medical and non-medical employees were indicated for 6 of the 11 target departments. Occupations and departments reporting increased interaction. As described in the sections above, both non-medical workers and computer users perceived more change in "information exchange" and "knowledge of work of other departments" than did other employees. The analyses in the preceding section, however, examined changes with the target departments one by one. In addition to the analyses focusing on individual target departments, two scores were created for each respondent: an overall (1) "average increase in information exchange" score and an overall (2) "average increase in knowledge of other departments' work" score (see Chapter 3). Thus each respondent's ratings for all of the target departments were averaged, representing the individual's changing relationships with all SHS departments outside their own. Respondents were then grouped by their own occupation and department for analyses similar to the analyses of respondent attitudes in Chapter 4. Table 5.8 and Figure 5.5 present the results of these analyses by occupation. ANOVA results indicated significant differences between occupational groups. 196 T a b le 5 .8 j Average Chancre in Information Exchange/Understanding Work of All Other SHS Departments bv Occupation Information Exchange3 n Mean (S.D.) Understanding Work3 n Mean (S.D.) Total 57 4.53 60 4.50 (.66) (.62) Occupation Administrators 6 4.90 6 4.50 (.80) (.54) MDs 4 3.98 4 3.98 (.13) (.13) RNs 10 4.32 11 4.42 (.51) (.50) Other Medical 15 4.28 15 4.25 (.49) (.49) Office/Clerical 22 4.80 23 4.80 (.81) (.81) AN0VAb F (4,52)=2.87 * F (4,55)=2.79 * Medical/Non-Medical Occupation Medical 29 4.25 31 4.27 (.47) (.46) Non-Medical 28 4.82 29 4.74 (.79) (.76) t-test t (44)=3.42 ** t (45)— 2 .98 ** 3 Average change with all departments in SHS except the respondent's own department. b A posteriori Duncan multiple range tests comparing pairs of means showed that Office/Clerical differed significantly from MDs and Other Medical on both Information Exchange and Understanding Work. * p <.05. ** p <.01. =Sig. Decrease 4=N o Change 7=Sig. Increase Figure 5.5 Change i n Information Exchange/Understanding Work of Other SHS Departments by Occupation 7 4- 3- 2 - Admin M D s RN s Oth Med Off/Cler Occupation Variable ■ Information Exchange E 3 Understanding Work 198 office/clerical and administrative employees perceived increases in both overall "information exchange" and "understanding work," while physicians perceived no change at all. A posteriori Duncan tests showed that the office/clerical employees perceived significantly greater changes than did either physicians or other medical employees. Results also showed that administrators perceived a larger change in "information exchange" than in "understanding work." Possibly administrators felt that they already understood the work of SHS employees in other departments, even before implementation of the computer system. Results for the two variables were nearly identical, however, for the other occupational groups. Table 5.9 and Figure 5.6 present similar results for respondents grouped by department instead of by occupation. Overall, there were significant differences between departments in increases in "understanding work," but a barely non-significant difference between departments (p<.06) increase in "information exchange." Findings from a posteriori Duncan multiple range tests indicated that Medical Records personnel perceived significantly greater increases in both the overall "exchange of information" with other departments and the 199 T a b l e 5 . 9 Average Change in Information Exchange/Understanding Work of All Other SHS Departments by Department Information Understanding Exchange3 Worka n Mean n Mean (S.D.) (S.D.) Department*5 Finance/Personnel 8 4.75 8 4.59 (.75) (.66) Primary Care 13 4.43 14 4.44 (.66) (.65) Women's Health 9 4.21 9 4.20 (.42) (.41) Specialty Clinics 5 4.42 5 4.54 (1.00) (.99) Medical Records 6 5.33 7 5.33 (.80) (.78) Lab 4 4.23 5 4.14 (.29) (.31) Health Education 5 4.36 5 4.36 (.41) (.42) AN0VAc F (6,43)=2 .26 ns F (6,46)=2.67 * a Average change with all departments in SHS except the respondent's own department. b Includes departments with at least five employees responding to both Time 1 and Time 3 questionnaires. c A posteriori Duncan multiple range tests comparing pairs of means showed that Medical Records differed significantly from other departments on both variables (with the exception of Finance/Personnel on Information Exchange). * p <.05. Figure 5.6 Change in Information Exchange/Understanding Work of Other SHS Departments by Department 7 Finan P C W H Spc M R Lab HE Department Variable H Information Exchange S3 Understanding W ork 2 0 1 overall "understanding the work of other departments" than did other employees in other departments. Thus while Medical Records (along with the Lab and several other departments) was a target of increased information exchange and knowledge of work between departments (see preceding analyses), Medical Records personnel also reported this increased interaction. Computer users also perceived a significantly greater increase in overall understanding of other departments* work (t (45) = 2.28, p< .03) than did non-users. Greater increases in information exchange with other departments were also perceived by computer users, but the difference between users and non-users was not statistically significant. The interview findings described below extend these analyses by exploring the "how" and "why" of the statistical findings. Interview Findings The interviews conducted at SHS detected several changes in interaction patterns to corroborate the statistical findings for specific departments detailed above. The reasons for each of the changes, however, differed. This section will describe the changes in interaction patterns observed or related by interview respondents. The discussion in Chapter 6 will detail a 202 more complete typology of the specific examples described here and discuss the implications of the findings. Medical Records. Statistical analyses indicated that Medical Records personnel were both targets of and initiated increased exchange of information and understanding between departments. Interview findings supported these conclusions, as several respondents (generally without being questionned on this particular point) described a number of ways in which their communications with Medical Records had increased. First, and perhaps foremost, the Medical Records department head was also the computer system coordinator/trainer. This coordinator/trainer fostered warm personal relationships with individuals throughout the organization as she worked with them in solving system problems. Although the initial computer orientation sessions were conducted for small groups, most subsequent instruction was on a one-on-one basis. The coordinator/trainer would come to the employee's work area and work with her/him at the computer terminal. New employees are now frequently trained by others in their department. This study, however, included only personnel who were at SHS throughout the study period and, consequently, were exposed to the original training arrangements. 203 The nature of the computer coordinator/trainer's involvement with the computer system and with computer users in all departments led to similar involvement for other Medical Records employees. Based upon their proximity and loyalty to their department head, as well as their own computer tasks, they became knowledgable about the system. The informal one-on-one style of interacting was accepted as a norm for computer instruction and employees from other departments throughout SHS would find time to come over to Medical Records to discuss computer problems or share new ways they had found to accomplish computer tasks. A second type of interaction with Medical Records related specifically to the traditional medical records function of coding diagnostic categories in the students' medical records. These diagnostic codes, entered by clinicians in the medical record, are coded and entered in the computer by Medical Records clerks. The diagnostic codes are central to any studies in which patients or visits are categorized according to specific diagnosis. One nurse practitioner from Women's Health, who was planning to use the new computerized database to conduct a study, described her discussions with Medical Records. She was particularly concerned about reaching agreement on the coding of sensitive diagnostic information (e.g., 204 rape, venereal disease). While she preferred to indicate a general reason for the student's visit on the more public encounter form, it was essential that confidential coding in the database reflect the appropriate diagnosis for the study. Communication with Medical Records accomplished this goal. In addition to these new relationships with Medical Records, it is important to consider the traditional function of Medical Records as the center for any medical records, either paper and pencil or computerized. Related to this more traditional type of interaction, however, respondents uniformly emphasized their new independence in being able to retrieve student information such as telephone numbers through the computer without going to Medical Records to look the information up in the student's medical record. While Medical Records did, in fact, supply this information by downloading it each quarter from the campus computer, interpersonal communication was no longer necessary to transfer the information to other departments. Thus, the centrality of Medical Records (at least in terms of interpersonal communication) attributable to traditional Medical Records functions seemed to decrease. while Medical Records employees' new role as computer "gurus" for the 205 organization as a whole increased their communication with other departments. Finance/Personnel. Interview respondents also described changes in their relationships with employees in Finance/Personnel, changes that were confirmed by questionnaire results. The most striking new interactions involved Finance/Personnel's new role in tracking the operations of all SHS departments. The negotiation of this new role, supported by SHS administrators, occasioned ongoing exchanges between Finance/Personnel and other SHS departments, both to accomplish the task and to gain acceptance from other departments of Finance/Personnel1s new role in monitoring SHS operations. The central task in this new role involves the reconciliation of "activity codes" entered in the computer by each department with the information entered on encounter forms. SHS policy specifies that the department closest to each activity enter the codes in the computer from the encounter forms. Thus the Lab enters lab tests; the clinics enter visits, injectables, etc. As described in Chapter 3, an employee from Finance/Personnel personally goes to each department to collect the departmental copies of the encounter forms. Finance/Personnel then reconciles these copies with the 206 data entered in the computer and generates "follow-up reports" that are returned to the department indicating errors in computer entry that need correcting. The computerized information from the activity codes provides the organization with much closer tracking of operations than was possible in the past. In fact, before the computer system was implemented, little information was available. During the summer months, when students are required to pay for services, students often did not understand SHS's summer policy and walked out without paying. Finance/Personnel had to depend upon clinicians for information concerning any medical services provided to students. In addition, according to Finance/Personnel employees, the system has also highlighted operational problems and made the need for policies and procedures obvious, a need not felt before the computer system was implemented. As one respondent noted, the system "forces you to articulate things" and understand how things are related. Before the computer system, different departments had different procedures; "now it's necessary to know the proper way." The procedures for Finance/Personnel's new reconciliation of activity codes evolved during the system implementation process. In fact, during the early stages of the computer system, 40 percent of the 207 encounter forms did not match the data coded into the computer by the departments. Initial feedback to the clinics concerning errors and missing encounter forms was met with resentment at first, especially on the part of physicians in the clinics. In general, employees in Finance/Personnel seemed sensitive to the possibility that their new role might threaten some employees. Finance/Personnel’s "follow-up report" refers to errors as "follow-ups" rather than errors, but does make percentage comparisons by department. This new interaction between SHS departments and Finance/Personnel actually created an occasion for clerks in other departments to improve understanding of the system and data entry procedures. Employees in Finance/Personnel, however, also learned about the nature of the tasks performed by other departments. The employee assigned to handle the follow-up reports (a new SHS employee) spent over two hours in each department observing the different methods of doing computer tasks and then worked with administrators to resolve differences and standardize the system. She approaches errors as problems to be solved rather than "errors." Both "walk-outs" and "follow-ups" have decreased The enlarged role of Finance/Personnel has elicited different reactions in different departments. Most 208 interview respondents simply noted that someone from Finance/Personnel picked up their copies of the encounter forms and worked with them on errors. One respondent, however, vehemently described her as someone who "does nothing else but analyze errors and circulate graphs showing the errors of all departments for everyone to see." Some of these problems had dissipated by Time 3, however, and Finance/Personnel employees were beginning to resemble Medical Records employees as informal computer "gurus" for computer users in other departments. SHS administrators were also aware of the threatening nature of the new administrative aspects of the system. Not only has the system added both additional work and surveillance of this work, it is also unclear what benefits employees, as a whole, may expect from the system. System implementers have been careful to refer to the computerized information entered by each department as "activity codes" rather than "billing codes" (as they are called in system documentation). Administrators hope to communicate to departments that the computer will provide the departments themselves with useful reports on their own activities, rather than just tracking information for administration. Many employees, from clerks to technologists to nurse practitioners, however, feel no need for reports on their department's 209 activities. In addition, clinicians who wish additional reports not automatically generated by the system must go through their own department heads to request them. In the interviews, even some department heads saw no need to have a record of the numbers of different procedures their department performed. Conclusions The hypotheses concerning changes in boundaries between departments predicted that participation in the implementation process and system use would influence employee perceptions of increased (1) "information exchange," and (2) "understanding the work of other departments." Results from the regression analyses indicated that the participation variables, but not system use alone, predicted perceptions of increased information exchange between departments. In addition, only certain types of participation were predictive of perceived changes in departmental boundaries. Specifically, Relations with Computer Staff and Work Group Communication predicted increases in information exchange between departments. Thus, ongoing discussion with the computer staff and one's own co-workers not only predicted, but perhaps actually constituted, the increased information exchange. 2 10 Similar results were found for increases in understanding the work of other departments. Regression analyses showed that specific participation variables, but not system use, predicted increased understanding of the work of other departments. In this case, however, t-tests did indicate significant differences between computer users and non-users in increases in understanding the work of other departments. Based upon these results, Hypotheses 7a and 7b, predicting participation in the implementation process as a determinant of increased information exchange and understanding between departments, were not rejected. Hypotheses 8a, predicting use of the computer system as a determinant of increased information exchange between departments, was rejected. Hypothesis 8b, predicting use of the computer system as a determinant of increased understanding of other departments' work was also tentatively rejected, despite the t-test results. The regression analyses indicated participation to be overwhelmingly more important than computer use in predicting changes in department boundaries. Summary The results for changes in department boundaries indicated that participation in the implementation process (Hypothesis 7), but not computer use alone 2 11 (Hypothesis 8), predicted increases in the openness of boundaries between departments. Thus the model detailed in Figure 2.3 (Chapter 2) was only partially confirmed. Additional analyses, as well as interview findings, pinpointed actual departments and negotiations between them to illustrate the statistical findings. These different types of interactions, and their implications, will be discussed in further detail in the next chapter. 212 Chapter 6 DISCUSSION Chapter 4 detailed findings indicating that (1) occupational and departmental social worlds, (2) specific types of participation in the implementation process, and (3) several aspects of computer use predicted employee attitudes toward the computer system. Chapter 5 extended the analysis by showing that participation in the implementation process, but not computer use alone, predicted perceptions of increased openness between departments. The present chapter discusses these findings and suggests implications that follow from them. The first section examines the theoretical implications within the framework of the symbolic interactionist perspective presented in Chapter 2. The second section addresses implications for practice in organizations involved in technological innovation and for medical care organizations implementing integrated information systems in particular. Theoretical Implications The symbolic interactionist framework adopted for the present study provides researchers with a useful perspective for understanding the "how" and "why" of changes taking place within an organization faced with 213 implementing a technological innovation, specifically an integrated information system. The present dissertation used a case study approach to explore the impacts of a computerized medical information system on the social worlds of the Student Health Service (SHS) of a major university. Findings indicated that existing social worlds tended to shape individual attitudes toward the new computer system. These social worlds themselves were, in turn, shaped and changed by negotiations among their members during the computer implementation process. Thus, the existing social structure shaped individual reactions to the computer system. But these same individuals, in turn, creatively altered their own patterns of interaction in ways that could ultimately change the social structure of the organization (Stryker, 1981). Figure 6.1 illustrates this overall model of organizational change. According to this model, existing occupations, task arrangements, and organizational structures shape the attitudes of individuals and the interactions that occur. These interactions, in turn, however, create new task arrangements and interdependencies that may, in time, reshape the organization as well as the occupations of individuals working within it. 214 Figure 6.1 Model of Change in Organizational Social Worlds Organizational Social Worlds Attitudes Negotiations Organizational Social W orlds J 2 15 The following sections describe this process in more detail by connecting the study findings with the basic concepts of the symbolic interactionist framework and its notion of negotiated order. First, we describe the ways in which social worlds determined individual reactions to the computer system. Second, we address the negotiations involved in the implementation process and, finally, we discuss the ways in which individuals, reacting to new work demands, changed communication patterns between the social worlds of the organization in which they worked. The use of the symbolic interactionist perspective serves to connect the present research with prior studies in the symbolic interactionist tradition describing a variety of different social worlds. While the boundaries of the social worlds described are often defined more broadly than in the present study, they share an approach to understanding observed phenomena. In describing the allocation of tasks in "art worlds," for example, Becker (1982, pp. 11-12) notes the following parallel with health care settings: Each kind of person who participates in the making of art works, then, has a specific bundle of tasks to do. Though the allocation of tasks to people is, in an important sense, arbitrary— it could have been done differently and is supported only by the agreement of all or most of the other participants— it is not therefore easy to change. The people involved typically regard the division of tasks as 216 quasi-sacred, as "natural" and inherent in the equipment and the medium. They engage in the same work politics Everett Hughes (1971, pp. 311-315) describes among nurses, attempting to get rid of tasks they regard as tiresome...seeking to add tasks that are more interesting, rewarding, and prestigious. Thus the present study shares Becker's (1982) focus on the allocation of tasks and issues of change and negotiation between members of a particular social world, aspects of the division of labor that ultimately determine how the work is carried out. Social Worlds as Predictors The individual's social world, characterized by both occupation and department, was hypothesized to predict attitudes toward the computer. Findings indicated that both occupation and department predicted initial expectations for the computer system, and also influenced changes in attitudes by (1) determining the ways in which computer tasks were allocated, and (2) providing interpretations (e.g., exciting, challenging, burdensome, difficult, etc.) of these new work experiences for individuals within the group. Neither occupation nor department, however, emerged as the more powerful influence. Rather, occupation and department seemed to influence different groups differently. Professional norms, for example, probably caused SHS physicians to expect to influence system 217 decisions and react negatively when they perceived they had lost control over system decisions. While other departments also expressed dissatisfaction with their level of involvement in decision-making, lack of involvement seemed to be the deciding issue for physician attitudes. Occupational expectations, however, also affected the interpretations of computer system use for other medical employees. Learning and using the computer seemed burdensome to many. Nurse practitioners, x-ray technologists, and others objected to using the system, maintaining that it was an inappropriate use of time for people trained to perform medical work. Many also felt that learning the computer system was too much to expect on top of an already stressful job. These perceptions on the part of medical employees must also be viewed in light of work pressures in the health care industry at the time of the study. Nurses in many settings were in short supply and frequently found themselves working extra shifts with an inadequate number of nurses to complete the work. While SHS employees did not complain of short staffing, triage nurses had to deal with lines of students waiting to be seen, while nurse practitioners were also scheduled with student appointments throughout the day. The flow of work at SHS 218 did not allow nurses time specifically to work on the computer. Nurse practitioners, however, were also strongly influenced by the department in which they worked. (There were not enough physicians in departments outside of Primary Care to make comparisons between physicians in different departments.) Nurse practitioners in Primary Care, for example, had initial difficulties using the system while doing triage, eventually negotiated for a clerk to do computer entry for the two newly-hired triage nurses, and, in the long run, were actually forbidden by administrators to use the computer. In Women's Health, however, all personnel, including nurse practitioners, used the system and shared system tasks, just as all Women's Health personnel were expected to take their turn at the front desk. While the norm in Women's Health was sharing the work, Primary Care defined distinct jobs and negotiated new work arrangements that clearly delineated everyone's job description. Most of the other departments more closely resembled Women's Health, sharing the new tasks among all employees. Clearly, different departments approached system implementation differently, guided by pre-existing understandings between social world members concerning how work is done. 219 Computer Implementation and Negotiation In addition to occupational and departmental social worlds, certain types of participation in the computer implementation process influenced individual attitudes and interpretations of system use. The analyses consistently showed that two variables, an individual's Relations with the Computer Staff and the amount of computer-related Work Group Communication, predicted both changes in attitudes toward the computer system and increased communication with individuals in other departments in the organization. These participation variables reflected the nature of the implementation process at SHS. Rather than conducting a series of formal meetings involving representatives of different occupations or departments, much of the work was conducted on a one-on-one basis involving the system coordinator/trainer and one (or a few) computer users in a particular department. System policy decisions were made by a small group that included the SHS executive director, system coordinator/trainer, and system analyst. Individuals in the various departments had little input in formal policy making, but they did have as much opportunity for informal interaction with those knowledgable about the system as their other work would allow. Opinions varied, however, 220 on whether the available time was actually sufficient to learn to use the system. Many respondents complained that learning time was limited and training inadequate. The variables measuring Relations with Computer Staff and Work Group Communication reflected the importance of these factors in SHS1s informal approach to system implementation. SHS's implementation arrangement, however, also precluded several types of interaction between departments that could have occurred. Formal meetings in which individuals from a number of different departments discuss problems and issues related to the computer system did not occur at SHS. On the other hand, a norm was established for informal interpersonal sharing of computer problems and ideas (although medical respondents, in particular, noted that they had no time for such interactions). Respondent interactions with Medical Records and some of the interactions with Finance/Personnel reflect this type of communication. Thus the SHS implementation process was characterized by ongoing interpersonal communication, sandwiched into a busy work schedule. Individuals often selected their own contacts to discuss the computer system, and a few individuals assumed the role of liaison or "guru" for workers in a number of departments. 221 The SHS computer implementation differed in an additional way from other implementation contexts. Dependence upon the information system at SHS varied by department, but was minimal for most departments. Previous research on medical information systems examined hospital systems in which physician medication orders were (1) entered in the computer by nursing, (2) verified by pharmacy, and (3) used by both pharmacy and nursing to carry out physician orders (Aydin, 1989). In these instances, maintenance of the computerized database became a superordinate goal, "compelling for the groups involved, but not... achieved by a single group through its own efforts and resources" (Sherif & Sherif, 1969, p. 255; Worschel, 1986). Such superordinate goals have been found to induce cooperation between groups, even if the groups have been hostile in the past (Worschel, 1986). In contrast, most SHS departments had little real need to use much of the data, with the exception of student telephone numbers, follow-up billing (cashier's office), and eligibility information. Thus, the implementation process at SHS did not involve departments negotiating issues related to an information resource upon which they all depended. At SHS, the clinics were most concerned with how efficiently the computer could schedule patients. They also expected Medical Records to 222 make the university student database available. Otherwise, each department simply entered activity codes ' primarily for the use of Finance/Personnel and administrators in tracking SHS operations. Other benefits such as the increased legibility of the encounter form and fewer errors in ordering lab tests actually resulted from the new forms accompanying the system, rather than from use of the integrated database itself. Negotiations between individuals, however, did occur on several different levels. The negotiated order in an organization includes both explicit and implicit rules governing how the organiztion works (Lucas, 1987). Different groups within an organization may attempt to have their model of reality dominate the organization's negotiated order. In the case of SHS, for example, physicians lost the power to define the computer as a clinical rather than administrative system. Administrators, however, were sensitive to system opposition on the part of many employees and attempted to convince medical personnel that the computer system would benefit them as well, at least in the long run. One strategy involved administration attempts to influence employee opinions of the value of the system by renaming what the system originally called "billing codes" as 223 "activity codes." This change in terminology implied that these "activity codes" would be useful for departments to l track their own activities, in addition to providing a financial database for SHS. Finance/Personnel's use of the term "follow-up" rather than "error" to make the encounter form reconciliation procedures more palatable involved a similar negotiating strategy. According to Finance/Personnel employees, the computer system can be used to improve student service in the long run if employees have time to learn to retrieve the relevant data. Changes in Organizational Social Worlds As noted by Kling (1980), computers "do" nothing to anybody, but are adopted and organized to fit the interests of dominant parties in a given social world. The foregoing findings provide ample evidence for the dominance of SHS administration in selecting the functions and dictating the organization of the new computer system. Individuals within the organization, however, also creatively altered communication patterns within the organization in ways that could affect the functioning of the organization as a whole. While system planners dictated some changes in interaction patterns through the design of the system itself, more changes in communication patterns were 224 initiated by employees themselves surrounding the computer system. These changes involved increased interpersonal communication between departments about the computer system, rather than simply changes from interpersonal to computer communication dictated by system capabilities. These increases in interpersonal communication constituted increased openness of boundaries between departments. The openness of boundaries between departments within an organization can be conceptualized as a continuum ranging from completely closed boundaries, with no contact or communication between departments, to very open boundaries, where contacts between employees are frequent and communication flows freely. The concept, however, is most useful in a comparative sense to measure change within the organization or to compare the relative openness of one department with that of another. Furthermore, the level of communication appropriate to the relationships between different departments may be different, depending upon work needs. The present study predicted and documented a number of different types of boundary changes, each of which has implications for organizational functioning. Planned changes. Computer system planners often deliberately change the tasks or roles of individual 225 departments with the implementation of a computer system. Often, however, planners do not consider either the positive or negative effects of these changes on the relationships between departments. Both Finance/Personnel and the Laboratory at SHS are examples of departments with newly assigned tasks or roles related to the computer system. Both departments were involved in increased communication with other departments since implementation of the computer system. Finance/Personnel, in particular, had to negotiate an entirely new role in relation to the other SHS departments. One Finance/Personnel employee, in fact, visited other departments daily to collect encounter forms and discuss data entry errors. The success of this new relationship depended upon administrative support, the sensitivity of Finance/Personnel employees, and the willingness of other departments to accept Finance/Personnel's new "watchdog" role. Time 3 interviews indicated that, after initial resentment, most departments accepted the change. In fact, some of the other departments even began to view Finance/Personnel employees as informal computer "gurus," intiating contacts beyond those required, in order to discuss computer problems. Thus, the boundaries between Finance/Personnel and other departments involved with the 226 computer system showed increased contacts, especially interpersonal communication, and an increase in the knowledge of the work of the other department. Mutual dependence. As noted above, fewer departments at SHS actually depended upon system information than in other organizations with medical information systems (e.g., Aydin, 1989). For the most part, Finance/Personnel depended upon other departments to enter the data required to generate reports on SHS operations. This dependence was, undoubtedly, an important factor in Finance/Personnel1s diplomatic approach to other departments when reconciling problems with "activity codes." Again, increased contact between departments resulted. Another example of mutual dependence involved departments that wished to conduct special studies and depended upon Medical Records for appropriate coding of the diagnostic information used to categorize patients. In this instance, Medical Records also depended upon the other department (e.g., clinicians in Women's Health) to enter the diagnosis in the medical record for coding. A Women's Health respondent described discussions with Medical Records personnel to ensure that proper coding was done, another example of increased communication across department boundaries. Even by Time 3, however, 227 few departments had begun to generate studies or reports requiring this type of dependence upon each other. Informal communication. The emergence of both Medical Records and Finance/Personnel employees as informal computer "gurus" for other SHS computer users resulted in additional contacts between both of these departments and computer users in other departments. These interpersonal contacts developed surrounding the computer system with the computer system as the topic of communication. A clinical assistant in Women's Health, for example, noted that she frequently went over to Medical Records to discuss computer problems or new ways of doing things. Both Medical Records and Finance/Personnel respondents reported that others contacted them frequently with questions about the computer system. A larger question concerns whether employees have actually created a new social world through these new informal communciation patterns. Numerous researchers have described social worlds based upon a "computer culture" (e.g., Kling & Gerson, 1977; Sproull, Kiesler, & Zubrow, 1984; Turkle, 1984). In Chapter 2, we defined a social world as a: subset of an organization's members who interact regularly with one another, identify themselves as a distinct group within the 228 organization, share a set of problems commonly defined to be the problems of all, and routinely take action on the basis of collective understandings unique to the group. (Van Maanen & Barley, 1985, p. 38) SHS respondents who used the computer system reported ongoing interactions related to a common set of problems (i.e., the computer), upon which they also took action (i.e., tried new ways of doing things). They did not, however, identify themselves as a distinct group. Furthermore, while most interacted with Medical Records and Finance/Personnel, the amount of interaction with each other was questionnable. Future data is needed to determine whether these new communication patterns did, in fact, constitute a social world in the making. One final point must be made concerning the position adopted in this study. In contrast to the pluralist argument advanced in the present study, some researchers within the pessimist tradition have predicted increased isolation between workers within organizations as a result of computerization (Hirschheim, 1985). The present study, however, found little evidence for increased isolation. Those instances in which certain types of communication did decrease were more than counterbalanced by instances of increased communication between the same groups (although this need not have been the case). Medical Records was a case in point. Employees 229 from other departments no longer needed to physically retrieve medical records to get student telephone numbers, thus eliminating one type of interpersonal contact between Medical Records and other departments. This reduction in communication, however, was more than counterbalanced by increases in contacts to discuss issues related to the computer system. These findings, however, may also be attributed to particular characteristics of the organization under study. Different outcomes might well occur under different conditions; e.g., (1) in a larger organization, (2) without SHS's ongoing personal relationships between employees and the computer implementation staff, and where (3) more workers actually depend upon the information provided by the computer. Further research is essential to determine the limiting assumptions and conditions under which specific results might be expected (McGuire, 1983). In summary, at SHS employees altered communication within the organization as a whole by initiating new interpersonal contacts surrounding the computer system. These patterns were all the more noteworthy because most departments did not depend upon each other for entry or maintenance of data. They all needed to accomplish work using the computer, but each department's employees could 230 have, for the most part, worked separately if they had so desired. The new communication patterns described in this study may indicate the beginning of a new social world surrounding the computer system. The members of this social world were not computer "hackers.” Their concerns and the terminology they used probably had little in common with most social worlds centered around computers. Clerical workers (for the most part), as well as medical personnel, created patterns of communication that worked for them as they attempted to find the best ways to integrate a new computer system into their work. The practical implications of these documented changes in interaction patterns between departments are discussed below. Implications for Practice The delivery of medical care hinges on effective communication between interdependent departments in health care organizations. Changes in communication between these departments have the potential to affect the coordination of medical care in the organization as a whole. The present study has documented (1) the importance of communication within pre-existing social worlds in determining employee attitudes toward a new integtated information system, and (2) changes in 231 communication patterns across the boundaries of these social worlds accompanying computer system implementation. Results have implications for both (1) managing the implementation of a medical information system, and (2) the effective functioning of the organization. The medical information system at SHS created a student database used by all departments for student demographic and eligibility information. In addition, the entry of activity codes has provided information to monitor SHS clinic operations. The system has made scheduling of student appointments more efficient. The encounter form, generated by the computer system and used to enter data concerning all visits and procedures, has clarified operations and simplified paperwork for student patients. The increased openness of boundaries between departments also has the potential to improve communication and understanding in all contacts, not just those related to the computer system. The increased knowledge of the work of other departments can smooth interactions between departments, whether or not the interactions concern the computer system. In addition, the computer system has the potential to improve the quality of medical care by providing information needed 232 to generate quality assurance reports concerning the medical care provided by SHS for student patients with specific diagnoses. The computer system has also created additional work for many employees, some of which generates information that is, so far, useful only to SHS administrators. Although part-time students enter much of the data, medical personnel, in particular, have found it difficult to add computer tasks to an already busy work day. They have found it difficult to (1) find time to learn to use the computer, (2) explore the reports and analyses available through the system, and (3) interrupt their other duties to enter data. Office/clerical workers who use the computer terminals most of the day, on the other hand, have developed positive attitudes toward a system that makes their work easier. To date, most computer tasks have been absorbed within existing positions, creating a situation in which personnel feel they have reached the limits of what they can handle in their jobs. Results also showed non-medical employees to have more positive attitudes toward the computer system than medical employees. This finding was traced to two phenomena. First, the system, to date, had been operating primarily as an administrative system. The computer system was more useful to clerical and 233 administrative employees than to medical workers. Second, medical workers, because of the demands of their jobs, found it more difficult to devote the amount of time necessary to learn and use the system well (although they were also divided on whether they wanted to use it at all). Work Group Communication concerning the computer system was a consistant predictor of positive attitudes toward the system. Medical employees complained that it was impossible for them to find time for such communication. If, however, medical employees are to become effective system users, time must be provided for learning and using the system. In addition, however, to the time concerns of medical employees, SHS employees as a whole have absorbed computer system tasks into their pre-existing jobs. If system functions are to be expanded to include clinical information such as the reporting of lab results, etc., additional employee time or additional staff must be provided to accomplish these tasks. The problem of who is to be assigned data entry tasks, however, is a major issue in health care settings in general (e.g., Aydin, 1989; Ischar & Aydin, 1988). Solutions vary by setting, even within the same organization. In SHS, for example, Primary Care nurse practitioners negotiated for a division of labor in which 234 a clerk was assigned to do data entry for the new triage nurses. In the Laboratory, however, everyone shared the computer tasks. Both the amount of work and the unit's ongoing work patterns will probably affect final negotiations on task assignments. The issue of delegation of computer tasks, however, should also be examined in light of the conflicting technological and institutional bases for the traditional division of labor in health care (Meyer & Scott, 1983). Some tasks are assigned based upon technological imperatives such as the educational preparation of different occupational groups. The delegation of other activities to the appropriate occupations, however, is "socially expected and often legally obligatory over and above any calculations of its efficiency" (Meyer & Rowan, 1983, p. 25). The common assumption prevailing in many health care organizations that physicians should not be expected to enter their own orders in the computer fits the latter definition of an institutionalized myth. Descriptions of the processes through which concerns for efficiency may, in time, alter this assumption are an important goal for future research. System planners must also face the issue of employee involvement in the implementation process. While most SHS employees wanted more influence (as well as more 235 training), involvement became an overriding issue in physician attitudes toward the system. In fact, at Time 3, SHS administrators were attempting to alleviate some concerns of managers not involved in system implementation by forming a new "Managers' System Users Group." 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On the Validity of the ! Analytic-Heuristic Instrument. Utilized in "The j Minnesota Experiments." Management Science. 24. ! 1088-1090. I jZmud, R.W.(1979). Individual Differences and MIS Success: A Review of the Empirical Literature. Management Science, 25, 966-979. Zmud, R.W. & Cox, J.F. (1979). The Implementation Process: A Change Approach. MIS Quarterly. 3 , 35-43. Zuboff, S. (1988). In the Age of the Smart Machine. New York: Basic Books, Inc. Zuboff, S. (1982). New Worlds of Computer-Mediated Work. Harvard Business Review. 60, 142-152. 248 Appendix i Time 1 Questionnaire September 23, 1986 SHS NEEDS YOUR HELP! I As you know, the Student Health Center will soon begin using a I computer-based information system to help provide service to the UCLA I community. In order to better understand how the system can help SHS meet ] its goals, SHS will be working with researchers from the Graduate School of i Management at UCLA (Dr. Lynne Markus, 825-8494) and from the Annenberg School of Communications at USC (Dr. Ron Rice, 743-7427). | The SHS Information System Study Group would like to ask you to help by completing and returning this questionnaire. It should take about 20 minutes, j Your participation is very valuable! This is not a test. There are no right or wrong answers. We are only interested in your candid opinions. Throughout the questionnaire, simply circle or write in the number that best represents your response to the specific question. (The small numbers in the margins are for keypunching purposes only.) The last page is a separate questionnaire with its own instructions. Please do not discuss the questionnaire with others until you have mailed it in the return envelope. In order to understand how your opinions about your work and the new information system might change, and to authorize your participation in this study, it is very important that you write your name on the questionnaire. The researchers guarantee the confidentiality of all respondents bv providing return envelopes addressed to Dr. Markus1 office. SHS personnel will not have access to your questionnaires or individual responses. All respondents to this questionnaire will receive executive summaries of the results and will have access to the full technical reports. You can request a summary of vour responses at the end of this questionnaire. Please let us know your opinions by completing the questionnaire, placing it in the envelope, and putting the envelope in campus mail today. You may want to keep this cover sheet for your information. I j We thank you for your thoughts and time, | The SHS Information System Study Group I Time 1 Questionnaire (continued) 249 SHS INFORMATION SYSTEM STUDY I. This section asks you a few questions about yourself and your job. Please print and sign your name. This is very important, as it makes it possible to ask you how your opinions and experiences with the system change over time. It also indicates your consent to participate in the SHS Study. Your responses will be completely confidential. No SHS personnel will have access to your answers. /-S' Printed Name Signature How long have you been in the health field? / How long have you been employed in SHS? /_ What is your job title? _________________ Are you full or part-time? Full-time 1 What is your age? ____ What is your sex? Female 1 years / months years / months Part-time years Male 6-f A>-<r^ HHf It — / ? - « — I ? — What is your highest level of formal education? High School 1 Some Graduate School 4 Some College 2 Master's Degree 5 College Graduate 3 Ph.D. or M.D. 6 Please circle the highest level of experience you have had with computers: None 1 Using reports or information produced by a computer 2 Entering data by using a terminal 3 Doing word processing on a terminal or computer 4 Using other applications (databases, statistics, etc.) 5 Programming 6 For how many years have you had that highest level of experience? years H - b - II. This section asks about your expectations concerning learning how to use the new SHS information system. Your job may involve providing information to, or using information from, the system. Even if you may not actually use the system yourself, please give your opinions about these statements. Use the following code to indicate your response: How much do you agree with the following statements? The system will be easy to learn to use. The system will be easy to use for different kinds of tasks. I will continue to learn new ways to use the system. A lot of training will be needed to use the system well. It will take a long time to become competent at using the system. There are tasks in SHS that could be done better with the system. 1 - Strongly disagree 2 - Disagree 3 - Slightly disagree 4 - Neutral 5 - Slightly agree 6 - Agree 7 - Strongly agree 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 *1 Time 1 Questionnaire (continued) 250 How long do you think it will take you (estimate days OR weeks OR months) to learn the system well? days __ weeks __ months _ How long do you think it will take you to be able to use the system to improve services at SHS? __ days __ weeks __ months _ 33-35* 111. These questions ask about your expected use of the system. Even if you will not actually use the terminals, your work may provide some information to, or may require some information from, the system. Thus, answer these questions with a very broad notion of "use" in mind. How much do you expect to use the new system? Never Use the terminals 1 Provide information for the system 1 Use information provided by the system 1 Use reports provided by the system 1 Once a week 2 Several Once a day Times a day Most the 5 of day IV. This section asks you a few questions about the nature of the work you do in SHS. In answering the following questions, please describe your job as objectively as you can, by circling the appropriate number for each question: 1. To what extent does your job require you to WORK CLOSELY with other people (either "patients" or people in related jobs in SHS)? 1-Very little; dealing with other people is not at all necessary in doing the job. 4—Moderately, some dealing with others is necessary. 7—Very much, dealing with other people is an absolutely essential and crucial part of the job. 2. How much AUTONOMY is there in your job? That is, to what extent does your job permit you to decide ON YOUR OWN how to go about doing the work? 1—Very little; the job gives me almost no personal "say" about how and when the work is done. f t-- 4—Moderate autonomy; many things are standardized and not under my control, but but I can make some decisions about work. 7—Very much; the job gives me almost complete responsibility for deciding how and when the work is done. 251 Time 1 Questionnaire (continued) 3. To what extent does your job involve doing a "WHOLE" and IDENTIFIABLE piece of work? That is, is the job a complete piece of work that has an obvious beginning and end? Or is it only a part of the overall piece of work, which is finished by other people or by automatic machines? 1-My job is only a tiny part of the overall piece of work; the results of my activities cannot be seen in the product or service. 4—My job is a moderate - sized "chunk" of the overall piece of work; my own contribution can be seen in the final outcome. ■&- 7—My job involves doing the whole piece of work, from start to finish; the results of my activities are easily seen in the final product or service. 4. How much VARIETY is there in your job? That is, to what extent does the job require you to do many different things at work, using a variety of your skills and talents? 1—Very little; the job requires '4-Moderate me to do the same routine variety, things over and over again. 7—Very much; the job requires me to do many different things, using a number of different skills & talents. 5. In general, how SIGNIFICANT or IMPORTANT is your job? That is, are the results of your work likely to significantly affect the lives or well-being of other people? 1-Not very significant; the 4=Moderately outcomes of my work are not significant, likely to have important effects on other people. 7-Highly significant; the outcomes of my work can affect other people in very important ways. 6. To what extent do managers or co-workers LET YOU KNOW how well you are doing on your job? 1-Very little; people almost never let me know how well I am doing. 4—Moderately; some times people may give me "feedback", other times they may not. 7—Very much; managers or co-workers provide me with almost constant "feedback" about how well I am doing. 7. To what extent does DOING THE JOB ITSELF provide you with information about your work performance? That is, does the actual work ITSELF provide clues about how well you are doing -- aside from any "feedback" co-workers or supervisors may provide? 1-Very little; the job itself is set up so I could work forever without finding out how well I doing. 4-Moderately; sometimes doing the job provides "feedback" to me; sometimes it does not. 7-Very much; the job is set up so that I get almost constant "feedback" as I work about how well I am doing. 252 Time 1 Questionnaire (continued) V. Below are five items which summarize the degree to which you feel satisfied with various aspects of your job. Please read each carefully and circle the response which best describes your feelings. Use the following code to indicate your response: How s a t i s f i e d a r e y o u w i t h : 1 - Strongly dissatisfied 2 — Dissatisfied 3 - Neutral or no opinion 4 - Satisfied 5 - Strongly Satisfied ...the nature of the work you perform? 12 3 4 5 ...the person who supervises you - - your organizational superior? 12 3 4 5 ...your relations with others in the organization with whom you work -- with your co-workers? 12 3 4 5 ...the pay you receive for your job? 12 3 4 5 ...the opportunities which exist in this organization for advancement -- with promotion? 12 3 4 5 VI. These questions ask you a few more questions about the nature of your job. 1 ■ = Very inaccurate 2 — Mostly inaccurate 3 - Slightly inaccurate 4 - Uncertain 5 — Slightly accurate 6 = Mostly accurate 7 = Very accurate Use the following code to indicate your response: How accurate is each of the following statements about vour job? The job requires me to use a number of complex or high-level skills. The job requires a lot of cooperative work with other people. The job is arranged so that I do not have the chance to do an entire piece of work from beginning to end. Just doing the work required by the job provides many chances for me to figure out how well I am doing. The job is quite simple and repetitive. The job can be done adequately by a person working alone --without talking or checking with other people. The supervisors and co-workers on this job almost never give me any "feedback" about how well I am doing in my job. This job is one where a lot of other people can be affected by how well the work gets done. The job denies me any chance to use my personal initiative or judgement in carrying out my work. Supervisors often let me know how well they think I am performing the job. The job provides me the chance to completely finish the pieces of work I begin. The job itself provides very few clues about whether or not I am performing well. The job gives me considerable opportunity for independence and freedom in how X do the work. The job itself is not very significant or important in the broader scheme of things. 4 4 4 4 4 2 3 4 5 6 7 2 3 4 5 6 7 2 3 4 5 6 7 2 3 4 5 6 7 if-- 5V l > 5 253 Time 1 Questionnaire (continued) VII. This section asks you to rate how satisfactory are the following aspects of SHS service Use the following code to indicate your response: How satisfactory do vou think SHS is in these aspects of service? Number of patient complaints about service Number of students/patients seen Availability of clinicians Flexibility of staff schedules Number of lost files Ability to retrieve specific demographic data from patient files for use in identifying patient populations, medical needs, etc. Mixing up files, confusing patients, etc. Turnaround time on handling patient cases Overall quality of care Followup of patients Very unsatisfactory Mostly unsatisfactory Slightly unsatisfactory Uncertain Slightly satisfactory Mostly satisfactory Very satisfactory to T h e s e a r e m o r e g e n e r a l a c t i v i t i e s . I n t h e s a m e w a y y o u r a t e d t h e a b o v e a c t i v i t i e s , p l e a s e r a t e h o w s a t i s f a c t o r y SHS I s c u r r e n t l y i n a c c o m p l i s h i n g t h e s e a c t i v i t i e s . Other non-medical record keeping 1 2 3 4 5 6 Operational planning and organizing 1 2 3 4 5 6 Operational monitoring and analysis 1 2 3 4 5 6 Appropriate job-related use of the telephone 1 2 3 4 5 6 Distributing mail Availability of resources for 1 2 3 4 5 6 copying, collating, sorting Availability of policy and 1 2 3 4 5 6 procedure information 1 2 3 4 5 6 Preparing presentation materials Inter-personal communication with: 1 2 3 4 5 6 -- co-workers 1 2 3 4 5 6 -- patientsl 1 2 3 4 5 6 - - supervisors or managers 1 2 3 4 5 6 Use of time for meetings 1 2 3 4 5 6 Scheduling appointments, keeping calendars 1 2 3 4 5 6 // 1 3 VIII. This section asks you to indicate the overall attitude of different people about the new system. 1 - Strongly disagree 2 - Disagree Use the following code to 3 - Slightly disagree indicate your response: 4 — Neutral 5 - Slightly agree 6 — Agree 7 - Strongly agree To what extent do you agree that the following people think that the new SHS information system will be worth the time and effort required to use it? Your co-workers Your supervisor Your closest friends at SHS Students who are SHS patients You -- your opinion * r 254 Time 1 Questionnaire (continued) IX. This section asks you to indicate your attitudes and the attitudes of your co-workers and supervisor about work in general at SHS. 1 — Strongly disagree 2 - Disagree 3 — Slightly disagree 4 — Neutral 5 — Slightly agree 6 - Agree 7 - Strongly agree Use the following code to indicate your response: How much do you agree with the following statements? The work I do on this job is very meaningful to me. 1 2 It's hard, on this job, for me to care very much about whether or not the work gets done right. 1 2 I usually know whether or not my work is satisfactory on this job. 1 2 Most of the things I have to do on this job seem useless or trivial. 1 2 4 4 4 4 I feel a very high degree of personal responsibility for the work I do on this job. 1 2 3 4 5 6 7 I often have trouble figuring out whether I'm doing well or poorly on this job. 1 2 3 4 5 6 7 I feel I should personally take the credit or blame for the results of my work on this job. 1 2 3 4 5 6 7 Whether or not this job gets done right is clearly my responsibility. 1 2 3 4 5 6 7 I generally do not have the time to learn or experiment with possible new procedures or uses of equipment. 1 2 3 4 5 6 7 My co-workers and/or I develop new procedures and/or uses of equipment. 1 2 3 4 5 6 7 Other people do not generally encourage me to experiment with new procedures or uses of equipment. 1 2 3 4 5 6 7 Organizational policies generally discourage me from developing new procedures or uses of equipment. 1 2 3 4 5 6 7 The new SHS information system will be worth the time and effort required to use it. 1 2 3 4 5 6 7 How much do you agree with the following statements? Most people on this job ... ...find the work very meaningful. ...feel a great deal of personal responsibility for the work they do. ...have a pretty good idea of how well they are performing their work. ...feel that the work is useless or trivial. ...feel that whether or not the job gets done right is clearly their own responsibilty. ...have trouble figuring out whether they are doing a good or bad job. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 3 V 255 Time 1 Questionnaire (continued) X. This last section is a bit different, and fun to answer. You can read the detailed directions on the next page, but you do not need to do so. These are the basic instructions: 1. Write your name on the front page. This will again make it possible to understand how your opinions and thoughts about your work and the new SHS information system might change. Your name is also necessary if you would like to receive your individual results. 2. Your answers to this "Myers-Briggs Type Indicator" will help show how you like to look at things and how you like to go about deciding things. i i j 3. Do not open the booklet, even though the back says to do so after you j finish. Just turn the booklet over and check the preferred box for each i question in both Part I and Part II. As with the whole questionnaire, there ! are no "right" or "wrong" answers. The outside researchers -- not SHS personnel -- will score the booklet for you. 4. Check here if you would like to receive a summary of your individual responses to the SHS Study questionnaire. You will receive your summary individual responses in 6 weeks or so, and the SHS summary will be available before the end of the quarter. Yes, I would like to receive a summary of my responses to this questionnaire ____ 5. Please -- keep the questionnaire and this extra section stapled together, -- make sure your name is on both sections, -- put the questionnaire with this extra section in the attached envelope, -- and mail the envelope in University mail to Dr. Markus' assistant. The return address should read: Ms. Ginny Hyatt Room 5350A Graduate School of Management CONFIDENTIAL Thank you for your important contribution to the SHS Study! V 7 - S 6 37-55 256 Time 2 Questionnaire SHS INFORMATION SYSTEM STUDY Please print and sign your name. This is very important, as it makes it possible to ask you how your opinions and experiences with the system change over time. It also indicates your consent to participate in the SHS Study. Your responses will be completely confidential. No SHS personnel will have access to your answers. __ Printed Name Signature I. This section asks you how different people think about the new SHS system. To what extent do you agree that the following people think that the new SHS information system will be worth the time and effort required to use it? 1 - Strongly disagree 2 Use the following code to 3 indicate your response: 4 5 6 7 Your co-workers 1 Your supervisor 1 Your closest friends at SHS 1 Students who are SHS patients 1 You - - your opinion 1 - Disagree - Slightly disagree - Neutral - Slightly agree - Agree - Strongly agree How important are the opinions of these people in influencing how you think about the new system? Use the following code to indicate your response: Your co-workers Your supervisor Your closest friends at SHS Students who are SHS patients 1 - Very important 2 - Important 3 - Slightly important 4 - Not important at all 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 II. This section asks you a few questions about the nature of the work you do in SHS. In answering the following questions, please describe your Job as objectively as you can, by circling the appropriate number for each question: 1. How much AUTONOMY is there in your job? That is, to what extent does your job permit you to decide ON YOUR OWN how to go about doing the work? 1-Very little; the job gives me almost no personal "say" about how and when the work is done. 4—Moderate autonomy; many things are standardized and not under my control, but but I can make some decisions about work. 7-Very much; the job gives me almost complete responsibility for deciding how and when the work is done. Time 2 Questionnaire (continued) 257 1 2. How much VARIETY is there in your job? That is, to what extent does the job require you to do many different things at work, using a variety of your skills and talents? 1-Very little; the job requires me to do the same routine things over and over again. How a c c u r a t e a r e t h e f o l l o w i n g s t a t e m e n t s a b o u t v o u r j o b ? 4-Moderate variety. Use the following code to indicate your response: The job is quite simple and repetitive. The job requires me to use a number of complex or high-level skills. The job denies me any chance to use my personal initiative or judgement in carrying out my work. The job gives me considerable opportunity for independence and freedom in how I do the work. 7-Very much; the job requires me to do many different things, using a number of different skills & talents. 1 - Very inaccurate 2 - Mostly inaccurate 3 - Slightly inaccurate 4 - Uncertain 5 - Slightly accurate 6 — Mostly accurate 7 - Very accurate 1 2 3 4 1 2 3 4 5 6 7 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 III. Listed below are several characteristics which could be present on any job. People differ about how much they would like to have each one present in their own jobs. We are interested in learning how much you personally would like to have each one present in your job. Use the following codes to indicate your response: Please indicate the degree to which you would like to have each of the characteristics present in your j ob... - Would like having this only a moderate amount (or less) - Would like having this very much. - Would like having this extremely much. -high respect and fair treatment from my supervisor. -great job security. -stimulating and challenging work. -chances to exercise independent thought and action in my job. -a sense of worthwile accomplishment in my work, -opportunities to be creative and imaginative in my work. -very friendly co-workers. -opportunities to learn new things from my work, -high salary and good fringe benefits, -opportunities for personal growth and development in my job. -quick promotions. moderate amount 1 1 1 very much 4 4 4 4 4 4 4 4 4 4 4 extremely much 6 6 6 6 6 6 6 6 6 6 6 Time 2 Questionnaire (continued) 258 IV. This section asks you questions based upon your expectations or actual use of the system. We have a broad notion of "use" in mind -- it may include using the terminals, providing some information to the system, or using some information from the system, or using reports produced by the system. Some people have already had some experience with the system. Some people have not had any experience with the system yet, but expect to use it in the future. And some people may not expect to use the system in any way. Even if you have not or may not actually use the system yourself, please give your opinions about these statements. Have you had any experience with using the SHS Information System? yes ___ no __ If ves. please answer the following questions based upon your actual experiences concerning learning how to use the new SHS information system. If no, please answer them based upon your expectations concerning learning how to use th new system. Use the following code to indicate your response: How much do you agree with the following statements? 1 - Strongly disagree 2 - Disagree 3 - Slightly disagree 4 - Neutral 5 - Slightly agree 6 - Agree 7 - Strongly agree The system is/will be easy to learn to use. The system is/will be easy to use for different kinds of tasks. I will continue to learn new ways to use the system. A lot of training is/will be needed to use the system well. It took/will take a long time to become competent at using the system. There are tasks in SHS that could be done better with the system. 4 4 4 4 4 4 5 5 5 5 5 5 6 6 6 6 6 6 How long do you think it takes to learn the system well? How long do you think it takes to be comfortable with the system? How long do you think it takes to be able to use the system to improve services at SHS? (estimate days OR weeks OR months) days __ weeks __ months days _ weeks __ months days __ weeks __ months If you answered the earlier question, ves. you have had experience with the system, please answer the next questions according to how much you have used it. If no, please answer them according to how much you expect to use the system. How much have you used, or expect to use, the system? Several Most of Never Once a week Once a day Times a day the day Use the terminals 1 2 3 4 5 Provide information for the system 1 2 3 4 5 Use information provided by the system 1 2 3 4 5 Use reports provided by the system 1 2 3 4 5 259 Time 2 Questionnaire (continued) V, This section asks you to rate how satisfactory are the following aspects of SHS service. Use the following code to indicate your response: How satisfactory do you think SHS Is in these aspects of service? Number of patient complaints about service Number of students/patients seen Availability of clinicians Flexibility of staff schedules Number of lost files Ability to retrieve specific demographic data from patient files for use in identifying patient populations, medical needs, etc. Mixing up files, confusing patients, etc. Turnaround time on handling patient cases Overall quality of care Followup of patients 1 - Very unsatisfactory 2 - Mostly unsatisfactory 3 - Slightly unsatisfactory 4 - Uncertain 5 - Slightly satisfactory 6 - Mostly satisfactory 7 - Very satisfactory 4 4 4 4 4 These are more general activities. In the same way you rated the above activities, please rate how satisfactory SHS Is currently in accomplishing these activities. Other non-medical record keeping Operational planning and organizing Operational monitoring and analysis Appropriate job-related use of the telephone Distributing mail Availability of resources for copying, collating, sorting Availability of policy and procedure information Preparing presentation materials Inter-personal communication with: -- co-workers - - patients - - supervisors or managers Use of time for meetings Scheduling appointments, keeping calendars 4 4 4 4 4 Time 2 Questionnaire (continued) VI. This question is a little different. Your answers will help describe how some jobs are related to other Jobs. Again, we assure you that your answers will be kept complete confidential. Please indicate: How f r e q u e n t l y , o n t h e a v e r a g e , d o y o u h a v e s i g n i f i c a n t d i s c u s s i o n s w i t h o t h e r SHS p e r s o n n e l a b o u t how y o u a c c o m p l i s h v o u r w o r k ? 0 - Not once since September 1986 For each person, please 1 - Once a month or so circle the number 2 - Several times a month that best indicates 3 - Every week the frequency 4 - Several times a day of those discussions. 5 - Every day 6 - Several times a day SHS SHS Once/ Several Every Several Every Several Personnel___________ Unit Never Month Times/mo Week Times/wk Day Times /day DIR 0 2 3 4 5 6 INS 0 2 3 4 5 6 IMM 0 2 3 4 5 6 MR 0 2_ 3 4 5 6 LAB 0 2 3 4 5 6 ADM 0 2 3 4 5 6 PC 0 2 3 4 5 6 MR 0 2 3 4 5 6 PC 0 2 3 4 5 6 ADM 0 2 3 4 5 6 ADM 0 2 3 4 5 6 WHS 0 2 3 4 5 6 PC 0 2 3 4 5 6 MR 0 2 3 4 5 6 ADM 0 2 3 4 5 6 PC 0 2 3 4 5 6 LAB 0 2 3 4 5 6 PC 0 2 3 4 5 6 WHS 0 2 3 4 5 6 SPC 0 2 3 4 5 6 PC 0 2 3 4 5 6 PC 0 2 3 4 5 6 HE 0 2 3 4 5 6 RX 0 2 3 4 5 6 SPS 0 2 3 4 5 6 PC 0 2 3 4 5 6 PC 0 2 3 4 5 6 PC 0 2 3 4 5 6 Once/ Several Every Several Every Several Never Month Times/mo Week Times/wk Day Times/day Time 2 Questionnaire (continued) How frequently, on the average, do vou have significant discussions with other SHS personnel about how vou accomplish vour work? SHS SHS Once/ Personnel __________ Unit Never Month PC 0 1 LAB 0 1 PC 0 1 SPC 0 1 WHS 0 1 PUR 0 1 WHS 0 1 SOC 0 1 PC 0 1 RX 0 1 INS 0 1 DDS 0 1 SOC 0 1 LAB 0 1 ADM 0 1 PUR 0 1 PC 0 1 PP 0 1 ADM 0 1 PC 0 1 IMM 0 1 PC 0 1 PC 0 1 RAD 0 1 PC 0 1 SPC 0 1 HE 0 1 PC 0 1 ADM 0 1 WHS 0 1 INT 0 1 PC 0 1 HE 0 1 PC 0 1 HE 0 1 MR 0 1 Several Every Several Every Several Times/mo Week Times/wk Day Times/day 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 Once/ Several Every Several Every Several Never Month Times/mo Week Times/wk Day Times/day 262 Time 2 Questionnaire (continued) How ... you're half-way through! please continue and give your best estimate... frequently, on the average, do vou have significant discussions with o t h e r SHS p e r s o n n e l a b o u t h o w v o u a c c o m p SHS P e r s o n n e l i s h v o u r w o r k ? SHS Unit Never Once/ Month Several Times/mo Every Several Every Week Times/wk Day Several Times/dav PC 0 1 2 3 4 5 6 MR 0 1 2 3 4 5 6 DDS 0 1 2 3 4 5 6 PC 0 1 2 3 4 5 6 PC 0 1 2 3 - 4 5 6 DIR 0 1 2 3 4 5 6 SPC 0 1 2 3 4 5 6 WHS 0 1 2 3 4 5 6 PC 0 1 2 3 4 5 6 HE 0 1 2 3 4 5 6 INS 0 1 2 3 4 5 6 MR 0 1 2 3 4 5 6 WHS 0 1 2 3 4 5 6 HE 0 1 2 3 4 5 6 LAB 0 1 2 3 4 5 6 ADM 0 1 2 3 4 5 6 MR 0 1 2 3 4 5 6 DDS 0 1 2 3 4 5 6 ADM 0 1 2 3 4 5 6 DIR 0 1 2 3 4 5 6 WHS 0 1 2 3 4 5 6 HE 0 1 2 3 4 5 6 INT 0 1 2 3 4 5 6 WHS 0 1 2 3 4 5 6 MR 0 1 2 3 4 5 6 LAB 0 1 2 3 4 5 6 ADM 0 1 2 3 4 5 6 SPC 0 1 2 3 4 5 6 MR 0 1 2 3 4 5 6 PC 0 1 2 3 4 5 6 PC 0 1 2 3 4 5 6 ADM 0 1 2 3 4 5 6 WHS 0 1 2 3 4 5 6 IMM 0 1 2 3 4 5 6 Once/ Several Every Several Every Several Never Month Times/mo Week Times/wk Dav Times/dav Time 2 Questionnaire (continued) 263 How frequently, on the average, do vou have significant discussions with SHS Personnel SHS Unit Never Once/ Month Several Times/mo Every Several Every Week Times/wk Dav Several Times/dav SPC 0 1 2 3 4 5 6 PC 0 1 2 3 4 5 6 ------ LAB 0 1 2 3 4 5 6 RX 0 1 2 3 4 5 6 ------ DIR 0 1 2 3 4 5 6 WHS 0 1 2 3 4 5 6 — - PC 0 1 2 3 4 5 6 PC 0 1 2 3 4 5 6 ------ SPC 0 1 2 3 4 5 6 MR 0 1 2 3 4 5 6 ------ ADM 0 1 2 3 4 5 6 RX 0 1 2 3 4 5 6 ------ DDS 0 1 2 3 4 5 6 RAD 0 1 2 3 4 5 6 ------ AUT 0 1 2 3 4 5 6 SPC 0 1 2 3 . 4 5 6 ------ PC 0 1 2 3 4 5 6 MR 0 1 2 3 4 5 6 ----- WHS 0 1 2 3 4 5 6 PC 0 1 2 3 4 5 6 ______ MR 0 1 2 3 4 5 6 SPC 0 1 2 3 4 5 6 ------ SPC 0 1 2 3 4 5 6 WHS 0 1 2 3 4 5 6 - - - PC 0 1 2 3 4 5 6 SOC 0 1 2 3 4 5 6 ______ WHS 0 1 2 3 4 5 6 DIR 0 1 2 3 4 5 6 ______ SPC 0 1 2 3 4 5 6 WHS 0 1 2 3 4 5 6 -- MR 0 1 2 3 4 5 6 WHS 0 Never 1 Once/ Month 2 Several Times/mo 3 Every Week 4 5 6 Several Every Several Times/wk Dav Times/dav THANK YOP! YOUR PARTICIPATION IN THE SHS INFORMATION SYSTEM STUDY IS VERY IMPORTANT. Please check to see that you wrote and signed your name at the beginning. Please return your questionnaire in the envelope with the return address to: Ms. Ginny Hyatt, Room 5350A, Graduate School of Management 264 Time 3 Questionnaire SHS COMPUTER SYSTEM STUDY Please print and sign your name. This is very important, as it makes it possible to ask you how your opinions and experiences with the system change over time. It also indicates your consent to participate in the SHS Study. Your responses will be completely confidential. No SHS personnel will have access to your answers. Printed Name Signature JL3___ 1-5 I. This section asks you a few questions about yourself and your job. What department do you work in? ___________________________ .__ 6 How long have you been in the health field? __ years ___ months 8 How long have you been employed in SHS? years months 12 What is your age? years 16 Are you full or part-time? Full-time 1 Part-time 2 __ What is your sex? Female 1 Male 2 __ What is your highest level of formal education? High School 1 Some Graduate School 4 Some College 2 Master's Degree 5 College Graduate 3 Ph.D. or M.D. 6 20 Please circle the highest level of experience you have had with computers before your experience with the SHS computer system: None 1 Using reports or information produced by a computer 2 Entering data by using a terminal 3 Doing word processing on a terminal or computer 4 Using other applications (databases, statistics, etc.) 5 Programming/repairing 6__________________ For how many years have you had this highest level of experience? ____ years 22 II. This section asks you a few questions about the nature of the work you do in SHS. In answering the following questions, please describe your job as objectively as you can: 1. To what extent does your job require you to WORK CLOSELY with other people (either "patients* or people in related jobs in SHS)? 1—Very little; dealing with other people is not at all necessary in doing the job. 4—Moderately, some dealing with others is necessary. 7—Very much, dealing with other people is an absolutely essential and crucial part of the job. 2. How much AUTONOMY is there in your j ob? That is, to what extent does your job permit you to decide ON YOUR OWN how to go about doing the work? 25 1-Very little; the job gives 4-Moderate autonomy; 7-Very much; the job gives me almost no personal about how and when the work is done. say" many things are standardized and not under my control, but but I can make some decisions about work. me almost complete responsibility for deciding how and when the work is done. Time 3 Questionnaire (continued) 265 3. To what extent does your job involve doing a "WHOLE* and IDENTIFIABLE piece of work? That is, is the job a complete piece of work that has an obvious beginning and end? Or is it only a part of the overall piece of work, which is finished by other people or by automatic machines? 26 1-My job is only a tiny part of the overall piece of work; the results of my activities cannot be seen in the product or service. 4-My job is a moderate - sized "chunk" of the overall piece of work; my own contribution can be seen in the final outcome. 7-My job involves doing the whole piece of work, from start to finish; the results of my activities are easily seen in the final product or service. 4. How much VARIETY is there in your job? That is, to what extent does the job require you to do many different things at work, using a variety of your skills and talents? l=Very little; the job requires 4-Moderate me to do the same routine variety, things over and over again. 7-Very much; the job requires me to do many different things, using a number of different skills & talents. 5. In general, how SIGNIFICANT or IMPORTANT is your job? That is, are the results of your work likely to significantly affect the lives or well-being of other people? 1-Not very significant; the 4-Moderately outcomes of my work are not significant, likely to have important effects on other people. 7-Highly significant; the outcomes of my work can affect other people in very important ways. 6. To what extent do managers or co-workers LET YOU KNOW how well you are doing on your job? 1—Very little; people almost never let me know how well I am doing. 4-Moderately; some- 7—Very much; managers or times people may co-workers provide me with give me "feedback", almost constant "feedback" other times they about how well I am doing, may not. 7. To what extent does DOING THE JOB ITSELF provide you with information about your work performance? That is, does the actual work ITSELF provide clues about how well you are doing -- aside from any “feedback" co-workers or supervisors may provide? 30 1-Very little; the job itself is set up so I could work forever without finding out how well I doing. 4-Moderately; sometimes doing the job provides "feedback" to me; sometimes it does not. 7-Very much; the job is set up so that I get almost constant "feedback" as I work about how well I am doing. Time 3 Questionnaire (continued) 266 III. This section asks you questions based upon your expectations or actual use of the system. We have a broad notion of "use" -- It may Include using the terminals, providing some Information to the system, or using some Information or reports from the system. E v e n I f v o u h a v e n o t , o r m a y n o t , a c t u a l l y u s e t h e s y s t e m , p l e a s e g i v e u s v o u r o p i n i o n s . Have you used the system in any way? Yes No 31 If yes. please answer the next questions based upon your experiences with the system. If no, please answer them according to how much you expect to use the system. How much have vou used. or expect to use, the system? Use the system's terminals Once Once Several Most of Never a week a day Times a day the day 1 2 3 4 5 Provide information to it 1 2 3 4 5 Use information provided by it 1 2 3 4 5 Use reports provided by it 1 2 3 4 5 Use the following code to indicate your response: How much do vou agree with the following statements about the SHS system? The system will be/is easy to learn to use. The system will be/ls easy to use for different kinds of tasks. A lot of training will be/is needed to use the system well. I will continue to learn new ways to use it. It will take/took a long time to become competent at using the system. There are tasks in SHS that could be done better with the system. The new SHS computer system is worth the time and effort required to use it. 1 - Strongly disagree 2 — Disagree 3 - Slightly disagree 4 - Neutral 5 - Slightly agree 6 - Agree ■ Strongly agree 2 2 2 2 2 2 4 4 4 4 4 4 36 Strongly Disagree Neutral Strongly Agree How lone do vou think it takes to... (estimate in days OR weeks OR months) learn the system well? become comfortable with the system? __ days __ weeks __ months 43 days weeks __ months 46 at SHS? __ days __ weeks __ months 49 267 Time 3 Questionnaire (continued) IV. This section asks about learning to use the system. Use the following code to indicate your response: Please indicate the extent to which vou agree with the following statements: I attend regular meetings where we talk about how to use the system. Organizational policies generally discourage me from developing new procedures or uses of the system. I receive praise for developing new ways to use the system to accomplish my job, or to solve problems in using the system... - from my supervisor - from my co-workers I generally do not have the time to learn or experiment with possible new procedures or uses of the system. My co-workers and/or I develop new procedures and/or uses of the system. Other people do not generally encourage me to experiment with new procedures or uses of the system. I talk about ways to use the system to accomplish my job or solve problems... - with my supervisor - with my co-workers To what extent to you agree that the following are useful in training you to use the system? - documentation, manuals, instruction sheets - co-workers - official trainers in training sessions - yourself - learning by using the system Strongly disagree Disagree Slightly disagree Neutral Slightly agree Agree Strongly agree 4 4 4 4 2 3 4 5 6 7 2 3 4 5 6 7 2 3 4 5 6 7 2 3 4 5 6 7 2 3 4 5 6 7 52 V. This section asks how others think about the system. To what extent do vou agree that these people think that the system is worth the time and effort Strongly required to use it? Disagree Neutral Strongly Agree Your co-workers Your supervisor Your closest friends at SHS Students who are SHS patients 2 3 2 3 2 3 2 3 65 1 - Very important How important are the opinions 2 - Important of these people in influencine 3 - Slightly important how vou think about the new svstem? 4 - Not important at all Your co-workers 1 2 3 4 Your supervisor 1 2 3 4 Your closest friends at SHS 1 2 3 4 Students who are SHS patients 1 2 3 4 Very Not at all Important Important 268 Time 3 Questionnaire (continued) VI. This section asks some more detailed questions about the nature of your job. Use the following code to indicate your response: How satisfied are vou with: The nature of the work you perform? The person who supervises you -- your organizational superior? Your relations with others in the organization with whom you work -- with your co-workers? The pay you receive for your job? The opportunities which exist in this organization for advancement - - with promotion? Use the following code to indicate your response: How accurate is each of the following statements about vour lob? The job is quite simple and repetitive. The job requires me to use a number of complex or high-level skills. The job requires a lot of cooperative work with other people. The job is arranged so that I do not have the chance to do an entire piece of work from beginning to end. Just doing the work required by the job provides many chances for me to figure out how well I am doing. 1 The job can be done adequately by a person working alone - - without talking or checking with other people. 1 The supervisors and co-workers on this job almost never give me any "feedback” about how well I am doing in my j ob. 1 This job is one where a lot of other people can be affected by how well the work gets done. 1 The job denies me any chance to use my personal initiative or judgement in carrying out my work. 1 Supervisors often let me know how well they think I am performing the job. 1 The job provides me the chance to completely finish the pieces of work I begin. 1 The job itself provides very few clues about whether or not I am performing well. 1 The job gives me considerable opportunity for independence and freedom in how I do the work. 1 The job itself is not very significant or important in the broader scheme of things. 1 Very Inaccurate Strongly dissatisfied Dissatisfied Neutral or no opinion Satisfied 23 Strongly Satisfied 1-2 Very inaccurate Mostly inaccurate Slightly inaccurate Uncertain Slightly accurate Mostly accurate Very accurate 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 4 4 4 4 4 4 4 21 Un certain Very Accurate Time 3 Questionnaire (continued) VII. This section asks you to Indicate your attitudes, and the attitudes of your co-workers and supervisor, about work in general at SHS. Use the following code to indicate your response: How much do vou agree with the following statements? The work I do on this job is very meaningful to me. It's hard, on this job, for me to care very much about whether'or not the work gets done right. I usually know whether or not my work is satisfactory on this job. Most of the things I have to do on this Job seem useless or trivial. I feel a very high degree of personal responsibility for the work I do on this job. I often have trouble figuring out whether I’m doing well or poorly on this job. I feel I should personally take the credit or blame for the results of my work on this job. Whether or not this job gets done right is clearly my responsibility. 1 - Strongly disagree 2 - Disagree 3 - Slightly disagree 4 - Neutral ■ Slightly agree ■ Agree ■ Strongly agree Most people on this job ... find the work very meaningful. feel a great deal of personal responsibility for the work they do. have a pretty good idea of how well they are performing their work, feel that whether or not the job gets done right is clearly their own responsibility. feel that the work is useless or trivial, have trouble figuring out whether they are doing a good or bad job. Strongly Disagree 4 4 4 4 4 4 4 4 Neutral 4 4 4 4 4 4 Strongly Disagree Neutral Strongly Agree Strongly Agree Time 3 Questionnaire (continued) 270 VIII. This section asks you to evaluate your satisfaction with the implementation and accessibility of the SHS computer system, and with the information from the system. Please rate the following aspects, from (1) to (7), on the basis of their descriptions. Top management involvement in strong 2 3 4 5 6 weak implementing the system significant 2 3 4 5 6 insignificant__ Relationships with the harmonious 2 3 4 5 6 dissonant system analysts and trainers good 2 3 4 5 6 bad Processing of requests for fast 2 3 4 5 6 slow changes to the system timely 2 3 4 5 6 untimely Degree of training complete 2 3 4 5 6 incomplete __ provided to SHS staff high 2 3 4 5 6 low Your understanding sufficient 2 3 4 5 6 insufficient __ of the system complete 2 3 4 5 6 incomplete Your feeling of participation positive 2 3 4 5 6 negative 4 in the Implementation sufficient 2 3 4 5 6 insufficient __ Attitude of the system cooperative 2 3 4 5 6 belligerent __ analysts and trainers positive 2 3 4 5 6 negative Reliability of information high 2 3 4 5 6 low from the system superior 2 3 4 5 6 inferior Relevance of information useful 2 3 4 5 6 useless from the system relevant 2 3 4 5 6 irrelevant __ Accuracy of information accurate 2 3 4 5 6 inaccurate __ from the system high 2 3 4 5 6 low Precision of information high 2 3 4 5 6 low __5 from the system definite 2 3 4 5 6 uncertain Communication with the harmonious 2 3 4 5 6 dissonant analysts and trainers productive 2 3 4 5 6 destructive Time required to develop reasonable 2 3 4 5 6 unreasonable the system acceptable 2 3 4 5 6 unacceptable Completeness of Information sufficient 2 3 4 5 6 insufficient from the system adequate 2 3 4 5 6 inadequate __ Support by your supervisor in strong 2 3 4 5 6 weak __ implementing the system significant 2 3 4 5 6 insignificant__ Time to wait to use a terminal short 2 3 4 5 6 long __6 Time for the system to respond short 2 3 4 5 6 long __ Time to wait to get printed info short 2 3 4 5 6 long __ Physical distance to a terminal close 2 3 4 5 6 far Ability to log on to the system easy 2 3 4 5 6 hard Ability to understand the commands easy 2 3 4 5 6 hard 7 271 Time 3 Questionnaire (continued) IX. This section asks about changes In understanding or exchange of information between your department and other SHS departments, because of the system. By understanding. we mean understanding of the work each department does (including problems, procedures, decisions, information needed, etc.) By exchanging information, we mean any type of information exchanged in any way (such as from the computer, in person, by telephone, memos, meetings, etc.) Use the following code to indicate your response: Please rate the extent to which understanding or exchanging information with each of the following SHS departments has increased or decreased. 1 - Significantly Increased 2 — Increased 3 - Slightly increased 4 — No change, no opinion 5 — Slightly decreased 6 - Decreased 7 - Significantly decreased 33 1-2 Significantly No Significantly With this department, this process has: increased change decreased Office of Director understanding their work 1 2 3 4 5 6 7 3 exchanging information 1 2 3 4 5 6 7 __ Finance/Personnel understanding their work 1 2 3 4 5 6 7 exchanging information 1 2 3 4 5 6 7 __ Insurance understanding their work 1 2 3 4 5 6 7 . exchanging information 1 2 3 4 5 6 7 __ Medical Records understanding their work 1 2 3 4 5 6 7 exchanging information 1 2 3 4 5 6 7 __ Lab understanding their work 1 2 3 4 5 6 7 exchanging information 1 2 3 4 5 6 7 __ Pharmacy understanding their work 1 2 3 4 5 6 7 13 exchanging information 1 2 3 4 5 6 7 __ Radiology understanding their work 1 2 3 4 5 6 7 exchanging information 1 2 3 4 5 6 7 __ Primary Care understanding their work 1 2 3 4 5 6 7 exchanging Information 1 2 3 4 5 6 7 __ Specialty Clinics understanding their work 1 2 3 4 5 6 7 exchanging information 1 2 3 4 5 6 7 __ Womens' Health understanding their work 1 2 3 4 5 6 7 exchanging information 1 2 3 4 5 6 7 __ Health Education understanding their work 1 2 3 4 5 6 7 exchanging information 1 2 3 4 5 6 7 __24 Significantly No Significantly Increased Change Decreased X. Overall, to what extent has the system changed these two aspects of vour own denartment Ease of performing our department's work 1 2 3 4 5 6 7 Quality of our department's work 1 2 3 4 5 6 7 __26 Significantly No Significantly Increased Change Decreased 272 Time 3 Questionnaire (continued) XI. This section asks you to rate SHS services. Use the following code to indicate your response: How satisfactory do vou think SHS is in these aspects of service? Number of patient complaints about service Number of students/patients seen Availability of clinicians Flexibility of staff schedules Number of lost files Ability to retrieve specific demographic data from patient files for use in identifying patient populations, medical needs, etc. Mixing up files, confusing patients, etc. Turnaround time on handling patient cases Overall quality of care Followup of patients 1 - > Very unsatisfactory 2 - Mostly unsatisfactory 3 - Slightly unsatisfactory 4 - Uncertain 5 - Slightly satisfactory 6 - Mostly satisfactory 7 - Very satisfactory How satisfactory is SHS in these more general activities? Other non-medical record keeping Operational planning and organizing Operational monitoring and analysis Appropriate job-related use of the telephone Distributing mail Availability of resources for copying, collating, sorting Availability of policy and procedure information Preparing presentation materials Inter-personal communication with: -- co-workers -- patients -- supervisors or managers Use of time for meetings Scheduling appointments, keeping calendars Very Unsatisfactory 4 4 4 4 4 4 4 Un certain 27 37 XII. These final questions ask you for a few open-ended comments. Briefly describe one good aspect of the new system. Very Satisfactory 50 Briefly describe one bad aspect of the new system (other than this questionnaire!) __52 How would you have improved the implementation of the SHS Information system? 54 * * * * * THANK YOU FOR YOUR TIME AND THOUGHTS! * BE SURE TO MAIL THIS TODAY! * * * * *

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Asset Metadata

Creator Aydin, Carolyn E (author)

Core Title Bringing social worlds together: Information systems as catalysts for new interactions in health care organizations

Contributor Digitized by ProQuest (provenance)

Degree Doctor of Philosophy

Degree Program Communication Theory and Research

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, health care management,information science,information technology,OAI-PMH Harvest

Language English

Advisor Rice, Ronald (committee chair), [illegible] (committee member), Markus, Lynne (committee member), Rogers, Everett (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c17-716303

Unique identifier UC11342936

Identifier DP22437.pdf (filename),usctheses-c17-716303 (legacy record id)

Legacy Identifier DP22437.pdf

Dmrecord 716303

Document Type Dissertation

Rights Aydin, Carolyn E.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA