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Organizational communication and change

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Title:
Organizational communication and change a case study on the implemenation of an innovation at a Florida medical facility
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English
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Llenza, Erika G
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University of South Florida
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Tampa, Fla
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Subjects / Keywords:
Institutional transformation
Communicate change
Effective change execution
New technology training
Dissertations, Academic -- Mass Communications -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: This study examined how employees at a Florida medical facility felt regarding the upcoming change to a paperless system and whether a training program administered by the organization was effective in reducing anxiety, increasing understanding of the need for the change, increasing employee confidence using the new computer system, changing employee perceptions of the new system, and helping employees view the change as an organizational improvement. The results indicated that the training program marginally reduced anxiety, but did not significantly increase user confidence or understanding of the need for the change. While participants viewed the change as an organizational improvement, this view was only superficial. When means were examined by occupation, age group and gender, pre-training results indicated that the medical staff and older participants exhibited the most anxiety, understood the reason for the change the least and had the lowest confidence in their ability to use the practice management system. These same participants appeared to benefit the most from the training program. They reported reduced anxiety and increased confidence using the innovation. Post-training, younger participants and those who identified their occupation as "other" indicated increased anxiety levels and slight reductions in their confidence using the practice management system. The medical staff and older participants appeared to benefit the most from the training program.
Thesis:
Thesis (M.A.)--University of South Florida, 2008.
Bibliography:
Includes bibliographical references.
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by Erika G. Llenza.
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Title from PDF of title page.
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Document formatted into pages; contains 110 pages.

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University of South Florida Library
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University of South Florida
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aleph - 002000970
oclc - 319171598
usfldc doi - E14-SFE0002529
usfldc handle - e14.2529
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SFS0026846:00001


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Organizational Communication and Change: A Case Study on the Implementation of an Innovation at a Florid a Medical Facility by Erika G. Llenza A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts School of Mass Communications College of Arts and Sciences University of South Florida Major Professor: Kenneth Killebrew, Ph.D. Larry Leslie, Ph.D. Randy Miller, Ph.D. Date of Approval: April 30, 2008 Keywords: institutional transformation, comm unicate change, effective change execution, new technology training Copyright 2008, Erika G. Llenza

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i Table of Contents List of Tables iiiList of Figures viAbstract viiChapter 1: Introduction 1Chapter 2: Literature Review 7Communication and Uncertainty Reduction 9Diffusion of Innovations: Theories of Mass Communications 12Rate of Adoption 13The Innovation-Decision Process 19Innovations in Organizations 22Initiation Phase 24Implementation Phase 25Change Communication: Two-wa y vs. One-way Communication 26Employee Involvement in Change Efforts 27Information Access and Its Effects 29Internal Communication a nd Employee Motivation 30Research Hypotheses 32Research Questions 32Chapter 3: Methodology 33Quantitative Methodology 34Qualitative Methodology 35Chapter 4: Results 37

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ii Quantitative Results 38Qualitative Results Pre-Training 54Qualitative Results Post-Training 59Chapter 5: Discussion 62Hypotheses 62Research Questions 65Chapter 6: Conclusions 73Bibliography 79Appendices 82Appendix A: Survey 1 with variable codes 83Appendix B: Survey 2 with variable codes 87Appendix C: Survey Question Groupings 92Appendix D: Pre-Training Survey Means 94Appendix E: Post-train ing Survey Means 99Appendix F: Independent Samples T-tests 106Appendix G: Informed Consent 109

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iii List of Tables Table 1 Summed Mean Preand Post-training 39 Table 2-A Paired Samples Correlations 40 Table 2-B Paired Samples T-test 40 Age Group Tables Table 3 Summed Means 41 Table 4 One-way ANOVA 42 Table 5: Chi-Square Tests (pre) by Anxiety 43 Table 6 Chi-Square Test ( post) by Anxiety 43 Table 7 Chi-Square Test (p re) by Understanding 43 Table 8 Chi-Square Test (pos t) by Understanding 44 Table 9 Chi-Square Test (pre) by Confidence 44 Table 10 Chi-Square Test (pre) by Confidence 44 Occupation Tables Table 11 Summed Means 45 Table 12 One-way ANOVA 47 Table 13 Chi-Square Test (pre) Anxiety 47 Table 14 Chi-Square Test (post) Anxiety 48 Table 15 Chi-Square Test (pre) Understanding 48 Table 16 Chi-Square Test (post) Understanding 48 Table 17 Chi-Square Test (pre) Confidence 49 Table 18 Chi-Square Test (post) Confidence 49

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iv Gender Tables Table 19 Summed Means 50 Table 20 One-way ANOVA 51 Table 21 Chi-Square Test (pre) Anxiety 51 Table 22 Chi-Square Test (post) Anxiety 51 Table 23 Chi-Square Test (pre) Understanding 52 Table 24 Chi-Square Test (pre) Confidence 52 Table 25 Chi-Square Test (post) Confidence 52 Appendix Tables Table 26 Pre-training Understanding th e Need for the Change (Age) 94 Table 27 Pre-training Anxiet y Levels (Age) 94 Table 28 Pre-training Confid ence Levels (Age) 95 Table 29 Pre-training Understanding the Need for the Change (Occupation) 95 Table 30 Pre-training Anxi ety (Occupation) 96 Table 31 Pre-training Confidence (Occupation) 96 Table 32 Pre-training Understanding th e Need for the Change (Gender) 97 Table 33 Pre-training Anxiet y Levels (Gender) 97 Table 34 Pre-training Confiden ce Levels (Gender) 98 Table 35 Post-training Understanding the Need for the Change (Age) 99 Table 36 Post-training A nxiety (Age) 100 Table 37 Post-training Confidence (Age) 101 Table 38 Post-training U nderstanding the Need for the Change (Occupation) 102 Table 39 Post-trainin g Anxiety Levels (Occupation) 102

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v Table 40 Post-train ing Confidence Levels (Occupation) 103 Table 41 Post-training Understanding the Need for the Change (Gender) 104 Table 42 Post-training Anxiet y Levels (Gender) 104 Table 43 Post-train ing Confidence Levels (Gender) 105 Table 44 Independent T-te sts by Age Group 106 Table 45 Independent T-tests by Occupation 107 Table 46 Independent T-tests by Gender 108

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vi List of Figures Figure 1 Model of Stages in the Innovation-D ecision Process 25 Figure 2 Five Stages in the I nnovation Process in an Organization 30

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vii Organizational Communication and Change: A Ca se Study at a Florida Medical Facility Erika Llenza ABSTRACT This study examined how employees at a Florida medical faci lity felt regarding the upcoming change to a paperless system and whether a training program administered by the organization was effective in reduc ing anxiety, increasing understanding of the need for the change, increasing employee c onfidence using the new computer system, changing employee perceptions of the new system, and helping employees view the change as an organizational improvement. The results indicated that the training program marginally reduced anxiety, but did not si gnificantly increase user confidence or understanding of the need for the change. While participants viewed the change as an organizational improvement, this view was onl y superficial. When means were examined by occupation, age group and gender, pre-training results indicated that the medical staff and older participants exhibited the most anxiety, understood the reason for the change the least and had the lowest confidence in th eir ability to use the practice management system. These same participants appeared to benefit the most from the training program. They reported reduced anxiety and increas ed confidence using the innovation. Posttraining, younger participants and those who identified th eir occupation as “other” indicated increased anxiety leve ls and slight reductions in their confidence using the

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viii practice management system. The medical staff and older participants appeared to benefit the most from the training program.

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1 CHAPTER 1 Introduction Research in organizational communication has demonstrated that change efforts are difficult and disruptive. St udies have shown that for a change effort to be successful, communication is necessary, and that communi cation must be strategic and allow for both one-way and two-way communication. It ha s been shown that including both forms of communication gives employees the means through which to gather the necessary information to reduce the uncer tainty that accompanies chan ge (Kramer, 2004). This is because with change comes an upheaval of routine. “Organizational actors overwhelmingly favor familiar routines de rived from past experience … to vague, uncertain visions of the future” (Ford, 2001, 636) When left unchecked this uncertainty builds into anxiety, which result s in resistance (Kramer, 2004). Communication studies have shown that in times of change, anxieties arise, but many of these research studies focus on cha nge efforts that involve company downsizing. These change efforts are expected to genera te anxiety because they disrupt more than everyday work routines; they also result in a disruption of employee livelihood. In these instances, a lack of proper communication between an organization and its employees regarding the change effort resulted in a dr op in employee morale, yet another obstacle to overcome during an already strenuous time. Other studies have shown th at nearly all change efforts are met with resistance, some less so than others, depending on the seve rity of the change and its implications for

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2 affected employees. For example, a change in organizational procedur es is expected to meet less resistance and generate less anxiet y than a change that calls for downsizing. This is because the former implies a need to learn something new and adjust a work routine, while the latter threatens ot her aspects of the employee’s life. “Human beings do not resist change automatically; however many people do resist being changed [or] having change s imposed on them” (Lorenzi & Riley, 2000, 117). Organizational change normally involves some threat, real or perceived, of personal loss for those involved. This thread may vary from job security to simply the disruption of an establishe d routine. Furthermore, there may be trade offs between the long and short run. As an individual, I may clearly perceive that a particular proposed ch ange, in the long run, is in my own best interests, and I may be very in terested in seeing in happen, yet I may have short-run concerns that lead me to oppose particular aspects of the change or even the entire change project (Lorenzi & Riley, 2000, 117). Diffusion of innovations theory of mass communications postulates that change efforts possess characteristics that make them more likely to be accepted, and that communication is essential to facilitate the understanding and realization of those characteristics for an innovation to go from an abstract concept to an accepted and adopted solution (Rogers, 1995). This research will study the effectiveness of a communication effort at a Florida medical facility for the acceptance and adop tion of an innovation. It uses a survey approach to measure the dissonance and di sruption of a new technology and whether its adoption is facilitated thr ough the use of communication. It seeks to find a link among resistance, anxiety, and understanding and will use organizationa l change theory, uncertainty reduction theory, and aspects of di ffusion of innovations theory to analyze the results.

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3 The medical facility is a “multidiscip linary group of physicians, surgeons, and health care providers” ( www.floridamedicalclinic.com ) that brings together primary care physicians and multi-specialty physicians in one location to provide patients with a complete health care experience. In the Fall of 2006, the medical facility introduced a new technology into the everyday activities of the hospital that would affect both doctors and employees. It is the “biggest change for most of [their] employees ’ day to day activities that [the medical facility] has ever had” (J oe Delatorre, Interview 03/30/06). The change involves transferring the entire medical records syst em to a server thus becoming a paperless facility. The innovation was launc hed October 24 and within the span of six months it was expected that all departments would have changed over. The change would have many benefits for the hospital, such as f acilitating the exchange of patient records between doctors. By going paperless, the me dical facility would require employees, especially doctors, to change the way they are accustomed to doing their jobs significantly. Doctors would no longer have their paper charts with their patient’s medical history. Instead, these records would be kept on a server from which doctors could share the information and avoid perfor ming duplicate procedures such as blood work or X-rays. The change included adding computers to the exam rooms to allow for access to patient charts while doctors see w ith their patients. This new technology was expected to save time, money, make the overa ll health care experience easier for patients as well as facilitate the everyday activities of the hospital staff. Directors at the medical facility understood that this change was an enormous undertaking and informed employees that the change would taking place. The

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4 organization believed that the individuals who would pose the biggest challenge in this change would be medical staff, particularly those who did not regularly use the computer system was in place prior to the change effort. Other hospital employees were already accustomed to using a system very similar to the one being implemented on a daily basis and with the change over would only need to adjust to minor changes, such as the order in which the system requests information. The medical staff, on the other hand, did not use the original computer system nearly as often, with some of the doctors no t using it at all. Fo r these individuals the transformation was a severe change and the medi cal facility expected that without proper training the change would m eet a lot of resistance. As a result, the organization conducted tr aining programs for the medical staff. Doctors would be divided into beginner a nd advanced user groups. Advanced users would have some working knowledge of the current computer system, from already having many of their patient files on the curr ent server and were able to navigate through it with ease (J. Delatorre, 03/ 30/06). The rest of the physic ians fell into the beginner category. The advanced users were trained a nd expected to use the new system by the October 24 launch date. Physicians categorized as beginners were trained with their departments for the later launch dates. The first group of beginner physicians began their training in November and were expected to be ready to change over to the new system by December 11. Because physicians are so busy, they posed a special challenge. They had to learn the new system, but do so while st ill handling their regular patient load. To accommodate this, there were four, four-hour training session offered on Saturdays. During the span of these four hours, the phys icians would be taught how to use the new

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5 system, and would be allowed to return to a ny other training session if they felt they need extra help in any pa rticular section. The goal of the program was to get doctors to transition from a traditional medical documentation system to an electronic medi cal records system (J. Delatorre, interview 03/30/06). In doing so, the traini ng would “get the advanced users to fully understand and be comfortable with the new software, and get the basic users [to] an intermediate level of familiarity with the program” (J. Delatorre, Interview 03/30/06). Ideally, doctors would become acclimated to the program and fe el comfortable using it on a daily basis, understand the benefits that would follow its implementation, and demonstrate less resistance to using the new technology. The medical facility understood that users at the beginner level would likely not reach an advanced user stage after the tr aining program; however, the intention was to make them feel comfortable using the new sy stem, so they would be more inclined to accept it and continue making strides in learning the program with daily use. The thought behind this trai ning program resembles many of the deductions from organizational communications theories and mass communications theories in that the medical facility expects that the communi cation and training will help in reducing resistance to change while increasing unders tanding and, in turn, result in the acceptance and adoption of the new technology. They plan to accomplish this by showing the medical staff how to use the innovation. This research study examined the eff ectiveness of the training program in familiarizing, explaining, and adopting the ne w computer system among the medical staff

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6 at the Florida medical facility within the c ontext of organizational change and uncertainty reduction theories. Not unexpectedly, then, this research set out to determine the effectiveness of the training program in increasing user knowle dge of the new computer system and understanding of its benefit, re ducing user resistance and fee lings of uncertainty towards the new system and increasing accepta nce and adoption of the innovation.

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7 CHAPTER 2 Literature Review In this day and age organizational change is inevitable. Businesses today are fastpaced and globally minded. With the onset of globalization, advan ces in technology and amount of available information, change is not an exception but a rule. Organizations must adapt to keep up with societal tre nds and market demands. “As organizations attempt to cope with a progressively more turbulent economic, technological, and social environment, they rely increasingly on their employees to adapt to change” (Stanley, D.J., Meyer, J.P. & Topolnystsky, L., 2005, p. 429) Considering change is such a large and necessary part of any organization; or ganizations must find ways to implement necessary changes in the most efficient way possible. A great deal of research has gone into the effective implementation of organizational change. This research has indicated that implementing organizational change is no easy feat, and it often encount ers significant opposition. Change brings with it an uprooting of routine and comfortable tasks, which results in discomfort for organizational members. The typical employee spends at least eight hours a day doi ng, in general, fairly routine tasks… There’s a tangible agreement that if the employee does X, and does it well and on time, the employee will receive Y in compensation…. There is also a psyc hological contract between employee and company: As long as the employee fits into work and social patters, he or she “belongs” (Managing Change and Transition, 2003, p. 85). Change represents a redrafting of the social and psychological agreement. When major change must be implemented, there is a need for the organization to acquire new attributes that often call for new norms of behavior. Members’ previous identif ications, which involve cognitive,

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8 behavioral and affective component s and which were once functional, become a hindrance to the implementation of change …. Major change implies the loss of a system of relatio nships with coworkers, customers or other stakeholders, and a particular conception of one’s work, status and role within an organization (Chreim, 2002, p. 1123). During times of organizational change thes e agreements are more difficult to meet. Tasks change, and it is more difficult to complete work well and on time. “Change always requires the effort to learn the new, which is a loss in terms of time and energy that could have been used elsewhere” (L orenzi & Riley, 2000, p. 120). This results in social changes that leave organizational memb ers feeling out of place. Individuals seek out this identification because “it provides th e possibility of inclus ion in social groups …. Member identification satisfies a number of individual needs including needs for safety, affiliation, self-enhancement and meaning in one’s life” (Cherim, 2002, p. 1120). Changes can cause feelings of anxiety and loss, and are th e reasons attributed to the resistance organizations face during periods of change (Managing Change and Transition, 2003). Feelings of anxiety and loss are a re sult of uncertainty. “Giving up familiar attitudes, behaviors and perspectives that emanate form one’s identifications opens the possibility for the uncertain and creates fear of the unknown, leading people to hold on to past identifications” (Chreim, 2002, p.1123). Orga nizations must find effective ways to reduce uncertainty, anxiety, and feelings of lo ss in order to reduce resistance, and as a result, effectively implement a change effort It is necessary to provide meaning and background to change, so that organizational members are once again able to identify with the organization. Communication provi des the opportunity to furnish meaning

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9 (Cherim, 2002). Research has indicated that communication is necessary in any effective change effort (Managing Change and Transition, 2003). Communication is an effective t ool for motivating employees, for overcoming resistance to an initiative for preparing people for the pluses and minuses of change, and for givi ng employees a personal stake in the process. Effective communication can set the tone for a change program and is critical to implementation from the very start” (Managing Change and Transition, 2003, p. 60). Unfortunately, this seemingly simple solution is “often used poorly or thoughtlessly” (D’Aprix, 1996, p. 3). It is neces sary to have a powerful rationale to help reduce or fight the cynicism that results from uncertainty and confusion (D’Aprix, 1996). If communication is not used properly, it can worsen the situation. For example, research indicat es that “when personal experiences contradict persuasive effort s by [an] organization, the la tter’s discourse is ignored and members will rely on their past expe riences to guide their interpretations” (Chreim, 2002, p. 1133). To be effective, communication should be strategic. Strategic communication is “a process by which…an organization de liberately manages its communication proactively…” (D’Aprix, 1996, p.5). Stra tegic communication requires planning and forward thinking. This is not to say that all communicati on efforts must be planned and scripted, but for an organizati on to be aptly prepared, its members and communicators must have a clear und erstanding of what to expect. Communication and Uncertainty Reduction As discussed earlier, uncertainty is the primary cause associated with change resistance. “Because organizational change by its very nature is not linear, the most frequent psychological state resulting form organizational change is uncertainty (

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10 Jimmieson, N.L., Terry, D.J & Callahan, V.J ., 2004, p. 11). Uncertainty reduction theory, a formal communication theory, “attempts to explain human communication behaviors in uncertain situations” (Kramer, 2004, p.4). Uncer tainty is a fundamental experience. On an average day most adults spend their time in groups and organizational settings more than in any other activity. Understanding how they manage uncertainty is of grave importance. Jimmieson et al (2004) talk about the different kinds of uncertainty associated with organizational change. Those include role c onflict, role ambiguity, and role overload. Individuals experience role conf lict when role expectations af ter a change are in direct opposition to past expectations. Likewise, role ambiguity happens when old expectations are not replaced with new, clear-cut expectations. Additionally, “employees may experience role overload when too many task s are assigned in a given time period or when new job duties go beyond employees’ curre nt knowledge skills, and abilities” (p. 11). To ensure that change programs minimize uncertainty, information exchange is crucial. “When profound organizational cha nge is imminent, employees go through a process of sense-making, in which they need information to help them establish a sense of prediction and understanding of the situation” (Jimmies on et. al., p. 12). Generally, “when individuals feel that they are receiving insufficien t information, they experience uncertainty and as a result dissatisfaction. C onversely, when they feel they are receiving sufficient information, they experience cer tainty and as a result will experience satisfaction and confidence in their organizational roles” (K ramer, 2004, p. 42). This is of concern to organizations because with dissa tisfaction comes various problems, namely,

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11 low productivity and employee turnover. Therefor e, during times of ch ange it is vital to communicate with employees every step of th e way. Otherwise, employees will seek to subdue their fears by searching for informa tion elsewhere. This is a particularly dangerous alternative because the information they will rely on will likely be based on speculation and half truths. If employees can not receive information fr om formal sources they will turn to informal sources, such as the grapevine or rumor mill. Unfortunately, these informal sources can carry with them incomplete info rmation or incorrect information that may increase anxiety (Kramer, 2003). Results from research examining how individuals manage uncertainty as a result of organizational change are fa irly consistent… Due to a lack of adequate information surrounding orga nizational changes, organizational members experience uncertainty. The uncertainty frequently leads to dissatisfaction and intentions to l eave. Additional communication with organizational supervisors or other me mbers results in uncertainty reduction and more positive feelings toward the organization and intentions to remain in the organization (Kramer, 2004, p. 55). One can conclude, then, that uncertain ty reduction theory demonstrates the need for internal communication in an organization, especially during times of change. Communication leads to understandi ng, understanding reduces uncertainty, and as a result reduces resistance. But how doe s this sequence of events take place? What makes communication effective? What kind of communication is necessary to reduce uncertainty, reduce resistance, and ensure successful implementation of change programs?

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12 The diffusion of innovations theory of mass communications takes a look at how innovations are accepted by groups and individuals and the strategic communication necessary to achieve this acceptance. Diffusion of Innovations: Theories of Mass Communications Diffusion of innovations theory of mass communication provides a theoretical framework for the adoption of new ideas by indi viduals or members of a social system. It evolved from the two-step flow model (Severin & Tankard, 2001). According to diffusion of innovations, an innovation is “an id ea, practice or object that is perceived new by an individual or other unit of adoption” (Rogers, 1995, p. 11). Diffusion of innovations, then, is “a social process in which subjectively perceived information about a new idea is communicated. The meaning of an innovation is thus gradually worked out through a process of social construc tion” (Severin & Tankard, p. 208). It is important to note that this theory takes into account the uncertainty that innovations and technologies br ing with them. As mentioned, uncertainty is the primary motivator for resistance to change. Diffu sion of innovations po stulates that “an innovation generates a kind of uncertainty in th at it provides an a lternative to present methods or ideas…” (p. 208) An innovation’s rate of adoption is affected by the degree to which adopters view the innovation as ha ving relative advantage, trialability, observability, and reduced complexity.

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13 Rate of Adoptionon Innovations possess characteristic s that affect the rate at which they are accepted and adopted. These characteristics are base d on the “perceptions of the innovation, characteristics of the people who adopt the innovation, or fail to do so; and contextual factors, especially involv ing communication, incentives, leadership, and management” (Berwick, 2003, p. 1970). Both Rogers (1995) and Berwick (2003) postulate that between 49 and 87 percent of variance in the rate of adoption can be at tributed to the perceptions individuals have regarding an innovation. Rogers referred to these as: relative adva ntage, compatibility, complexity, trialability, and observability. Relative advantage refers to the “degree to which an innovation is perceived as better than the idea it supe rsedes” (Rogers, 1995, p. 15). Relative advantage can be measured according to various terms. It is essentially, the perceived benefit of the change. “Individuals are more likely to a dopt an innovation if th ey think it will help them” (Berwick, 2003, p. 1971). It can have economic advantage, social prestige, convenience, and satisfaction, among others (Rogers, 1995). The more advantage is perceived, the more useful th e innovation is considered. This idea is a more complicated idea than it appears … because for most people who accept or reject an innova tion, benefit is a relative matter – a matter of the balance between risks and gains and of risk aversion in comparing the known status quo with the unknown future if the innovation is adopted. The relative cal culation of value involves risk and benefit. The more knowledge individuals can gain a bout the expected consequences of an innovation … the more likely they are to adopt it (Berwick, 2003, p. 1971). Another aspect that assist s in the diffusion of an i nnovation is its compatibility. This refers to the “degree to which [it] is perceived as being consis tent with the existing

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14 values, past experiences and [current] need s of potential adopte rs” (Rogers, 1995, p. 15). In other words, a change must resonate with the perceived needs and belief systems of an individual or organization (Berwick, 2003). The more an innovation strays from the values of an individual or an organization the more ch allenging its adoption. “The adoption of an incompatible innovation often requires the prior adoption of a new value system,” this is a relatively slow process and it is important to know ahead of time if such an undertaking is in the works (Rogers, 1995, p. 16). An innovation’s complexity refers to how difficult it is to understand and use (Rogers, 1995). “Generally, simple innovations spread faster than complicated ones” (Berwick, 2003). “Some innovations are r eadily understood by members of a social system,” these will be adopted more easily th an those that are more complicated (Rogers, 1995, p. 16). Familiarity and understanding reduc e uncertainty. As discussed, the less uncertainty an innovation creates the less resistance it will meet. This makes understanding a key component in the adoption of an innovation. Giving individuals the opportunity to experiment with an innovation can positively affect adoption. This experimentati on is referred to as trialability. In organizations, it is sometimes wise to implem ent change processes on a trial basis in one department to see how successful the innovati on will be. If the innovation is successful within that department, its success can be used as a reas on to adopt it throughout the organization. Trialability and observability are closely connected. If the results of an innovation are visible to other individuals, and considered positive, those individuals are more likely to adopt it (Rogers, 1995).

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15 To successfully implement any change effort, organizational leaders must understand how these characteristics apply to their specific change effort. This way, communication efforts can be specifically tail ored to focus on the areas of change that will encounter the most resistance. For example, a change efforts’ relative advantage may be easy to see; however it may be a complex change. Communication should be concentrated on the change efforts’ complex ity more than on its relative advantage. Employing change agents to diffuse information Communication is an essentia l part of the diffusion of innovations theory; it is, after all, a mass communications theory. “Di ffusion is a particular type of communication in which the message content that is exch anged is concerned with a new idea. The essence of the diffusion process is the info rmation exchange” (Rogers, p.17). Considering that organizational change efforts are form s of innovation, then communication is also essential in successfully implementing a change program. As mentioned earlier, the diffusion of i nnovations theory evolved from the twostep flow theory of mass communications. Th e two-step flow mode l uses opinion leaders as communication agents because of the in fluence they have on message receivers. According to the two-step flow theory, “i nfluences stemming from the mass media first reach ‘opinion leaders’, who, in turn, pass on wh at they read and hear to their every-day associates for whom they are influential” (K atz, 1957, p. 61). In the two-step flow theory, communication usually takes place between homophilous individuals (Severin & Tankard, 2001). “Homophily is the degree to which two or mo re individuals who interact are similar in certain attri butes” (Rogers, 1995, p. 19).

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16 It should come as no surprise that diffu sion of innovations also takes into account the influence that change agents have in th e adoption of a new idea. However, unlike in two-step flow, “one of the most distinctiv e problems in the diffusion of innovations is that the participants are usually quite he terophilous” (Rogers, p.19). Generally, change agents or “early adopters” (Berwick, 2003, p. 1972) are more technically savvy than the individuals with whom they are communicating. In the case of organizational change, the communications specialist is usually more in formed about what is taking place with the change program than the employees he or she is communicating with. Also, it is common in many organizations for decision making to come from above and filter down through the organization. As a result, the individua ls affected and adopting the change are inherently different from those imposing or communicating the change. “This difference frequently leads to ineffective communication as the participants do not talk the same language” (Rogers, p.19). To overcome the hete rophily, change agents often employ the use of aides “recruited from the local population” for a more successful communication process (Severin & Tankard, 2001, p.211). These aides, often referred to as change agents, are typically, well conne cted socially, and, watched among the “early majority” (Berwick, 2003, p. 1972). The early majority, the first wave of individuals to which an innovation is diffused, “learn mainly from people they know well, and they rely on personal familiarity, more than on science or th eory, before they decide to test a change” (p. 1972). David J. Stanley, John P..Meyer and La ryssa Topolynytsky (2005) speak of the benefits of employing change agents in th eir study of employee cynicism and change resistance. Their findings indi cated that while communication is important in overcoming

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17 change resistance, management faces an a dditional challenge when that resistance is based on employee cynicism. Employee cynicism is distinguished fr om other forms of resistance because it is “based on the disb elief in motives [which] cannot be easily addressed with facts and figur es” (p. 457). To address the distrust in organizational motives, the researchers suggest management “identify trusted individuals within an organization, who once convinced of the sincer ity of managements’ motives, can help to gain the support of empl oyees at large” (p. 458). Nancy Lorenzi and Robert Riley (2000), in their studies of change management in health care organizations, found that past medical advances were primarily stand-alone systems, affecting limited and specific area s. However, as time has passed, more and more advances were affecting more hetero geneous groups and areas. As a result, major challenges to innovation success are behavioral “Effective leadership can sharply reduce the behavioral resistance to change” (p. 116) “Creating change st arts with creating a vision for change and then empo wering individuals to act as ch ange agents to attain that vision” (p. 118). The communication process between early adopters and the early majority is referred to by Ikujiro Nonaka, Geor g von Krogh and Sven Voelpel (2006) as organizational knowledge creation. Accordi ng to Nonaka et al., “organizational knowledge creation is the process of making available and amplifying knowledge created by individuals … and connecti ng it with an organization’s knowledge system” (p. 1179). In their research they addr ess the concept of knowledge activists. Knowledge creation theory states that knowledge is “created locally, where tasks ar e attended to, problems defined and resolved.”

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18 Therefore a knowledge activist must be ab le to share that knowledge beyond the context and into the remaining areas of the organization. They do so by coordinating knowledge creation, initiatives, and determin ing opportunities for knowledge sharing. A knowledge activist will “bring different knowledg e sets and introduce ‘creative abrasion’ that leads to conflicting ideas but also new possibilities to create knowledge” (p. 1187). Many studies tout the benefits of e ffective communicators. To ensure an innovation is heard and accepted, the communi cation method plays a key role. Change agents control the dissemination of informati on in such a way as to “provide an overall direction for the knowledge creation” (Inonaka et al., 2006, p. 1188). As a result, it is imperative that organizational l eaders take heed to identify the correct change agents for individual change efforts. Studies have found that “opinion leaders [are] not concentrated in the upper brackets…but [are] located in almo st equal proportions in every social group and stratum” (Katz, 1957, p. 72). In his anal ysis of research done on opinion leaders, Katz (1957) found that there are certain traits that make a person more likely to be an opinion leader: (1) who the pers on is (possessing certain valu e sets), (2) what the person knows, and (3) who the person knows. “Inf luence is often successfully transmitted because the influencee wants to be as much like the influential as possible” (p. 73); however, what an individual knows and how acce ssible he or she is will also play an important role. In order for change agents to be successful, they mu st be selected carefully. Electing opinion leaders based so lely on their position in an organization is a guarantee for success. Opinion leaders and the people whom th ey influence are very much alike and typically belong to the same pr imary groups of family, friends and

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19 coworkers. While the opinion leader may be more interested in the particular sphere in which he is in fluential, it is highly unlikely that persons influenced will be very far behind the leader in their level of interest. Influentials and influencees may exchange roles in different spheres of influence (Katz, 1957, p. 77). There must be a level of trust and re spect among the communicator and those with whom he or she is communicati ng for there to be any influence. The Innovation-Decision Process A communication process must undergo a se ries of steps in order to achieve a successful change effort. The decision-innova tion process “is the process through which an individual passes…to [reach] implementation and use of [a] new idea” (Rogers, 1995, p. 20). Knowing the stage of the innovati on decision process is essential to the communication process. This knowledge allows for proper preparation of communication messages. The process consists of five stages as illustrated in Figure 1. Figure 1

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20 The knowledge stage of the process is when a group or an individual learns about the innovation. During this stage individuals mainly seek “information that reduces uncertainty” (Rogers, 1995, p.21). Therefore, the knowledge stage is an “informationseeking and information-processing activity” ( p. 165). Here individua ls seek to learn what the innovation is and in which ways it will affect them. Diffusion of innovations theory states that during th is stage there are three t ypes of knowledge gathering: awareness-knowledge, how-to knowledge and principles-knowledge. During awareness-knowledge an indivi dual knows that the innovation exists; how-to knowledge is the information necessary for using the innovati on; and principlesknowledge is “information dealing with th e function principles underlying how the innovation works” (Rogers, 1995, 166). In the knowledge stage, information exchanged is generally one-way. This is when communicators educate individuals about an innovation. However, the communicators must soon prepare for a two-way communication process. Once individuals are aware of the innovation, it is only a matter of time before they will have questions. Furthermore, additional res earch has demonstrated that two-way communication practices are more fa vorable than one-w ay communication. The persuasion stage of the decision pr ocess occurs when individuals form attitudes towards the in novation. It is during this stage th at an individual “becomes more psychologically involved with the innovation” (Rogers, 1995, p. 168). At this time, providing “evaluation information,” is most likely to reduce the uncertainty associated with the “innovation’s expected consequences” (p. 21). Organizations must take heed to provide individuals with avenue s to gather this information and take the initiative to

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21 provide channels for two-way communication. It is during this time that individuals are more likely to seek information from their peer s. If there is no in formation available to reduce uncertainty, then individuals will re ly on information they receive through the grapevine and the speculations of their peers. It is wise for organi zations to keep up-todate on the information disseminated through th e grapevine as it is an information-rich indication of individuals’ attit udes towards change (Rogers, 1995). After the persuasion stage comes the deci sion stage. During this stage individuals engage in “activities that l ead to a choice to adopt or reject the innovation” (Rogers, 1995, p.21). One of the best ways to cope w ith the “inherent uncertainty about an innovation’s consequences is to try out the new idea on a partial basis” (Rogers, p. 171). Testing out a change program in one department and then spreading it to others can aid its adoption. A trial by others “provides a kind of vicarious trial for an individual.” (Rogers, p. 171). It also provide s an organization with valuable information. Trial runs will make difficulties with implementation visible. This can help prepare communicators for roadblocks in widespread implementation and result in a smoother transition for the change effort. Once decision makers come to an understanding on th e best approach, the implementation and confirmation stages will begin. During the implementation phase individua ls put the innovation to use and during the confirmation stage they seek reinforcement on the decision to accept the innovation (Rogers, 1995). If there is no opportunity for a trial run, then adoption problems become visible during the implementation stage. Cha nge implementers must then evaluate and revise message strategies to k eep the process moving forward. It is important to note, that

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22 communication is essential th roughout the adoption on any innovation, from beginning to end. Innovations in Organizations Diffusion of innovations research initia lly focused on how individuals adopt or reject an innovation. Later studies stressed th e “implementation stages involved in putting an innovation to use in an organizati on” (Roger, 1995, p. 371). The implementation decision process is much more complex with in an organization. It “typically involves a number of individuals, each of whom plays a different role in the innovation-decision process. Further, implementation amounts to mutual adaptation in which the innovation and the organization change in important ways” (p. 372). For innovations in an organization there appear to be three kinds of innovationdecisions. 1. Optional innovation-decisions – choices to adopt or reject an innovation that are made by an individual independent of the decisions by other members of a system. 2. Collective innovation-decisions – choices to adopt or reject an innovation that are made by consensus among the members of a system. 3. Authority innovation-decisions – choices to adopt or reje ct an innovation that are made by a relatively few individuals in a system who posses power, status, or technical expertise (Rogers, 1995, p. 372). In addition, innovativeness in orga nizations is related to indivi dual leader characteristics, internal organizational stru cture and external organi zational characteristics. Research has indicated that centraliz ation in organizations is negatively associated with innovativeness. This means the more power is “concentrated in an organization the less innovativ e the organization tends to be” (Rogers, 1995, p. 380). This is because the leaders are making the change decisions and filtering them down within the organization. The problem with this is leaders are often poorly equipped to identify problems because they are not in the midst of everyday organizational activities, or in the

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23 trenches. Their decisions are met with re sistance because employees feel that the individuals making those deci sions do not understand what em ployees’ everyday jobs are really about (Rogers, 1995). Another organizational ch aracteristic that can affect the adoption of organizational change is its degree of forma lization. Rogers describes this as the ‘degree to which an organization emphasizes follo wing rules and procedures in the role performance of its members” (p. 380). This can hinder the consideration of innovations, but may encourage their implementation. Stri ctly following rules can affect creativity because people are often not encouraged to think outside the box. However, if an organization decides to implement any kind of change effort, employees that are used to adhering to rules may simply follow suit w ith organizational decisions (Rogers, 1995). Organizational interc onnectedness can also affect the adoption of an innovation. Interconnectedness in an organizat ion is the degree to which “un its in a social system are linked by interpersonal networ ks” (Rogers, 1995, p. 381). This can be very useful in spreading innovations throughout the organizati on, but it can also make things very difficult, it is all contingent upon empl oyee reactions to the change effort. When it comes to organizat ional research and innovations studies have primarily focused on the implementation rather than th e adoption or rejecti on of innovations. This is because organizations are often seen as “constraints or resistances to innovations” (Rogers, 1995, 391). On the other hand, the difficulties faced by an organization in implementing a change effort can also be attr ibuted to an ill fit between the innovation and the organization (Rogers, 1995).

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24 The innovation-decision process for organizatio ns consists of similar steps as that for individuals. However, it is divided into tw o parts, as illustrated in Figure 2. The first phase is the initiation subpro cess and the second phase is the implementation subprocess (Rogers, 1995). Figure 2 Initiation Phase The initiation phase occurs when all th e information gathering and planning for the adoption of an innovation takes place and ends once the organization make a decision to adopt. The initiation stage consists of ag enda-setting and matchi ng processes. During agenda-setting an “organizational problem that may create a perceived need for an innovation is defined” (Rogers, 1995, p. 3 91). It is an ongoing process within organizations. To continue operating effici ently, an organization must understand the steps it must take to improve. During ag enda-setting problems are identified and prioritized; often a time consuming task (Rogers, 1995).

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25 Once problems are identified and prioriti zed the matching stage begins. This is when organizational problems are fit with approp riate innovations or ch ange efforts. It is when “organizational members attempt to dete rmine the feasibility of the innovation in solving the organization’s problem…” and it includes “thinking about the anticipated problems that the innovation mi ght encounter if it were implemented” (Rogers, 1995, p. 394) Implementation Phase Once an organization decides to adopt an innovation the implementation subprocess begins. It consists of three stag es: redefining/restruct uring, clarifying and routinizing (Rogers, 1995). During the first stage, an innovation is wo rked to fit the orga nization’s needs and structure more closely. At the same time, orga nizational structure is modified to fit the innovation. To a certain degree, both the i nnovation and the organi zation must change. “This mutual adaptation must occur because the innovation almo st never fits perfectly in the organization in which it is to become embedded” (Rogers, 1995, p. 395). Next comes the clarifying stage. This occu rs when an innovation is put to use in an organization so that the innovation’s mean ing becomes clearer to its members. It consists of a “social construction.” “When a new idea is first implemented in an organization it has little meaning to the or ganization’s members” (Rogers, 1995, p. 399). This results in uncertainty. The clarifying stage is when questions about the innovation are answered so that organizational members can gain a common understanding. Common understanding occurs over time through a social process of human interaction.

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26 Finally, comes the routinizing stage. It is when the innovation has become a regular part of the everyday activities of organizational me mbers. At this point the innovation processes is complete. Change Communication: Two-Way vs. One-Way Communication So far, the theories discussed have illustrated the need for effective and appropriate communication to implement su ccessful change programs. Additionally, several research stud ies have demonstrated the impor tance of continued communication during change efforts. In one such study, Goodman and Tru ss, 2004, analyzed two organizations’ communication strategies when implementing their change programs and the effects the strategies had on the employ ees. In particular, the study focused on the timing of the change messages, the use of appropriate media, and their effect on employee uncertainty. For each organization the researcher s used the following approaches: A review of company documentation; unstructured interviews or electronic communication with a small number of staff to ascertain the principal issues in the change program and to provide essential background information; three semi-structured interviews in each organization with senior managers to explore the design and purpose of the communication strategy; and a ques tionnaire of a random selection of two-thirds of employees in ea ch organization, excluding senior management, to uncover reactions to the change and communication strategies (p. 221). The semi-structured interviews yiel ded important information. One of the organizations primarily used one-way comm unication, while the other company used a combination of oneand two-way comm unication. These communication efforts consisted of face-to-face communication, and a re ward system to celebrate individuals’ successes during the change program. Results from employee surveys demonstrated that

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27 employees in both organizations preferred face-to-face, two-wa y communication about change programs and that they would like th eir opinions to be included in the decision making process (Goodman & Truss, 2004). Overall, the research results were qu ite interesting. The st udy found that both organizations were unsuccessful in the impl ementation of their change processes even though one of the organizations used twoway communication. Findings indicated that the organization still neglected some key el ements in its communi cation strategy. Their research indicated that management was “ out of touch with employee concerns…and they did not understand how the changes would affect them” (Goodman &Truss, 2004, p.225), which indicates the importance of k eeping employees in mind when developing any communication strategy. According to the findings, communica tion should be twoway, and employees should be given the opportun ity to provide feedback. Also, as a part of any communication strategy, organizational leaders should continuously evaluate the results to ensure that strategi es continue to be effective by revising approaches that are not providing results. Employee Involvement in Change Efforts These research findings go hand in hand with the findings of Prashant Bordia, Elizabeth Hobman, Elizabeth Jones, Cindy Ga llois and Victor Callahan, 2004. Bordia et al., studied uncertainty in or ganizations during times of change. They hypothesized that “management communication and particip ation in decision-making would reduce uncertainty and increase feelings of cont rol” (Bordia et al., 2004, p.507). Uncertainty, defined as “an individual’s inability to predict something accurately” is the source of stress that often causes resistance to change in organizations (p. 508).The study focused

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28 on individuals’ level of uncertainty during chan ge and the ways in which this uncertainty can be reduced. As cited earlier, effective manageme nt communication is one way to reduce uncertainty. However, Bordia’s et al., study (2004) went a st ep further. This study also proposed that participation in decision-m aking would positively aid the management communication process in effectively implem enting organizational change. Literature on this topic typically indicates that particip ation in decision making has a positive impact. “It has been shown that when employees ar e involved in the implementation of new programs they are more likely to perceive the program as being beneficial. Employee involvement in tactical decisions has been found to lead to employee acceptance or openness toward change” (B ordia et al., 2004, p.515). The findings of the study support th e findings of Goodman and Truss. “Management communication is effective in re ducing uncertainty about strategic aspects of change,” but to “reduce feeling of uncer tainty…participative strategies are required” (Bordia et al., 526). The study also found that “by being involved in and contributing to decision-making, employees experience less uncert ainty about issues affecting them and feel more in control of the change outcomes” (p. 526).

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29 Information Access and Its Effects Tourish, Paulsen, Hobman and Bordia (2004), also studied the effects of organizational change on levels of trust and uncertainty in employees. Their findings were similar to those discussed previous ly, with one notable exception. This study provided a unique opportunity to observe a nd study those affected negatively by the change efforts as well as those affected positively. This research focused on a downsizing change effort in a hospital. Subjects affect ed negatively were those employees who were let go, while those affected positively were t hose who did not lose th eir jobs. This study demonstrated that individuals undergoing ch ange efforts are all affected similarly regardless of which end of the spectrum they fa ll into. Tourish et al. (2004) found that the communication efforts espoused by the organizati on were largely to blame for the anxiety levels held by both groups of employees. By holding back information, senior managers left middle and lower level managers with little or no information to pass on to employee concerns. As a result, middle and lower leve l managers could not elaborate or appease employees. They received the same amount of information as employees did and were at a loss when it came to answering questions. Ther efore, employees were left to speculate and rely on rumors to gather information. The results of this study provide further evidence of the importance of effective communication efforts. Organizational change of ten rouses feeling of fear that lead to resistance. Effective communication can lower these constraints and the tendency to rely on rumors as sources of information. Most importantly, it emphasi zes the effects of change. Both those who are affected by changes and those who are not will suffer the same amount of distrust and uncertainty wh en provided with insufficient information.

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30 Another important finding to take notice of is that research participants indicated that information alone would not have been enough to lower their uncertainty levels, further emphasizing the importance of two-way commun ication. Employees felt it was necessary to be able to ask questions and have the oppor tunity to engage in discussions regarding what is to be expected during a ch ange effort (Tourish et al., 2004). Internal Communication and Employee Motivation : The necessity of communication is obvi ous from the findings of the previous studies. However, studies have only discusse d the need for communi cation strategies, not the reason internal communication is su ccessful in aiding change efforts. “As the trend toward organizational change continues, strong internal communication programs will increase in importance. Bridging the gap between employees and managers has become a critical goal for organizations today. Massive orga nizational changes…have turned traditional employee confidence and l oyalty to uncertainty, antagonism and fear about the future” (Heidelberg, 1999, p.5) Heidelberg (1999) proposes that internal communication is not only necessary during times of change, but it has a greater pur pose than that of persuasion. Internal communication serves as a tool for unders tanding and fostering employee motivation. Due to the psychological side effects of cha nge, it has been noted that employees undergo an emotional process that in turn leads to ch ange resistance in order to fight the anxieties that change brings. When inte rnal communication is seen as more than just a one-way attempt at persuasion it opens up an ave nue for employee motivation. In order to maintain employees motivated they must have a sense of job satisfaction. Therefore, internal communication can serve for more than just change implementation. It can help shap e and establish an organizati onal culture that fosters high levels of employee morale and theref ore high levels of employee motivation.

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31 Given the scope and nature of the change taking place at the medical facility and the findings from previous studies on co mmunication and change management, it would seem obvious to assume that the organization’ s training program woul d be beneficial to the implementation of their change effort. Th is study sought to determine if the training program is not just beneficial but also effective in facili tating the adoption of the new electronic medical records tec hnology among its most discerning and resistant members. The audience for this training program posed a more difficult hurdle because doctors at the medical facility are not employees, but shareholders and board members who could ultimately decide to take their practice elsewhere. For them, it is not just a matter of adopting a change their employer is enforci ng, loss of status or uncertainty in their position, but instead it is a matter of how this change will ultim ately be of benefit to the everyday operations of their medical practice. If they are to change their set ways, they must understand the beneficial imp lications of the new software. The medical facility’s decision to impl ement this innovation was an authority innovation decision (a top down decision). A select group of individuals, possessing the power and expertise, chose the innovation and th en filtered the decision to the rest of the members of the orga nization (Rogers, 1995). As a result, this research study set out to determine the effectiveness of the training program in: Increasing user knowledge of the new computer program Increasing user understanding of the bene fits of the new computer program Reducing user resistance and feeli ngs of uncertainty towards the new computer program

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32 Increasing user acceptance a nd adoption of the innovation Research Hypotheses : H1: Communication training reduced pa rticipant anxiety about the change. H2: Communication training increased user understanding of the n eed for the innovation. H3: Communication training improved leve ls of confidence us ing the innovation. Research Questions: R1: How did the training communication aff ect participant groups (occupation, gender, age)? R2: Did participants in the training believe the training functionally reduced anxiety and improved acceptance of the change? R3: How did participants perceive the changes? R4: Were the changes viewed as organizational improvements?

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33 CHAPTER 3: Methodology This research employed a multiple methods approach to obtain information in this study. Both survey and qualitative data helped find trends that determined the rise or fall of anxiety and uncertainty levels (quant itative) and allow for a more detailed understanding of the ‘why’ behind any gr oup changes discovered (qualitative). Doctors were divided into beginner and advanced user groups. Advanced users had some working knowledge of the current computer system from already having many of their patient files on the current server, and were able to navigate through it with ease (J. Delatorre, 03/30/06). The rest of the phys icians fell into the beginner category. The advanced users were trained and expected to use the new system by the October 24 launch date. Physicians categorized as beginne rs were trained with their departments for the later launch dates. The first group of beginner physicians began their training in November and were expected to be r eady to change over by December 11, with subsequent groups training and going live over the span of six months. Because physicians are so busy, they posed a special ch allenge. They had to learn the new system, but do so while still handling their regular pa tient load. To accommodate this, there were nine, four-hour computer-based training sessions offered on Saturdays through the beginning of April (see Appendix D). During the span of these four hours, the physicians were taught the how-to’s of the new system, a nd were given the opportunity to return to any other training session if they felt they need extra help in any specific section.

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34 In doing so, the training would “get the a dvanced users to fully understand and be comfortable with the new softwa re, and get the basic users [to] an intermediate level of familiarity with the program” (J. Delatorre Interview 03/30/06). Ideally, doctors would become acclimated with the program and feel comfortable with using it on a daily basis, understand the benefits it would bring and de monstrate less resistance to using the new technology. The medical facility understood that users at the beginner level were unlikely to reach an advanced user stage after the tr aining program; however the intention was to make them feel comfortable using the new sy stem, so they would be more inclined to accept it and continue making strides in learning the program with daily use. Quantitative Methodology Data for this study was collected using two questionnaires (in a pr eand post training setting) surveying employee groups particip ating in the training program. The first questionnaire (see Appendix A) was used to assess their attitudes towards the new practice management system prior to the tr aining program, and the second (see Appendix B) to assess their attitudes regarding the pr actice management system after the training program to determine if there is any cha nge. Secondary research has indicated that organizational change management is depe ndent on communication to reduce anxieties and feelings of uncertainty th at often result in resistance to an organizational innovation. A total of 90 members of the medical sta ff (physicians, physician assistants and nurse practitioners) were required to undergo tr aining. However, because the full conversion into a paperless facility was spread over six months, not all departments were trained at the same time. Each group has approximatel y five to ten individuals. This research

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35 focused on the first employee groups undergoi ng training that were classified as beginners. Because of the size of the group participating in the training program, all trainees were asked to participate, ma king the survey sample a purposive sample. Surveying several training groups would allow th e researcher to gather information from a representative sample. Survey methodology was used to gather as much information from the group as possible within a relatively short timeframe. This research study used surveys to gather information on any behavioral changes in attitude (anxiety and uncertainty levels) regarding the innovation and change effort, resulting fr om the training program. Seven-step, Likert-scaled questions were employed to determine any change in attitude toward the innovation that helped facilitate its adoption and to gauge whether participants felt theoretical components of the Diffusion of Innovations Theory were present in the implemen tation of the innovation. Qualitative Methodology Qualitative data collection, in the form of open-ended questions, was added to the questionnaires (see Appendix A and B) to give the research a leve l of depth and detail that would otherwise be absent from the survey instrument. Quantitative data would allow the researcher to determine if there is any change in behavioral attitude toward the innovation as a result of the communication effort, but would not provide any details regarding the reasons for any change in beha vior, or the reasons for the feelings of anxiety and uncertainty (i f any are found). Qualitative questions would give the researcher more details rega rding the whys behind the behavioral changes that may occur.

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36 Qualitative data collection would make it po ssible to answer the proposed research questions. Adding the open-ended questions to the end of the survey instrument provided a way to gather detailed information from this group of individuals about how they felt about both the changes and the need for the change. As mentioned earlier, the medical staff was a busy group, and they were alrea dy setting aside time to attend the training sessions. In-depth interviews and focus gr oups would require more imposition on their already taxed schedules and it was determined they would not be as effective. It was decided that having a represen tative and captive sample of employee groups present at the training sessions was the ideal time to ga ther the necessary information. Keeping the qualitative portion of the research as part of the survey instrument would make the process easiest for participants, while stil l providing a well-rounded understanding of the concerns and attitudes participants hold toward the change program. Although 90 individuals will undergo training, this study involved a representative group, although small. The results of this the study are treated as a case study from which others can examine the pros and cons of the approach taken by the Florida medical facility to implement an innovation. It serves as a reference to some of the obstacles organizations may face during times of change.

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37 CHAPTER 4 Results This section reviews the resu lts of various statistical analyses to determine the influence of training on the use of new t echnology on group particip ants. Specifically, participants in the medical field were trai ned in the use of a new computer system. As discussed in the methodology, the research er administered a survey before and after each training session. Particip ant responses were analyzed to determine if there were changes in reported anxiety, confidence a nd understanding toward the need for the innovation. Analysis included Chi-Square, an alysis of variance (ANOVA), and paired ttests. The researcher also examined re sponses according to participant age group, occupation and gender. Breakdown of Training Participants Survey questionnaires were made up of Likert-scale questions and open-ended questions to gather as much information as possible on participant attitudes toward the new practice management system. Thirty participants took pa rt in the training classes in which the researcher administered the survey questionnaire. Th e original training schedule called for only medical staff to participate in the training. However, due to scheduling difficulties, staff members in the medical offices (e.g., offi ce managers and medical assistants) were included in the training comm unication program with their respective group of doctors (doctors and their staff members would partic ipate in the training program together). Of the 30 participants, 60 pe rcent (N=18) identified themselves as part of the medical staff (physicians or nurses) and 40 percent as “other” (N=12). Thirty-seven

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38 percent were under 41 years of age and 60 pe rcent were over 40. Forty-seven percent of participants were male (N=14) and 53 per cent (N=16) were female. Only 29 respondents (97 percent) provided information on their ag e, while all 30 provided information on their occupation. Survey Questions In order to determine participant anxi ety, confidence, and understanding of the need for change, respondents were asked to ra te their level of agreement, on a scale of one to seven (with one meaning “strongl y disagree” and seven meaning “strongly agree”), with various statements in the survey instrument. Preand post-training questions aligning to anxiety addressed participant comfor t with the upcoming change, their view on the amount of time given to pr epare and plan for the change, the practice management system’s user-friendliness as well as the training program’s usefulness. Those related to understanding the need fo r the change addressed the innovation’s potential benefits, as well as asked if part icipants understood the reason for the change. Finally, statements aligning to confidence we re related to participant’s view of the practice management system’s usability, their expectations of the training program (if they expect it will be difficult, then likely not confident in thei r ability to learn/use innovation) and whether those expectations were met. Means for individual survey instrument questions are found in Appendix D and E, grouped according age, gender, and occupation. The means for individual questions were aggregated to create one variable for a nxiety, confidence, and understanding preand post-training. Quantitative Results

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39 Table 1: Summed Means P reand Post-training Table 1 shows the summed means of ques tions related to anxi ety, confidence, and understanding the need for change before and after training. Pa rticipants reported increased means for anxiety (+ 0.35) and c onfidence (+ 0.26), i ndicating that after training participants felt more comfortable and less anxious about the upcoming change and more confident about their ability to us e the practice management system. However, participants reported decreased means for unde rstanding (0.14) the ne ed for the change, which indicates that the trai ning program did not appear to increase thei r understanding of the innovation’s relative advantage or expl ain why they needed to make this change. Pre-training Post-training Mean Std. Deviation Mean Std. Deviation Total Group N=30 Anxiety Levels 4.95 1.247 5.30 1.100 Confidence Using the Innovation 5.03 1.235 5.29 1.117 Understanding Need for Change 4.83 1.623 4.69 1.595

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40 Table 2-B: Paired Samples Test Paired Differences Mean Std. Deviation Std. Error Mean 95% Confidence Interval of the Difference t df Sig. (2tailed) Lower Upper Pair 1 Anxiety Pre – Anxiety Post -.34762 .97230 .17752 -.71068 .01544 -1.958 29 .060 Pair 2 Understanding Pre – Understanding Post .14444 1.16383 .21249 -.29014 .57903 .680 29 .502 Pair 3 Confidence Pre – Confidence Post -.26121 .94003 .17163 -.61223 .08980 -1.522 29 .139 T-tests were run on the summed means fr om Table 1 to determine if the changes in mean were significant. Tables 2A-B show th e results of the paired samples t-tests. The decrease in anxiety reported after training, although not si gnificant, is approaching significance (p=0.06). While p>0.05, and not within the 95 percen t confidence level, it is relatively close, and could have been affected by the small size of the sample population. The increased mean relate d to confidence was not signi ficant (p=0.139), as shown in Table 2-B. This suggests that while we sa w a positive change in participant confidence levels, that change was not significantly diffe rent from the mean reported pre-training. The same can be said for means related to understanding the need fo r change (p=0.502). Table 2-A: Paired Samples Correlations N Correlation Sig. Pair 1 Anxiety Pre& Post-training 30 .663 .000 Pair 2 Understanding Pre& Post-training 30 .739 .000 Pair 3 Confidence Pre & Post-training 30 .685 .000

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41 To get a better understanding of the trai ning program’s effect on participants, the researcher also examined participant re sponses to questions related to anxiety, confidence, and understanding the need for th e change according to participant age, occupation, and gender. Table 3 shows summed means for age groups, and Table 4 and 5 the results of ANOVA tests and crosstabs, re spectively, used to de termine significance. Age Groups Table 3: Summed Means by Age Group 0-40 (N=11) Over 40 (N=18) Mean Std. Deviation Mean Std. Deviation Pre-training Anxiety Levels 5.73 1.011 4.47 1.189 Confidence Using the Innovation 5.87 .796 4.50 1.212 Understanding Need for Change 5.60 1.262 4.33 1.701 Post-training Anxiety Levels 5.75 .745 4.98 1.213 Confidence Using the Innovation 5.85 .714 4.90 1.199 Understanding Need for Change 5.62 1.245 4.19 1.585 According to Table 3, prior to undergoi ng training younger part icipants (ages 40 and under) felt less anxious (m=5.73), more c onfident (m=5.87), and understood the need for change (m=5.60) better than participants over 40. Participants over age 40 reported an anxiety mean of 4.47, a confidence mean of 4.50 and a mean of 4.33 for their understanding of the need for the change. Wh ile younger participants still reported higher means than older participants after undergoing tr aining, their means remained relatively the same, with changes of only 0.02 in eith er direction. On the other hand, older

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42 participants, reported lowered anxiety w ith a mean increase of 0.51, and increased confidence with a mean increase of 0.40. Howe ver, while younger participants appeared to remain the same in their reported understa nding, older participants reported a decrease in their understanding of the need for the change by 0.14. Table 4: One-way ANOVA Sum of Squares df Mean Square F Sig. Anxiety Pre Between Groups 10.823 1 10.823 8.530 .007 Within Groups 34.256 27 1.269 Total 45.078 28 Anxiety Post Between Groups 4.039 1 4.039 3.567 .070 Within Groups 30.571 27 1.132 Total 34.609 28 Understanding Pre Between Groups 10.954 1 10.954 4.542 .042 Within Groups 65.120 27 2.412 Total 76.074 28 Understanding Post Between Groups 14.080 1 14.080 6.529 .017 Within Groups 58.221 27 2.156 Total 72.301 28 Confidence Pre Between Groups 12.866 1 12.866 11.091 .003 Within Groups 31.322 27 1.160 Total 44.188 28 Confidence Post Between Groups 6.126 1 6.126 5.600 .025 Within Groups 29.533 27 1.094 Total 35.659 28

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43 Table 5: Chi-Square Tests Anxiety (pre) by Age Value df Asymp. Sig. (2-sided) Pearson Chi-Square 19.797a 19 .407 Likelihood Ratio 26.359 19 .120 Linear-by-Linear Association 6.722 1 .010 N of Valid Cases 29 a. 40 cells (100.0%) have expected count less than 5. The minimum expected count is .38. Table 7: Chi-Square Tests Understanding (pre) by Age Value df Asymp. Sig. (2sided) Pearson Chi-Square 20.505a 20 .427 Likelihood Ratio 27.406 20 .124 Linear-by-Linear Association 4.032 1 .045 N of Valid Cases 29 a. 42 cells (100.0%) have expected count less than 5. The minimum expected count is .38. Table 6: Chi-Square Tests Anxiety (post) by Age Value df Asymp. Sig. (2sided) Pearson Chi-Square 13.072a 15 .597 Likelihood Ratio 17.362 15 .298 Linear-by-Linear Association 3.268 1 .071 N of Valid Cases 29 a. 32 cells (100.0%) have expected count less than 5. The minimum expected count is .38.

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44 Table 8: Chi-Square Tests Understanding (post) by Age Value df Asymp. Sig. (2sided) Pearson Chi-Square 22.629a 18 .205 Likelihood Ratio 30.178 18 .036 Linear-by-Linear Association 5.453 1 .020 N of Valid Cases 29 a. 38 cells (100.0%) have expected count less than 5. The minimum expected count is .38. Table 9: Chi-Square Tests Confidence (pre) by Age Value df Asymp. Sig. (2sided) Pearson Chi-Square 22.629a 16 .124 Likelihood Ratio 30.178 16 .017 Linear-by-Linear Association 8.153 1 .004 N of Valid Cases 29 a. 34 cells (100.0%) have expected count less than 5. The minimum expected count is .38. Table 10: Chi-Square Tests Confidence (post) by Age Value df Asymp. Sig. (2sided) Pearson Chi-Square 19.231a 19 .442 Likelihood Ratio 25.174 19 .155 Linear-by-Linear Association 4.810 1 .028 N of Valid Cases 29 a. 40 cells (100.0%) have expected count less than 5. The minimum expected count is .38. One-way ANOVA test results (Table 4) in dicate pre-training means for anxiety between the two age groups are significantly different (p=0.007), but the Pearson’s ChiSquare test (Table 5) indicates that th is difference may have occurred by chance (p=0.41). Post-training, the ANOVA test (Table 4) indicates that there is no longer a

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45 significant difference between participant anxiety according to age group (p=0.07) and the Pearson’s Chi-Square (Table 6) again indi cated this change could have occurred by chance (p=0.60). Tables 7 and 8 show that means for understanding the need for the innovation were significantly di fferent between the age grou ps both before (p=0.04) and after (p=0.02) training, as were means for confidence (pre-traini ng p=0.003; post-training p=0.03). Tables 8-10 show that the relati onship between age groups and understanding and confidence could have happened by chance (p>0.05). Occupation The following tables show the summed means for reported anxiety, confidence, and understanding the need for change according to participant occupa tion (Table 11) as well as the ANOVA and Pearson’ s Chi-Square tests to dete rmine significance (Tables 1218). Table 11: Summed Means by Occupation Medical Staff (N=18) Other (N=12) Mean Std. Deviation Mean Std. Deviation Pre-training Anxiety Levels 4.52 1.204 5.61 1.039 Confidence Using the Innovation 4.50 1.179 5.82 .859 Understanding Need for Change 4.04 1.598 6.02 .674 Post-training Anxiety Levels 5.27 1.277 5.35 .818 Confidence Using the Innovation 5.17 1.307 5.44 .780 Understanding Need for Change 4.16 1.76149 5.49 .869 Table 11 shows that prior to trainin g, the medical staff was more anxious (m=4.52), less confident (m=4.50) and had a lo wer understanding of the need for change

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46 (m=4.04) than other participants. Others reported means of 5.61 for anxiety, 5.82 for confidence and 6.02 for their understanding of the need for change. After training, the medical staff reported decreased anxiety (m =5.27), increased confidence (m=5.17) and a slightly better understanding for the change (m=4.16). Others indicated slightly higher anxiety (m=5.35), lower confidence (m=5.44), and decreased understa nding of the need for change (m=5.49).

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47 Table 12: One way ANOVA by Occupation Sum of Squares df Mean Square F Sig. Anxiety Pre Between Groups 8.574 1 8.574 6.570 .016 Within Groups 36.541 28 1.305 Total 45.116 29 Anxiety Post Between Groups .041 1 .041 .033 .858 Within Groups 35.075 28 1.253 Total 35.116 29 Understanding Pre Between Groups 28.006 1 28.006 16.201 .000 Within Groups 48.401 28 1.729 Total 76.407 29 Understanding Post Between Groups 12.711 1 12.711 5.830 .023 Within Groups 61.052 28 2.180 Total 73.763 29 Confidence Pre Between Groups 12.482 1 12.482 11.012 .003 Within Groups 31.737 28 1.133 Total 44.219 29 Confidence Post Between Groups .459 1 .459 .360 .553 Within Groups 35.724 28 1.276 Total 36.183 29 Table 13: Chi-Square Tests Anxiety (pre) by Occupation Value df Asymp. Sig. (2-sided) Pearson Chi-Square 20.972a 19 .338 Likelihood Ratio 28.244 19 .079 Linear-by-Linear Association 5.511 1 .019 N of Valid Cases 30 a. 40 cells (100.0%) have expected count less than 5. The minimum expected count is .40.

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48 Table 14: Chi-Square Tests Anxiety (post) by Occupation Value df Asymp. Sig. (2-sided) Pearson Chi-Square 20.833a 15 .142 Likelihood Ratio 28.105 15 .021 Linear-by-Linear Association .034 1 .854 N of Valid Cases 30 a. 32 cells (100.0%) have expected count less than 5. The minimum expected count is .40. Table 15: Chi-Square Tests Understanding (pre) by Occupation Value df Asymp. Sig. (2-sided) Pearson Chi-Square 20.972a 20 .399 Likelihood Ratio 28.244 20 .104 Linear-by-Linear Association 10.629 1 .001 N of Valid Cases 30 a. 42 cells (100.0%) have expected count less than 5. The minimum expected count is .40. Table 16: Chi-Square Tests Understanding (post) by Occupation Value df Asymp. Sig. (2-sided) Pearson Chi-Square 18.889a 18 .399 Likelihood Ratio 25.471 18 .112 Linear-by-Linear Association 4.997 1 .025 N of Valid Cases 30 a. 38 cells (100.0%) have expected count less than 5. The minimum expected count is .40.

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49 Table 17: Chi-Square Tests Confidence (pre) by Occupation Value df Asymp. Sig. (2-sided) Pearson Chi-Square 22.708a 17 .159 Likelihood Ratio 30.337 17 .024 Linear-by-Linear Association 8.186 1 .004 N of Valid Cases 30 a. 36 cells (100.0%) have expected count less than 5. The minimum expected count is .40. Table 18: Chi-Square Tests Confidence (post) by Occupation Value df Asymp. Sig. (2-sided) Pearson Chi-Square 17.639a 19 .547 Likelihood Ratio 23.240 19 .227 Linear-by-Linear Association .368 1 .544 N of Valid Cases 30 a. 40 cells (100.0%) have expected count less than 5. The minimum expected count is .40. The one way ANOVA (Table 12) shows that prior to training the difference in anxiety means between medical and non-medi cal staff were significant (p=0.02), while post-training they were not (p=0.85). The means for understanding were significantly different before (p=0.00) and after (p=0.01) training. The difference in confidence means for this group were significant before training (p=0.003) but not after (p=0.55). Pearson Chi-Square tests in Tables 13 -18 indicate these diffe rences could have happened by chance with p>0.05.

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50 Gender The following tables show the summed m eans for reported anxiety, confidence and understanding the need for cha nge according to participant occupation (Table 19) as well as the ANOVA and Pearson’s Chi-Square t-test s to determine significance (Table 8). Table 19: Summed means by gender Female (N=16) Male (N=14) Mean Std. Deviation Mean Std. Deviation Pre-training Anxiety Levels 5.46 1.016 4.37 1.260 Confidence Using the Innovation 5.65 .847 4.31 1.245 Understanding Need for Change 5.80 .876 3.73 1.590 Post-training Anxiety Levels 5.46 .931 5.11 1.277 Confidence Using the Innovation 5.58 .819 4.95 1.336 Understanding Need for Change 5.48 .987 3.79 1.704 According to Table 19, prior to partic ipating in the training program female participants were less anxi ous (m=5.46) than males (m=4.37); more confident (m=5.65) and understood the reason for the change be tter (m=5.80). Males reported means of 4.31 for confidence and 3.73 for understanding. After tr aining, female participants reported the same levels of anxiety, while males re ported decrease anxiety (m=5.11). Females indicated slightly lower confidence (m=5.58) after training, and decreased understanding of the need for the change program (m=5.48) Male participants felt slightly more confident (m=4.95) and their understanding for th e change appeared to remain relatively the same with a minor increase in mean (+0.06).

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51 Table 20: One-way ANOVA by gender Sum of Squares df Mean Square F Sig. Anxiety Pre Between Groups 8.984 1 8.984 6.963 .013 Within Groups 36.131 28 1.290 Total 45.116 29 Anxiety Post Between Groups .925 1 .925 .758 .391 Within Groups 34.191 28 1.221 Total 35.116 29 Understanding Pre Between Groups 32.038 1 32.038 20.219 .000 Within Groups 44.369 28 1.585 Total 76.407 29 Understanding Post Between Groups 21.413 1 21.413 11.453 .002 Within Groups 52.350 28 1.870 Total 73.763 29 Confidence Pre Between Groups 13.322 1 13.322 12.072 .002 Within Groups 30.897 28 1.103 Total 44.219 29 Confidence Post Between Groups 2.917 1 2.917 2.455 .128 Within Groups 33.267 28 1.188 Total 36.183 29 Table 20: Chi-Square Tests Anxiety (pre) by Gender Value df Asymp. Sig. (2-sided) Pearson Chi-Square 15.937a 19 .661 Likelihood Ratio 21.680 19 .300 Linear-by-Linear Association 5.775 1 .016 N of Valid Cases 30 a. 40 cells (100.0%) have expected count less than 5. The minimum expected count is .47.

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52 Table 21: Chi-Square Tests Anxiety (post) by Gender Value df Asymp. Sig. (2-sided) Pearson Chi-Square 17.143a 15 .310 Likelihood Ratio 23.635 15 .072 Linear-by-Linear Association .764 1 .382 N of Valid Cases 30 a. 32 cells (100.0%) have expected count less than 5. The minimum expected count is .47. Table 22: Chi-Square Tests Understanding (pre) by Gender Value df Asymp. Sig. (2-sided) Pearson Chi-Square 23.304a 20 .274 Likelihood Ratio 32.091 20 .042 Linear-by-Linear Association 12.160 1 .000 N of Valid Cases 30 a. 42 cells (100.0%) have expected count less than 5. The minimum expected count is .47.

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53 Table 23: Chi-Square Tests Understanding (post) by Gender Value df Asymp. Sig. (2-sided) Pearson Chi-Square 22.634a 18 .205 Likelihood Ratio 31.045 18 .028 Linear-by-Linear Association 8.418 1 .004 N of Valid Cases 30 a. 38 cells (100.0%) have expected count less than 5. The minimum expected count is .47. Table 24: Chi-Square Tests Confidence (pre) by Gender Value df Asymp. Sig. (2-sided) Pearson Chi-Square 19.286a 17 .312 Likelihood Ratio 26.546 17 .065 Linear-by-Linear Association 8.737 1 .003 N of Valid Cases 30 a. 36 cells (100.0%) have expected count less than 5. The minimum expected count is .47. Table 25: Chi-Square Tests Confidence (post) by Gender Value df Asymp. Sig. (2-sided) Pearson Chi-Square 19.152a 19 .447 Likelihood Ratio 26.408 19 .119 Linear-by-Linear Association 2.338 1 .126 N of Valid Cases 30 a. 40 cells (100.0%) have expected count less than 5. The minimum expected count is .47. One way ANOVA (Table 19) tests for gende r illustrate that pr ior to training both anxiety (p=0.01) and confidence (p=0.002) m eans were significantly different between males and females. However, after traini ng anxiety (p=0.39) and confidence (p=0.13) means were not significantly different. M eans for understanding the need for change were significantly different between genders both before (p=0.00) and after (p=0.002)

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54 training. An examination of Pearson Chi-Square tests (Table 20-25) indicate that any significance established in the ANOVA coul d have occurred by chance (p>0.05). Independent samples t-tests The researcher also ran independent sa mples t-tests to determine significance between participant groups and their reported anxiety, confidence and understanding. These tests yielded the same results as one way ANOVA tests. Tables illustrating results from the independent t-tests are found in Appendix F. Qualitative Results Pre-Training This section will examine the responses to the open-ended questions included in the pre-training survey. These questions were used to gather additional detail about participant attitudes toward the practice mana gement system that would shed some light on the quantitative results. First, respondents were aske d what three words best desc ribed their feelings about the clinic’s upcoming change to a paperle ss facility. Four general trends arose from participant responses to this inquiry: feelings of ange r, anxiety, readiness, and indifference. Within these four trends, it was possible to id entify various subcategories that shed some light on the possible drivers behind respondent s’ feelings regarding the change initiative. Some participants identified having a pos itive response to the implementation of a new computer system. Responses include d: “good,” “glad,” “happy,” “excited,” “optimistic,” “needed,” “important,” “necessa ry,” and “positive.” Within the positive responses to the change, participants identifi ed reasons for their optimistic attitude. They identified an understanding of the need for th e change, citing expecta tions of a “current,”

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55 “innovative,” and “modern” program that w ould result in “decreased overload,” improved workflow and “better patient car e.” One participant called the innovation a “light at the end of the tunnel.” However, it is important to note that not all participants had positive feelings about the practice management system and not all of those w ho identified positive feelings toward the innovation felt fully pr epared to undergo the change. One participant said, “I have a busy office and learning so mething new along with doing your daily work is hard, but after we get used to this, I think it will be great.” Prior to receiving the training communicati on, participants said they felt anxiety and concern regarding the change effort. Responses included: “anxious,” “nervous,” “worried,” “concerned,” “uncomfortable,” and “unsure.” Much like before, responses were grouped into subcategories that helped identify the drivers be hind the anxiety. Time constraints were among the reasons for c oncern. As with those who felt that the innovation would improve workflow, there were others who worried that learning new procedures would be “very time consuming,” affecting workflow and, as a result, patient care. Among his questionnaire responses one participant expressed how he felt the innovation would affect his res ponsibilities, “slowing down my work, more things for me to do.” Still, others identified feelings of an ger, resentment, and resistance toward the practice management system. Some of the term s these individuals used to describe their feelings toward it included: “bad,” “ineffi cient,” “terrible,” “wor thless,” “frustrating,” and “fear.” Upon closer look, th ese individuals also provided some insight into why they felt this way. Some participants felt the ch ange effort was chaotic and disorganized,

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56 which would correlate with their negative view of the change. Others stated the change was unnecessary (“needless”) — in stark contra st to the individuals who felt the clinic was due for a change that was “modern,” “i nnovative,” and “current .” However, as one participant pointed out “change is always reluctant” and there will always be individuals that would rather keep things the same. Finally, respondents also indi cated indifference toward th e change effort. Stating they were just fine or di d not know how they felt. Next, participants were asked to identi fy any concerns they had regarding the change effort. This question was designed to provide insight into the feelings that participants identified in th e previous question. The majority of respondents identified at least one concern regarding the practice ma nagement system and only a small number stated they had no reservations regardi ng the upcoming change. Those who declared entirely positive feelings re garding the change tended to have no concerns; however, there were still some of those who had worries. As identified in the previous question, pa rticipants had concerns regarding time constraints related to the innovation. Among them were the following: concern the program would take too long to learn, cause a slow transition into the new system, and result in too much time consumed in seeing and evaluating the pati ent which disrupts the workflow. One respondent felt “it [would] ta ke too much time to see and evaluate patients.” Time concerns went hand-in-hand with c oncerns regarding effi ciency and patient care. There was anxiety related to how th e new computer system would affect the timeliness of patient care and volume and wh ether it would have a negative effect on

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57 doctor-patient relationships as a result of depersonalizati on. One respondent said, “I am concerned about its effects on throughput, patient relations (too much time spent on computer rather than patient) slowing [the] patient care process.” It appears employees were concerned that the ne w computer system would re quire they spend more time entering data into the system and less time speaking with the patient and devoting the necessary one-on-one time that devel ops the doctor-patient relationship. The next area of concern was related to technological difficulties and information sharing. Participants were wo rried about what to do in the event of technological difficulties such as system failures and how they would affect workflow and patient care. They demonstrated concerns about “mis information,” system security, “lost information,” a lack of information sharing and with learning a new computer system. Participants were then asked how they first heard about the upcoming change effort in order to identify the primary form of communication regarding the change with employees. Many participants indicated that th ey first heard of the change in meetings with their supervisors, management, the board, or the CEO. Others indicated they heard it from their peers and the grapevine, while others said they received one-way communications such as memos and emails. They were also asked to identify th e different types of communication they received about the change in itiative prior to implementati on. Participants cited verbal forms of communication most of ten, indicating that the orga nization primarily used twoway forms of communication, among them: info rmation received at board meetings, meetings, from supervisors and training classe s and sessions. Others id entified written or one-sided forms of communication such as booklets, pamphlets, memos, mailers, and

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58 literature. There were several participants w ho indicated they did not receive any form of communication and others who commented on the time lapse between communications and implementation. For example, one particip ant said, “[I] receiv ed communication but it was very slow starting, so when we did start to [implement] the system, most had forgotten.” Participants were asked whether they felt the change initiative was necessary and why they felt that way. Responses indicated that a large number of respondents felt the change was needed at the me dical facility. So, although ma ny respondents have indicated anxiety and concerned feelings regarding the change initiative, they demonstrated some understanding of the reason behind the change, and that the reason is not without merit. Responses included the following: the ability to provide improved se rvice and care to patients, improvements in obtaining patient reco rds, the need to keep up with technology (“keep up with the times” and “all systems will eventually become paperless”), the ability to advance clinical research (“allow for clinical research”), and time-saving qualities. However, there were still a number of individua ls who indicated resist ance to the change initiative. Many of these indivi duals did not elaborate, simp ly saying “no,” they did not feel the change was necessary. One respondent said, “Maybe. I have been told, but am not convinced that there is a positive setup in patient care and management.” A lot of participants indicated that th e training program was needed in order to help them feel more comfortable using the computer system. Finally, participants were asked to speculate on whether they felt there was anxiety related to the change effort in th eir department and what they thought was causing it. Respondents indicated that there were anxiety issues resounding in their

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59 departments. Some of the reasons given for this were fear of the unknown and concerns regarding their ability to pr operly use the new computer sy stem. One participant said, “Some people are not feeling they can do it. ” Another participant said, “Everyone is worried about their role and its effect on th eir daily tasks.” Other concerns included the failure to provide information and loss of da ta; effects on workflow (“nervous about time consumption”) and patient care. Qualitative Results Post-Training After the training program, participants we re asked another series of questions to gauge if the training was effec tive in reducing any anxiety or resistance participants had regarding the new computer system and provi de additional detail to the post-training quantitative results. First, participants were asked to identi fy any concerns with the new computer system that were not covered during the trai ning program. Most participants stated they had no concerns without elaborating, and othe rs simply did not answer. However, of the individuals who identified con cerns the trends were relate d to the following: workflow and responsibility, patient care and experien ce (“How will it affect patient flow and volume [?]”), time, and technology. As with the concerns encountered prior to undergoing the training program, individuals were concerned that the new system would affect workflow because they would have difficulty going through their everyday tasks and as a result patient care would suffer. Time concerns were also present, as they were prior to the training, although it was not men tioned as much as before the training program. Finally, there were still particip ants who indicated concerns regarding technological difficulties, main ly, how to address patient care and daily tasks in the event

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60 of a computer malfunction. As one participant pu t it, “How will we take care of patients when the computer is down?” Then, participants were asked what th ree words best described how they felt about using the new computer system on a daily basis. As with the questionnaire administered prior to the training program several trends arose. Among them were: confidence and comfort, anxiet y and worry, and frustration. Many respondents indicated they were happy with the computer system after undergoing the training program. Responses included “comfortable,” “relaxed,” “confident,” “excited,” “convenient,” “m odern,” “interesting,” “hopeful,” and “necessary.” One respondent said, “I like [the practice management system], I am looking forward to going paperless.” Some stated they understood the programs’ timesaving qualities, referr ing to it as “convenient [and] time saving.” However, not everyone felt comfortabl e moving forward. There were still respondents who indicated they felt anxious about using the new computer system. Responses included worried, “still fear ful,” confused, “apprehensive,” and “overwhelmed.” From responses, it could be determined that some of the anxiety individuals felt had to do with their feelings that using the program would take up too much of their time and that it ran slowly. “Too slow (I find the computer freezes up),” one participant pointed out. Participants were next aske d if there was anything they would change about the training program and, if so, what it would be. A lot of respondents st ated they would not change anything about the trai ning program. Of the individuals who felt otherwise, they

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61 stated a need for additional time in tr aining, or one-on-one time to facilitate understanding and comfort. Finally, participants were asked if ther e was anything they would change about the communication they received regarding th e change initiative prior to implementation. Although most participants said no, some indi cated they would have preferred more oneon-one time and clearer comm unication. One participant sa id, “Even though there was plenty of communication [it] was somewhat confusing and unorganized with too many changes.”

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62 CHAPTER 5 Discussion This research study set out to determ ine the effectiveness of a training communication at a Florida medical facility in acclimating participants to its upcoming change to a paperless facility. The training pr ogram was intended to instruct participants, with a specific focus on the medical staff, on how to use the new practice management system. This section addresses the hypotheses and research quest ions set forth in this study in light of the results shown in the pr evious chapter. It will discuss whether the training communication functionally reduced participant anxiety toward the change, increased participant understanding of th e need for the innovation, and increased participant confidence using the practice ma nagement system. Additionally, trends in qualitative responses to the open-ended questions will help determine whether participants viewed the change as an organizational improvement, if the training communication helped change participant per ception of the change, and if it increased change acceptance and reduced resistance. It will also address how the training program affected the different participant groups (occupation, age, gender). Hypotheses H1: Communication training reduced par ticipant anxiety about the change. As shown in the previous chapter (Table 1), participants reported a higher mean for anxiety (m=5.30) after training, indicat ing they felt more comfortable and less

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63 anxious about the upcoming change. A paired t-test (Table 2-B) shows the change in mean was approaching significance (p= 0.06); however, H1 is rejected. According to means for individual questions (Appendix D, Table 30 and Appendix E, Table 39), after training partic ipants were slightly more comfortable adopting the practice management system (+0.56) likely because they were satisfied with the training (m=5.00) as they felt they we re able to ask questions freely (m=6.03), making training user-friendly (m=5.80). As a resu lt, participants believed they were more likely to use the practice management sy stem after undergoing training (m=5.60) H2: Communication training increased user understanding of the need for the innovation. Table 1 shows that overall understanding a bout the need for the change decreased after the training program by 0.14. But t-test results indicate that the decrease in mean is not significant (p=0.50), therefore not illustrating a change in attitude. Consequently, H2 is rejected. Still, it is interesting to note that this is the only theme for which the training program had the opposite effect as intende d (although that effect was relatively minor). The means for anxiety and confiden ce had positive movements, as predicted, while understanding means shifted in th e opposite direction from what was anticipated. The training program did not appear to address the innovation’s potential benefits, instead focusing more heavily on system us age. Accordingly, it did not appear to illustrate how the changes might help streamline work and improve efficiency. Instead, while participants vi ewed the change as “modern ” and “convenient” (as seen

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64 in qualitative data) they did not seem to link th ese qualities to the innovation’s benefits. They were more concerned with the amount of time it would take them to feel comfortable using the system to fully consider its advant ages in the long run. They were focused on how workload would be affected while they became accustomed to the changes. Some felt that it would take too much time to input data (“time-consuming,” “too slow”), or get used to the changes and therefore slow them down. This can account for the lower means, which can be seen preand posttraining for the statement, “I understand the need for this change.” Prior to training, participants had a mean of 5.57 (Appendix D, Table 29) and after it was 5.40 (Appendix E, Table 38). It is possible that these benefits will re veal themselves over time, once use of the practice management system has become sec ond nature and it is easier to step back and see the big picture. H3: Communication training improved levels of confidence using the innovation. While Table 1 shows there was a positive increase in participant reported confidence means, this change was not signi ficantly different (p=0.14), which suggests there was no marked change in attitude. As a result, H3 is rejected. The change in mean could have resulted by chance. As seen in Appendix E, Table 40, partic ipants were satisfie d with the training (m=5.00). It covered information pertinen t to system usage (m=5.40), was useful (m=5.80) and the trainer provided appropr iate feedback (m= 5.63), resulting in participants believing that others would benefit from undergoing training (m=5.90). However, this did not seem to make particip ants significantly more comfortable with the

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65 innovation. While they felt the program was us er-friendly (m=5.60), they were not as secure about their ability to use the practice management sy stem with little assistance (m=4.97) or fit it easily into their daily work routine (m=4.53). Research Questions This section addresses th e research questions proposed for this study by examining quantitative results for the total group of participants al ong with qualitative data gathered from the surv ey’s open-ended questions. R1: How did the training communication af fect participant groups (occupation, gender, age)? Pearson Chi-Square tests in Chapte r 4 show that preand post-training significance and similarities observed within groups could have resulted by chance (p>0.05), making it difficult to identify if the changes in means occurr ed as a direct result of training. As a result, the following di scussion on the potential effects of training according to participant groups is based in speculation. Younger participants (under age 41) did not seem to be nefit very much from the training program, as their means for anxi ety, confidence and understanding remained relatively the same after undergoing traini ng. Participants over 40, on the other hand, reported shifts in their anxiety, confidence and un derstanding. Before training, anxiety le vels between these two groups were significantly different, while after training, ttests indicate they are not (p=0.07). This seems to imply that the reported anxiety levels after traini ng were similar, thus training appeared to reduce older participants’ anxie ties and bring them to a leve l that approached those of younger participants (who reported little anxiety to begin with). However, confidence and

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66 understanding remained significantly different both before and after training. While older participants reported higher summed mean s for confidence (+0.40) younger participants felt significantly more secure moving forward. This could be because younger participants are more accustomed to using te chnology, as they have been exposed to it more often during their work. Y ounger participants were more likely to be a part of the office staff, and their jobs require they use the current computer system with more frequency than the medical staff to schedule pa tients, requests lab test s, etc. Additionally, younger individuals are more likely to be dext erous with technology as they, in a sense, grew up with it. Summed means for understanding the need for the change decreased (-0.14) for participants over 40, moving them farthe r from younger participants. The training focused more on the innovation’s usage. As di scussed earlier, qualita tive data indicated that participants were focused on the amount of time if would take them to feel comfortable enough with the new system and how this would affect efficiency and workflow in the meantime. It is possible that because of these concerns, participants were not able to focus on the long-term benefits once using the practice management system became second nature. As a result, they fe lt they understood the reason for the change less (with a summed mean slightly better than neutral m=4.19). Younge r participants felt relatively confident before and after traini ng. Upon closer inspecti on (Appendix E, Table 35) they felt they understood the need for the change (m=6.00) and agreed that changing to a paperless clinic woul d benefit the clinic (m=5.36), patients (5.36), and their relationship with patients (m=5.64).

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67 When summed means for anxiety, confid ence, and understanding are observed according to occupation, we see that the me dical staff reports d ecreased anxiety, and increased confidence and understanding after training, while “other” participants report increased anxiety, and reduced confidence and understanding. Prior to training, the means between the medical staff and “others” were significantly differe nt. This significance remains for confidence and understanding after training, but not for anxiety. It appears that “other” participants over estimated their ability to learn and use the system, and the training adjusted th eir expectations. Finally, the researcher checked for any di fferences in summed means according to participant gender. Females had significantly higher means than males for all measures. A closer look revealed that all male partic ipants were physicians, the group the medical facility knew would be the most resistant, as they have th e least interaction with the current computer system and thus would have to change their daily routine the most. This explains their relatively low summed means, which at their highest were only slightly better than neutral. The training appeared to benefit males and not females. After training, male summed means for anxiety increased to where they were no longer significantly different than females’ anxiety summed means (which remained the same after training). Males also reported increased summed means fo r confidence, while females’ confidence means decreased. However, it seemed the training simply adjusted female expectations, as their confidence levels remained high (m=5.58). When it came to understanding the need for the change, the training appeared to affect females as opposed to males. The men’s summed means remained relatively th e same (+0.06) while the women’s dropped by 0.32.

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68 These results appear to indicate that the training was more successful with specific groups. Members of the medical sta ff, which predominantly over 40 years of age and male (all male participants were physicia ns), appeared to benefit the most from the training program. This could have something to do with the fact that the training was led by another member of the medical staff, sp ecifically a physician. This individual may have served as a change agent for these speci fic groups, as he is a trusted peer, and likely speaks their “same language.” Additionally, the medical facility anticipated these groups would pose the most difficulty, as they would have to adjust the most to the change. Therefore, it appears that the training specifi cally focused on their needs, which could be why there were no large changes in summed means individuals who were not members of this group, which included most females and pa rticipants under age 41. Further research on tailoring training to sp ecific groups could yield interesting results. R2: Did participants in the training believe the training functionally reduced anxiety and improved acceptance of the change? Quantitative data indicated that, overall, participant’s experienced a reduction in anxiety, although t-tests indi cated that the reduction wa s only marginal (p=0.060). Based on quantitative data, the training helped reduce participant anxiety by increasing their confidence using the practice management system. It also demonstrated that all participants felt positively about the training they received. In the qualitative data, a decrease in resentment and a nxiety was observed, although it was not fully alleviated. This c ould account for some of the decreases in means observed in the age group analysis and some of the areas where the mean increases were not ve ry considerable.

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69 The resistance and anxiety that were iden tified in the qualitative responses were related to: concerns about time constraints, work disruption, technical difficulties, learning a new computer sy stem, and misinformation. The training program appears to have pr ovided sufficient information for some to reduce anxiety related to the us age of the practice management system, but didn’t seem to address other areas of concern. This was confirmed in the qualitative data when participants were asked if they had any concerns about the co mputer system that were not covered in the training program. A large portion said they had no concerns. The participants that identified concerns said th ey were concerned with the time it would take them to feel comfortable using the system (“difficulty getting tasks completed”) and how this would affect workflow (“How will it a ffect patient flow and volume [?]”). Another concern was how to address patient care and workflow in the event a system failur. As one participant put it, “How will we take ca re of patients when the computer is down?” All of this explains the quantitative re sults, where the group reported reduced comfort with the amount of time they were given to prepare for the change and some participant groups experienced decreases in anxiety variab le means. They did not feel the training addressed all of their concer ns, or maybe for some, traini ng brought concerns to their attention they had not considered. Respondents did seem somewhat more open to the clinic’s ch ange after training, with a much larger set of positive responses including, “comfortable,” “modern,” “hopeful,” and “modern.” Overall, the group experienced favorable changes in anxiety and confidence variables, and reported less anxiety and re sistance in the post-training open-ended

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70 questions. The training appears to have functionally (although marginally) reduced anxiety and resistance. However, it is impor tant to note that participants were not completely sold on the innovation. While they were more comfortable with using the practice management system, they did not em erge from training as new-found supporters; as can be seen in both qualitative and quant itative data. They still felt “concern[ed],” “anxious,” “nervous,” and “overw helmed,” but these emotions were mixed, as some of these same individuals said they were “hopeful” and “excited.” R 3: How did participants perceive the change? Qualitative and quantitative data demonstrated that participants were divided about the upcoming change prior to the traini ng. There were some who were ready for the change and simply wanted instruction on how to use the new computer system. These individuals felt “positive” about the change ; that it was “needed” and “modern … [and] convenient.” Some were slightly against th e change because they were nervous about how to use the practice management system or whether it would be beneficial. One individual said he was “optimistic” but “apprehensive” and found the change “frustrating.” And others were in complete opposition, saying that it was “worthless,” “terrible,” “bad,” “inefficient,” and could resu lt in depersonalizing pa tient care. As stated in Chapter 4, one individual said, “I am concerned about its effects on throughput, patient relations (too much time spen t on computer rather than pa tient), slowing patient care process.” After the training communication, quan titative data indicated a positive movement in participant attitude about th e change, but qualitative data indicates the movement represents varied degrees of accep tance. The individuals who were already

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71 proponents of the change, but were unsure how to use the innovation, had an improved outlook about the change. They said it was “convenient,” “modern,” and “necessary.” One participant said it was “cost effective, efficient, [and might] decrease overload.” Those who were concerned and apprehensive about the change because of their concerns with using the system had mixed results as did the ones who were in complete opposition. For the former, some perceived the change as necessary once they learned how to use it. One participant described it as “user-friendly, [and] necessary.” Others had new concerns once they finished training like, “Will patient value decline [?].” They felt more comfortable with using the practice manage ment system, but were concerned about computer failures and how that would aff ect workflow (“difficulty getting tasks completed”) and patient care. The same happened with the participants who were agai nst the change altogether. Some reported they were still unsure but hopefu l. These individuals were concerned with the time it would take them to feel comforta ble and how that would affect patient care and workflow in the meantime. One participan t said he felt the system was “complicated” and would “take excessive time.” There was also a concern for technology glitches. And finally, others were simply not convinced. One said, “Half of my job duties I have yet to understand.” They remained resistant. R 4: Were the changes viewed as organizational improvements? Quantitative data indicated a decrease in participants’ understanding for the need to change to a paperless system. While some participants still indicated they understood the need to change, they were not as conf ident in the practice management system’s benefits as they were prior to training. It is likely that these indivi duals gave the practice

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72 management system more credit than due, and when they actua lly used it in training, they had more realistic expectations. While some felt the innovations was “modern ” and “convenient,” it is possible they have not fully considered the long-terms be nefits once everyone was comfortable with the changes in place. And this can account for the lower quantitative means related to the innovation’s benefits. After all, participants had some con cerns about how long it would take them to learn and be comfortable with the system and how that might negatively affect workflow during that ti me. Some felt that it would take too much time to input data, or get used to the changes and therefore slow them down. Since the quantitative data puts the means above neutra l, and qualitative data indicates some acknowledgement of the benefi ts the innovation would potentially realize, it can be said that participants viewed the change as an organizational improvement. But, it is important to keep in mind that this view was only superficial.

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73 CHAPTER 6 Conclusions The size of the sample population taken for this study is not sufficient to generalize results to the medical facility’s employee population, nor to the population at large for that matter. However, survey result s can be looked at to see how well they line up with organizational change th eory and communication theory. One of the most evident findings is that although organizational and communication change theories espouse the importance of communication, it is important not to regard it as some sort of ma gical cure-all. Overall, participants indicated reduced anxiety and increased confidence using the innovation, but on the whole the changes were not dramatic. This not only shows that communication is not a magic remedy, it also demonstrates that it must exist over time, as opposed to one allencompassing communication session. It is not possible to cover everything in the necessary detail without overwhelmi ng those receiving the information. It is evident that medical facility’s training program was not able to do it all. Participants’ understanding of the need for the change decreased after undergoing training. While the change was not significant (p >0.05), the fact that there appeared to be no change in attitude about the innovatio n’s relative advantage merits mention. As discussed earlier, Rogers’ Diffusion of Innova tions theory (195) c onsiders understanding an innovation’s relative advantage a main driver in bringing individuals around to accepting change rather than resisting it. Seeing as individuals felt less confident regarding the need or benefits the practice management syst em would bring after training indicates there is still work to be done. W ithout this component, the medical facility will

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74 continue an uphill battle against change resi stance because its members will continue to search for meaning, as uncertainty is still pres ent. “Individuals are more likely to adopt an innovation if they think it will help them” (Berwick, 2003, p. 1971). Because the training program focuse d more on innovation usage, and was somewhat successful (marginally) in reducin g anxiety, it is possible that continued communication about the practice manageme nt system and prolonged exposure and usage will help participants better understa nd the innovation’s relative advantage and as a result the reason for the change initiative. According to Roger’s (1995) Diffusion of Innovations theory, this is known as the clarifyi ng stage in the initiation phase. It occurs when an innovation is put to use in an organization so th at the innovation’s meaning becomes clearer to its members. It consists of a “social constructi on.” “When a new idea is first implemented in an organization it has little meaning to the organization’s members,” which is what appears to be ha ppening in this particular case (p. 399). This research only focused on the traini ng communication, and as a result it is not possible to draw conclusions about any addi tional communication participants may have received. This is considered a limitation of this study. Perhaps a longitudinal study would indicate a change in particip ant attitude regarding the orga nization’s change effort. It would be interesting to see if anxiety and confidence continue to benefit over time, and whether time will also play a significant f actor in exposing the innovation’s relative advantage. That being said, this research study does not discredit the importance and necessity of communication in change facilitation. Study pa rticipants, in their qualitative responses, indicated that they would benefit from additional one-on-one sessions or more

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75 individualized training sessi ons (“more one-one-one”). This goes hand-in-hand with findings from Goodman and Truss’s 2004 study, where employees indicated a preference for two-way communication. Moreover, participants responded positivel y to the training they received, as illustrated by quantitative data (Appendix E). It is because of this that this research concludes that the training communicati on was somewhat useful and beneficial. Participants strongly felt that ot hers should take part in the training course. However, it is simply not possible to address a large cha nge effort during one training session. As one participant stated, “[We] should have training over several sessions.” Another training program attribute that merits mention, is that it was led by a member of the physician staff and not a representativ e from the software company that provided the innovation to the medical facility. It wa s evident from interaction in the training sessions that participants felt comfortable around the docto r who provided the training and regarded him a knowledgeable individual. There were no negative responses related to the training program and its facilitato r’s ability to communicate information to participants (Appendix E). The medical facility employed a change ag ent as the face of the training program supporting the practice management system. Ho wever, it would have likely benefited from employing more than one change agent. Not doing so places too much responsibility on one individual and increases chances for failure. Moreover, having more than one individual advocating this change would have provided participants additional people to turn to with questions, and woul d lend the change effort more credibility.

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76 Another approach that may have been bene ficial was to train a group of individuals through implementation before rolling the change effort out to the entire staff. Rogers (1995) referred to this as observability. If the change effort is successful in one department, and remaining organizational member s are able to observe this success, they are more likely to be receptive to adopti ng the innovation as well. Furthermore, rolling out a change effort in one department be fore doing so in the remainder of the organization can help with stra tegic planning. Organizations ar e able to identify pitfalls and work to address them before implem enting a change throughout. By not employing this method, the medical facility’s change effort seemed haphazard. Training sessions were postponed for long periods of time wh ile the organization addressed roadblocks, which did not go unnoticed. In the qualitativ e section of the research, one individual pointed out that from start to implementation th e change effort “was very slow starting so when we did start to [implement] the sy stem, most had been forgotten.” Another individual said, “Even though there was pl enty of communication, the communication was somewhat confusing and unorga nized with too many changes.” Overall, the training program was minimally successful in reducing anxiety, but did not increase confidence and participant unders tanding of the need for the change. The researcher encountered some limitations in her study. The small sample size made it difficult to draw a better understandi ng of participants’ view of the change and training. The medical facility’s training sess ion postponement added to this limitation. The researcher had difficulty staying informed of when training would restart, and missed training sessions that would have made it possible to collect additional survey questionnaires.

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77 As mentioned before, having only studied the training communication program also limited the conclusions that could be draw n. This study may have benefited from a longitudinal component that would have iden tified the effect of time and exposure to change acceptance or resistance. Additionally, there is an opport unity to expand and focus th is research specifically into the field of public relations, to emphasize or study the need for tailored and strategic communications to enact successful change efforts. While this study focused on the training communications directed at a small group, an extension of this research could include the study of multiple communication ve hicles, seeing as two-way and one-on-one communication is often time consuming and not always feasible. A study such as this one could shed additional light on effectiv e communication tools during different facets/stages of a change program. As a participant in this study pointed out, the communication received outside of traini ng from the initial announcement of the upcoming change to the change implementati on was sporadic, and made the effort seem haphazard. What types of communi cation efforts would have he lped alleviate this? When is one-way communication more effective th an two-way communication? How much and what types of communication vehi cles are best employed when? Also, expanding the sample size or possi bly extending the research over multiple hospitals or medical facilities could yield ge neralizeable results, especially considering the continued increase in the use of tec hnology in the workforce. As more medical facilities switch to electronic practice manage ment, what opportunities exist for training? This study showed a marked difference between medical staff members and nonmedical staff members regarding their comf ort, understanding and anxiety related to

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78 adopting the change to a paperless facil ity. The training communication appeared to resound more effectively among the medical sta ff than others. This supports a closer look into the need for strategically-tailored training and communication approaches for specific audiences. Would individuals who were not members of the medical staff have benefited from different forms of training ? Would they have needed less one-on-one? Was their training jeopardized by those who were not as advanced as they were with the computer system? What is it about training programs that ma ke them resonate better for some people than for others? Further research on this topic may yield interesting results. Yet another area that merits investiga tion is the appropriate development of interactive, multimedia training programs. As stated earlier, two-way communication, or one-on-one training is time-consuming and in this day and age not always viable. How can training communication work effectively in the digital age? How much can be taught through software programs and what need s additional attentio n from trainers?

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79 BIBLIOGRAPHY Abrahamson, E. (1991) Manage rial Fads and Fashions: Th e Diffusion and Rejection of Innovations. The Academy of Management Review, 16, 586-612. Berwick, D. (April, 16, 2003). Disseminati ng Innovations in Health Care. JAMA, 289, 1969-1975. Bond, F.W., Bunce, D. (2000). Mediators of Change in Emotion-Focused and ProblemFocused Workstie Stree Management In terventions. Journa l of Occupational Health Psychology, 5, 156-163. Bordia, P., Hobman, E., Jones, E., Gallois, C., Callan, V.J. (Summer 2004). Uncertainty during organizational change: Types, cons equences and management strategies. Journal of Business and Psychology, 18, 507-532. Burnes, B. (2004). Kurt Lewin and the Pla nned Approach to Change: A Re-appraisal. Journal of Manageme nt Studies, 41, 978-1002. Chreim, S. (Sept. 2002). Influencing organiza tional identification dur ing major change: A communication-based perspective. Human Resources, 55, 1117-1137. Daly, F., Teague, P., Kitchen, P. (2003). E xploring the role of internal communication during organisational change. Cor porate Communications, 8, 153-162. Daniels, K. (2006). Rethinking job characte ristics in work stress research. Human Relations, 59, 267-290. D’Aprix, R.M. (1996). Communi cating for change: Connecting the workplace with the marketplace (1st Edition). San Francisco: Jossey-Bass Publishers. Dent, E.B. & Goldberg, S. G. (1999). Challe nging ‘Resistance to Change’. Journal of Applied Behavioral Science, 35, 25-41.

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80 Drazin, R., Glynn, M.A.., Kazanjian, R. (A pr. 1999). Multilevel Theorizing About Creativity in Organizations: A Sensemaking Perspective. Academy of Management Review, 24, 286-306. Ford, C.M. (2002). The futurity of decisions as facilitator of organi zational creativity and change. Journal of Organizati onal Change Mangement, 15, 635-646. Goodman, J. & Truss, C. (Sept. 2004). The medium and the message: Communicating effectively during a major change initiati ve. Journal of Change Management, 4, 217-228. Haveman, H.A. (Mar., 1992). Between a Rock and a Hard Place: Organizational Change and Performance Under Conditions of Fundamental Environmental Transformation. Administrative Science Quarterly, 37, 48-75. Heidelberg, J.M. (1999). The forgotten th ree: Culture, internal communication and meetings in organizational change. Unpublished master’s thesis, University of South Florida, Tampa. Jimmieson, N.L., Terry, D.J., Callan, V.J. (2004). A Longitudinal Study of Employee Adaptation to Organizational Change: The Role of Change-Related Information and Change-Related Self-Efficacy. Journa l of Occupational Health Psychology, 9, 11-27. Katz, E. (1957). The Two-Step Flow of Communication: An Up-T o-Date Report on an Hypothesis. The Public Op inion Quarterly, 21, 61-78. Kramer, M.W. (2004). Managing uncertainty in organizational communication. Mahwah, NJ: Lawrence Erlbaum Associates.

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81 Llewellyn N., Harrison, A. (2006). Resisti ng corporate communicat ions: Insights into folk linguistics. Human Relations, 59, 567-596. Lorenzi, N.M., Riley, R.T. (2000). Managi ng Change: An overview. JAMIA, 7, 116-124. Managing change and Transition (2003) Boston, MA: Harvard Business School Publishing Corporation. McHugh, M. (1997). The Stress Factor: Anot her item for the change management agenda? Journal of Organizational Change, 19, 345-362. Moore, T. (Sept. 1996). Building Credibility in a Time of Change: How Can the CEO and Communication Team Ensure Credib le Communication Internally Today? Communication World, 13, 18-21. Nonaka, I., von Krogh, G., Voelpel, S. ( 2006). Organizational Knowledge Creation Theory: Evolutionary Paths and Future Advances. Organizational Studies, 27, 1179-1208. Rogers, E.M. (1995). Diffusion of Innovations (4th Edition). New York: The Free Press. Severin, W.J., Tankard, J.W. (2001). Communication theori es: Origins, methods, and uses in the mass media. New York: Longman. Sewell, J.D. (Mar., 2002). Managing the st ress of organizational change. FBI Law Enforcement Bulletin, 71, 14-20. Stanley, D.J., Meyer, J.P., Topolnytsky, L. (Summer 2005). Employee Cynicism and Resistance to Organizational Change. Journal of Business and Psychology, 19, 429-459. Tourish D., Paulsen N., Hobman, E, Bordia P. (2004). The downsides of downsizing: Communication processes and information n eeds in the aftermath of a workforce reduction strategy. Management Communication Quarterly, 17, 485-516.

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82 Appendices

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83 Appendix A Pre-Survey with variable coding Survey I 1. Please select one: V1 (1=physician; 2=nurse/nur se practitioner; 3=other) ___ Physician __ ___ Nurse ___Nurse practitioner __ __Other:_____ v1-a ______________ qualitative answer 2. Please select one: _____ Female _____ Male V2 (female=1; male=2) 3. Age: ______ V3 = numerical value Please select on a scale of 1 to 7, 1 being st rongly disagree and 7 being strongly agree, the accuracy of the following statement s as they pertain to you. V4 – V18 (Numerical value on a scale of 1-7) 4. I use the current software system r egularly (3 or more times per week) V4 1 2 3 4 5 6 7 5. I feel comfortable changing to a paperless system (practice management system). V5 1 2 3 4 5 6 7 6. I feel I need this training program in orde r to properly use the new software system. V6 1 2 3 4 5 6 7 7. I think the new software program will be beneficial to my everyday work activities. V7 1 2 3 4 5 6 7 8. I think the clinic will benefit from the new software system. V8 1 2 3 4 5 6 7 Strongly Disagree Strongly Agree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree Strongly Agree Strongly Agree

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84 9. I think this training program will be usef ul in acclimating me to the new system. V9 1 2 3 4 5 6 7 10. I feel we will have enough time in training to cover the information I will need to use the new software program. V10 1 2 3 4 5 6 7 11. I feel we have been given adequate time to prepare for the upcoming change to a paperless facility. V11 1 2 3 4 5 6 7 12. I understand the need for this change. V12 1 2 3 4 5 6 7 13. Doctor-patient relationships w ill improve because of this change. V13 1 2 3 4 5 6 7 14. There was sufficient planning for this change. V14 1 2 3 4 5 6 7 15. I believe patients will benefit from t he clinic becoming a paperless facility. V15 1 2 3 4 5 6 7 16. I expect this computer soft ware will be easy to learn. V16 1 2 3 4 5 6 7 Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree

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85 17. I expect the new computer system will be easy to use. V17 1 2 3 4 5 6 7 18. I expect this training program to be user-friendly. V18 1 2 3 4 5 6 7 Please answer the following questions fully. V19 – V24 = qualitative data 19. List three words that desc ribe how you feel about Florida Medical Clinic changing to a paperless system. V19 1. ________________________________________________________ 2. ________________________________________________________ 3. ________________________________________________________ 20. Do you have any concerns regarding the change over to a paperless system? If so, what are they and why do you feel this way? V20 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _______ 21. How did you first hear about this change? V21 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____ Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree

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86 22. What kind of communication did you receive about this change prior to implementation? V22 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____ 23. Do you think this training and change is necessary? Why? V23 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ______ 24. Do you think this change is causing anx iety in your department? If so, how and why? V24 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _______

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87 Appendix B: Post-Survey with variable coding Survey II 1. Please select one: V25 (1=physician; 2=nurse/nur se practitioner; 3=other) ___ Physician _____ Nurse ____Nurse practitioner ____Other:______ v25-a _____________ = qualitative data 2. Please select one: _____ Female _____ Male V26 (female=1; male=2) 3. Age: ______ V27 Please select on a scale of 1 to 7, 1 being st rongly disagree and 7 being strongly agree, the accuracy of the following statem ents as they pertain to you. (V28 – V51 = a numerical value from 1-7) 4. I was a regular user of the previous software system (3 or more times per week) V28 1 2 3 4 5 6 7 5. I feel comfortable with the new computer system. V29 1 2 3 4 5 6 7 6. I feel satisfied with the training I re ceived regarding the new computer system. V30 1 2 3 4 5 6 7 7. The trainer was able to communicate ideas clearly with me. V31 1 2 3 4 5 6 7 8. I believe I will be able to effectively use the ne w computer system with minimal assistance on a day-to-day basis. V32 1 2 3 4 5 6 7 9. The program will help improve the c linic’s relationship with patients. V33 1 2 3 4 5 6 7 Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree

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88 10. I feel the information discussed in training was clear and easy to understand. V34 1 2 3 4 5 6 7 11. I feel there was sufficient information exchanged to prepare me for this change. V35 1 2 3 4 5 6 7 12. Other employees could benefit from this training. V36 1 2 3 4 5 6 7 13. The clinic will benefit from being a paperles s facility by improving patient satisfaction. V37 1 2 3 4 5 6 7 14. The training I received was useful. V38 1 2 3 4 5 6 7 15. We have been given adequate time to prepare for the upcoming change to a paperless facility. V39 1 2 3 4 5 6 7 16. Patients will benefit from the clinic becoming a paperless facility. V40 1 2 3 4 5 6 7 17. I understand the need for this change. V41 1 2 3 4 5 6 7 Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree

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89 18. I feel the training program effectively co vered the information I needed to use the new software. V42 1 2 3 4 5 6 7 19. I am more likely to use the computer syst em after undergoing training than I was before. V43 1 2 3 4 5 6 7 20. The new program is user friendly. V44 1 2 3 4 5 6 7 21. This innovation will easily fi t into my daily work routine. V45 1 2 3 4 5 6 7 22. I had the opportunity to ask as many questions as needed in training. V46 1 2 3 4 5 6 7 23. I received appropriate feedback from the traine r to feel comfortable using the new computer system. V47 1 2 3 4 5 6 7 24. The training was user-friendly. V48 1 2 3 4 5 6 7 25. I feel the system will help improv e my relationship with my patients. V49 1 2 3 4 5 6 7 Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Disagree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Strongly Agree Very Effective

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90 26. How would you rate this training program overall? V50 1 2 3 4 5 6 7 27. How would you rate the ne w computer system overall? V51 1 2 3 4 5 6 7 Please answer the following questions fully (V 52V55 = qualitative data) 28. Do you have any concerns regarding the new co mputer system that were not covered in this training program? If so, what? V52 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ____________________________________________________ 29. What three words best describe how you f eel about using the new computer system on a daily basis? V53 1. __________________________________________ 2. ___________________________________________ 3.____________________________________________ 30. Is there anything you would change about the training program? V54 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _________________________________________________________ Not Effective Not Useful Very Useful

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91 31. Is there anything you would change about t he communication efforts by the clinic about the change prior to its implementation? V55 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

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92 Appendix C: Surveys: The survey questions will measure res pondent’s attitudes toward the innovation and the training communication. The survey questions will group together as follows: Pre-Training Survey Question Post Training Survey Question 1 1 2 2 3 3, 5, 11 4 18 5 6, 10 6 3, 5, 9, 11 7 15, 19, 20, 8 8 12 9 14 10 10, 22 11 12 12 13 13 16 14 17 15 19, 20, 21 The questions that do not group together are qu estions that could onl y be asked after the training communication has already taken place.

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93 Appendix C (Continued) How hypothesis themes match up to survey questions Pre-Training Anxiety Variable Understanding Variable Confidence Level Variables V5 V7 V6 V9 V8 V10 V11 V12 V16 V14 V13 V17 V16 V15 V18 V17 V18 Post-training Anxiety Variables Understanding Variables Confidence Variables V29 V33 V30 V30 V37 V32 V32 V40 V35 V39 V41 V36 V43 V4 V38 V46 V49 V42 V48 V43 V44 V45 V47 V51

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94 Appendix D Survey Question Groupings Pre-training The following tables show the individual pr e-training means for survey instrument questions related to anxiety, confidence and understanding the need for change. They are grouped according to age, occupation and gender. Age Groups Table 26: Understanding the Need for the Innovation: Table 27: Anxiety Levels: Survey Question 0-40 Over 40 Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel comfort changing to a paperless system (practice mana gement system). 5.18 11 1.888 3.28 18 1.934 4.00 29 2.104 I think this training program will be useful in acclimating me to the new system 6.27 11 1.555 6.17 18 1.150 6.21 29 1.292 I feel we have been given adequate time to prepare for the upcoming change to a paperless facility 5.82 11 1.079 4.78 18 1.437 5.17 29 1.391 There was sufficient planning for this change. 5.91 11 .944 5.33 18 1.085 5.55 29 1.055 I expect this computer system will be easy to learn. 5.73 11 1.348 3.72 18 2.024 4.48 29 2.029 I expect the computer system will be easy to use. 5.73 11 1.348 3.94 18 1.984 4.62 29 1.953 I expect this training program will be userfriendly. 5.45 11 1.214 4.06 18 1.697 4.59 29 1.659 Survey Question 0-40 Over 40 Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I think the new software program will be beneficial to my everyday work activities 6.27 11 2.043 4.06 18 2.043 4.90 29 2.006 I think the clinic will benefit from the new software system 5.36 11 2.292 4.83 18 2.121 5.03 29 2.163 I understand the need for this change. 6.09 11 1.044 5.28 18 1.904 5.59 29 1.659 Doctor-patient relationships will improve because of this change. 5.55 11 1.128 3.22 18 1.700 4.10 29 1.877 I believe patients will benefit from the clinic becoming a paperless facility. 4.73 11 2.195 4.28 18 1.742 4.45 29 1.901

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95 Appendix D (Continued) Table 28: Confidence Levels Occupation Table 29: Understanding the Need for the Innovation: Survey Question 0-40 Over 40 Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel I need this training program in order to properly use the new software system. 6.82 11 .405 6.56 18 .784 6.66 29 .670 I feel we will have enough time in training to cover the information I will need to use the new software program. 5.64 11 1.206 4.22 18 1.437 4.76 29 1.504 I expect this computer system will be easy to learn. 5.73 11 1.348 3.72 18 2.024 4.48 29 2.029 I expect the computer system will be easy to use. 5.73 11 1.348 3.94 18 1.984 4.62 29 1.953 I expect this training program will be userfriendly. 5.45 11 1.214 4.06 18 1.697 4.59 29 1.659 Survey Question Medical Staff Other Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I think the new software program will be beneficial to my everyday work activities 4.00 18 2.000 6.33 12 .778 4.93 30 1.982 I think the clinic will benefit from the new software system 4.11 18 2.220 6.50 12 .798 5.07 30 2.132 I understand the need for this change. 5.17 18 1.823 6.17 12 1.115 5.57 30 1.633 Doctor-patient relati onships will improve because of this change. 3.22 18 1.665 5.50 12 1.168 4.13 30 1.852 I believe patients will benefit from the clinic becoming a paperless facility. 3.72 18 1.873 5.58 12 1.240 4.47 30 1.871

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96 Appendix D (Continued) Table 30: Anxiety Levels: Table 31: Confidence Levels: Survey Question Medical Staff Other Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel comfort changing to a paperless system (practice mana gement system). 3.44 18 2.148 5.00 12 1.706 4.07 30 2.100 I think this training program will be useful in acclimating me to the new system 6.00 18 1.138 6.50 12 1.446 6.20 30 1.270 I feel we have been given adequate time to prepare for the upcoming change to a paperless facility 5.22 18 1.263 5.08 12 1.564 5.17 30 1.367 There was sufficient planning for this change. 5.33 18 1.138 5.75 12 .965 5.50 30 1.075 I expect this computer system will be easy to learn. 3.67 18 1.940 5.67 12 1.435 4.47 30 1.995 I expect the computer system will be easy to use. 3.78 18 1.768 5.83 12 1.467 4.60 30 1.923 I expect this trai ning program will be user-friendly. 4.17 18 1.757 5.42 12 1.311 4.67 30 1.688 Survey Question Medical Staff Other Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel I need this training program in order to properly use the new software system. 6.44 18 .784 6.92 12 .289 6.63 30 .669 I feel we will have enough time in training to cover the information I will need to use the new software program. 4.44 18 1.542 5.25 12 1.288 4.77 30 1.478 I expect this computer system will be easy to learn. 3.67 18 1.940 5.67 12 1.435 4.47 30 1.995 I expect the computer system will be easy to use. 3.78 18 1.768 5.83 12 1.467 4.60 30 1.923 I expect this training program will be userfriendly. 4.17 18 1.757 5.42 12 1.311 4.67 30 1.688

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97 Appendix D (Continued) Gender Table 32: Understanding the Need for the Innovation: Table 33: Anxiety levels: Survey Question Female Male Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I think the new software program will be beneficial to my everyday work activities 6.25 16 .775 3.43 14 1.869 4.93 30 1.982 I think the clinic will benefit from the new software system 6.13 16 1.544 3.86 14 2.107 5.07 30 2.132 I understand the need for this change. 6.13 16 1.025 4.93 14 1.979 5.57 30 1.633 Doctor-patient relati onships will improve because of this change. 5.25 16 1.238 2.86 14 1.610 4.13 30 1.852 Survey Question Female Male Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel comfortable changing to a paperless system (practice mana gement system). 4.94 16 1.611 3.07 14 2.200 4.07 30 2.100 I think this training program will be useful in acclimating me to the new system 6.44 16 1.315 5.93 14 1.207 6.20 30 1.270 I feel we have been given adequate time to prepare for the upcoming change to a paperless facility 5.06 16 1.482 5.29 14 1.267 5.17 30 1.367 There was sufficient planning for this change. 5.56 16 1.031 5.43 14 1.158 5.50 30 1.075 I expect this computer software will be easy to learn 5.38 16 1.408 3.43 14 2.102 4.47 30 1.995 I expect the new comput er system to be easy to use. 5.50 16 1.461 3.57 14 1.910 4.60 30 1.923 I expect this training program will be userfriendly. 5.38 16 1.310 3.86 14 1.748 4.67 30 1.688

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98 Appendix D (Continued) Table 34: Confidence Levels Survey Question Female Male Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel I need this training program in order to properly use the new software system. 6.81 16 .403 6.43 14 .852 6.63 30 .669 I feel we will have e nough time in training to cover the information I will need to use the new software program. 5.19 16 1.276 4.29 14 1.590 4.77 30 1.478 I expect this computer system will be easy to learn. 5.38 16 1.408 3.43 14 2.102 4.47 30 1.995 I expect the computer system will be easy to use. 5.50 16 1.461 3.57 14 1.910 4.60 30 1.923 I expect this training program will be userfriendly. 5.38 16 1.310 3.86 14 1.748 4.67 30 1.688

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99 Appendix E Survey Question Groupings Post-training The following tables show the indivi dual post-training means for survey instrument questions related to anxiety, confidence and understanding the need for change. They are grouped according to age, occupation and gender. Age Groups Table 35: Understanding the Need for the Innovation Survey Question 0-40 Over 40 Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation The program will help improve the clinic’s relationship with patients. 5.45 11 1.753 4.06 18 1.474 4.59 29 1.701 The clinic will benefit from being a paperless facility by improving patient satisfaction 5.36 11 1.804 4.39 18 1.754 4.76 29 1.806 Patients will benefit from the clinic becoming a paperless facility 5.36 11 1.804 4.17 18 1.823 4.62 29 1.879 I understand the need for this change. 6.00 11 1.095 5.00 18 1.847 5.38 29 1.656 I feel the system will help improve my relationship with my patients. 5.64 11 1.027 3.78 18 2.045 4.55 29 1.882 This innovation will easily fit into my daily work routine. 5.91 11 1.136 3.72 18 1.776 4.48 29 1.939

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100 Appendix E (Continued) Table 36: Anxiety Levels Survey Question 0-40 Over 40 Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel comfortable with the new computer system. 5.27 11 1.348 4.17 18 1.654 4.59 29 1.615 I feel satisfied with the training I received regarding the new computer system. 5.27 11 1.348 4.78 18 1.555 4.97 29 1.476 I believe I will be able to effectively use the new computer system with minimal assistance on a day to day basis. 5.82 11 1.328 4.39 18 1.420 4.93 29 1.534 I am more likely to use the computer system after undergoing training than I was before. 5.45 11 1.368 4.78 18 1.665 5.59 29 1.452 I had the opportunity to ask as many questions as needed in training. 6.09 11 .944 5.28 18 1.638 6.03 29 1.210 The training was user-friendly. 6.18 11 .982 5.94 18 1.349 5.79 29 1.177 We have been given adequate time to prepare for the upcoming change to a paperless facility 6.18 11 .751 5.56 18 1.338 5.03 29 1.569

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101 Appendix E (Continued) Table 37: Confidence Levels Survey Question 0-40 Over 40 Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel satisfied with the training I received regarding the new computer system. 5.27 11 1.348 4.78 18 1.555 4.97 29 1.476 I believe I will be able to effectively use the new computer system with minimal assistance on a day to day basis. 5.82 11 1.328 4.39 18 1.420 4.93 29 1.534 I feel there was sufficient information exchanged to prepare me for this change. 5.45 11 1.128 4.78 18 1.114 5.03 29 1.149 Other employees could benefit from this training. 6.27 11 .786 5.67 18 1.328 5.90 29 1.175 The training I received was useful. 6.45 11 .688 5.44 18 1.723 5.83 29 1.490 I feel the training program effectively covere d the information I needed to use the new software. 6.00 11 .894 5.00 18 1.283 5.38 29 1.237 I am more likely to use the computer system after undergoing training than I was before. 6.09 11 .944 5.28 18 1.638 5.59 29 1.452 The new program is user-friendly. 5.91 11 .831 4.83 18 1.618 5.24 29 1.455 This innovation will easily fit into my daily work routine. 5.64 11 1.027 3.78 18 2.045 4.48 29 1.939 I received appropriate feedback from the trainer to feel comfortable using the new computer system. 6.00 11 .775 5.39 18 1.243 5.62 29 1.115 How would you rate the new computer system overall? 5.45 11 1.368 4.61 18 1.420 4.93 29 1.438

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102 Appendix E(Continued) Occupation Table 38: Understanding the Need for Change Table 39: Anxiety Levels Survey Question Medical Staff Other Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation The program will help improve the clinic’s relationship with patients. 3.78 18 1.865 5.50 12 1.087 4.47 30 1.795 The clinic will benefit from being a paperless facility by improving patient satisfaction 4.00 18 2.114 5.58 12 .996 4.63 30 1.903 Patients will benefit from the clinic becoming a paperless facility 3.94 18 2.182 5.33 12 1.231 4.50 30 1.961 I understand the need for this change. 5.17 18 1.886 5.75 12 1.138 5.40 30 1.632 I feel the system will help improve my relationship with my patients. 4.00 18 2.223 5.42 12 1.311 4.60 30 1.868 This innovation will easily fit into my daily work routine. 4.06 18 2.014 5.33 12 .985 4.53 30 1.925 Survey Question Medical Staff Other Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel comfortable with the new computer system. 4.50 18 1.757 4.83 12 1.403 4.63 30 1.608 I feel satisfied with the training I received regarding the new computer system. 5.06 18 1.589 4.92 12 1.311 5.00 30 1.462 I believe I will be able to effectively use the new computer system with minimal assistance on a day to day basis. 4.72 18 1.447 5.33 12 1.614 4.97 30 1.520 I am more likely to use the computer system after undergoing training than I was before. 5.17 18 1.689 5.75 12 .866 5.60 30 1.429 I had the opportunity to ask as many questions as needed in training. 5.50 18 1.724 5.83 12 1.267 6.03 30 1.189 The training was user-friendly. 6.17 18 1.150 5.83 12 1.030 5.80 30 1.157 We have been given adequate time to prepare for the upcoming change to a paperless facility 5.78 18 1.263 4.92 12 1.379 5.07 30 1.552

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103 Appendix E (Continued) Table 40: Confidence Levels Survey Question Medical Staff` Other Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel satisfied with the training I received regarding the new computer system. 5.06 18 1.589 4.92 12 1.311 5.00 30 1.462 I believe I will be able to effectively use the new computer system with minimal assistance on a day to day basis. 4.72 18 1.446 5.33 12 1.614 4.97 30 1.520 I feel there was sufficient information exchanged to prepare me for this change. 5.22 18 1.114 4.83 12 1.193 5.07 30 1.143 Other employees could benefit from this training. 5.89 18 1.323 5.92 12 .900 5.90 30 1.155 The training I received was useful. 5.78 18 1.734 5.92 12 .996 5.83 30 1.464 I feel the training program effectively covered the information I needed to use the new software. 5.39 18 1.290 5.42 12 1.165 5.40 30 1.221 I am more likely to use the computer system after undergoing training than I was before. 5.50 18 1.724 5.75 12 .866 5.60 30 1.429 The new program is user-friendly. 5.00 18 1.680 5.67 12 .888 5.27 30 1.437 This innovation will easily fit into my daily work routine. 4.00 18 2.223 5.33 12 .985 4.53 30 1.925 I received appropriate feedback from the trainer to feel comfortable using the new computer system. 5.67 18 1.237 5.58 12 .900 5.63 30 1.098 How would you rate the new computer system overall? 4.83 18 1.543 5.17 12 1.267 4.97 30 1.426

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104 Appendix E (Continued) Gender Table 41: Understanding the Need for Change Table 42: Anxiety Survey Question Female Male Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation The program will help improve the clinic’s relationship with patients. 5.31 16 1.537 3.50 14 1.605 4.47 30 1.795 The clinic will benefit from being a paperless facility by improving patient satisfaction 5.44 16 1.504 3.71 14 1.939 4.63 30 1.903 Patients will benefit from the clinic becoming a paperless facility 5.19 16 1.601 3.71 14 2.091 4.50 30 1.961 I understand the need for this change. 5.88 16 1.025 4.86 14 2.033 5.40 30 1.632 I feel the system will help improve my relationship with my patients. 5.56 16 1.209 3.50 14 1.912 4.60 30 1.868 This innovation will easily fit into my daily work routine. 5.50 16 .966 3.43 14 2.174 4.53 30 1.925 Survey Question Female Male Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel comfortable with the new computer system. 4.94 16 1.569 4.29 14 1.637 4.63 30 1.608 I feel satisfied with the training I received regarding the new computer system. 5.06 16 1.389 4.93 14 1.592 5.00 30 1.462 I believe I will be able to effectively use the new computer system with minimal assistance on a day to day basis. 5.44 16 1.504 4.43 14 1.399 4.97 30 1.520 We have been given adequate time to prepare for the upcoming change to a paperless facility 5.13 16 1.360 5.00 14 1.797 5.07 30 1.552 I am more likely to use the computer system after undergoing training than I was before. 5.88 16 .885 5.29 14 1.858 5.60 30 1.429 I had the opportunity to ask as many questions as needed in training. 5.94 16 1.181 6.14 14 1.231 6.03 30 1.189 The training was user-friendly. 5.88 16 .957 5.71 14 1.383 5.80 30 1.157

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105 Appendix E (Continued) Table 43: Confidence Levels Survey Question Female Male Total Mean N Std. Deviation Mean N Std. Deviation Mean N Std. Deviation I feel satisfied with the training I received regarding the new computer system. 5.06 16 1.389 4.93 14 1.592 5.00 30 1.462 I believe I will be able to effectively use the new computer system with minimal assistance on a day to day basis. 5.44 16 1.504 4.43 14 1.399 4.97 30 1.520 I feel there was sufficient information exchanged to prepare me for this change. 5.13 16 1.204 5.00 14 1.109 5.07 30 1.143 Other employees could bene fit from this training. 6.00 16 .816 5.79 14 1.477 5.90 30 1.155 The training I received was useful. 6.06 16 .929 5.57 14 1.910 5.83 30 1.464 I feel the training program effectively covered the information I needed to use the new software. 5.50 16 1.155 5.29 14 1.326 5.40 30 1.221 I am more likely to use the computer system after undergoing training than I was before. 5.88 16 .885 5.29 14 1.858 5.60 30 1.429 The new program is user-friendly. 5.75 16 .856 4.71 14 1.773 5.27 30 1.437 This innovation will easily fit into my daily work routine. 5.50 16 .966 3.43 14 2.174 4.53 30 1.925 I received appropriate feedback from the trainer to feel comfortable using the new computer system. 5.69 16 .873 5.57 14 1.342 5.63 30 1.098 How would you rate the new computer system overall? 5.38 16 1.204 4.50 14 1.557 4.97 30 1.426

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106 Appendix F Independent Samples T-Tests Table 44: Independent Samples Test by Age Group Levene's Test for Equality of Variances t-test for Equality of Means F Sig. t df Sig. (2-tailed) Mean Difference Std. Error Difference 95% Confidence Interval of the Difference Lower Upper Anxiety Pre Equal variances assumed .294 .592 2.921 27 .007 1.25902 .43107 .37453 2.14351 Equal variances not assumed 3.040 23.973 .006 1.25902 .41409 .40432 2.11371 Anxiety Post Equal variances assumed 2.457 .129 1.889 27 .070 .76912 .40723 -.06644 1.60468 Equal variances not assumed 2.115 26.985 .044 .76912 .36366 .02293 1.51531 Understanding Pre Equal variances assumed .958 .336 2.131 27 .042 1.26667 .59435 .04716 2.48617 Equal variances not assumed 2.292 25.817 .030 1.26667 .55273 .13012 2.40321 Understanding Post Equal variances assumed 1.591 .218 2.555 27 .017 1.43603 .56199 .28293 2.58912 Equal variances not assumed 2.711 25.121 .012 1.43603 .52967 .34542 2.52663 Confidence Pre Equal variances assumed 1.393 .248 3.330 27 .003 1.37273 .41220 .52696 2.21849 Equal variances not assumed 3.678 26.782 .001 1.37273 .37321 .60667 2.13879 Confidence Post Equal variances assumed 1.691 .204 2.366 27 .025 .94720 .40026 .12594 1.76846 Equal variances not assumed 2.666 26.999 .013 .94720 .35522 .21834 1.67606

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107 Appendix F (Continued) Table 45: Independent Samples Test by Occupation Levene's Test for Equality of Variances t-test for Equality of Means F Sig. t df Sig. (2tailed) Mean Differenc e Std. Error Differenc e 95% Confidence Interval of the Difference Lower Upper Anxiety Pre Equal variances assumed .383 .541 2.563 28 .016 -1.09127 .42574 -1.96336 -.21918 Equal variances not assumed 2.642 26.01 8 .014 -1.09127 .41304 -1.94026 -.24228 Anxiety Post Equal variances assumed 3.632 .067 -.181 28 .858 -.07540 .41712 -.92982 .77902 Equal variances not assumed -.197 27.98 4 .845 -.07540 .38256 -.85906 .70827 Understanding Pre Equal variances assumed 4.518 .042 4.025 28 .000 -1.97222 .48998 -2.97591 -.96853 Equal variances not assumed 4.652 24.57 9 .000 -1.97222 .42391 -2.84604 -1.09841 Understanding Post Equal variances assumed 8.133 .008 2.414 28 .023 -1.32870 .55031 -2.45595 -.20145 Equal variances not assumed 2.739 26.26 5 .011 -1.32870 .48506 -2.32527 -.33214 Confidence Pre Equal variances assumed 1.294 .265 3.318 28 .003 -1.31667 .39677 -2.12941 -.50393 Equal variances not assumed 3.536 27.70 3 .001 -1.31667 .37240 -2.07986 -.55348 Confidence Post Equal variances assumed 2.923 .098 -.600 28 .553 -.25253 .42095 -1.11481 .60976 Equal variances not assumed -.662 27.76 8 .514 -.25253 .38154 -1.03436 .52931

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108 Appendix F (Continued) Table 46: Independent Samples Test by Gender Levene's Test for Equality of Variances t-test for Equality of Means F Sig. t df Sig. (2tailed) Mean Difference Std. Error Difference 95% Confidence Interval of the Difference Lower Upper Anxiety Pre Equal variances assumed .528 .473 2.639 28 .013 1.09694 .41572 .24538 1.94850 Equal variances not assumed 2.600 24.992 .015 1.09694 .42185 .22811 1.96576 Anxiety Post Equal variances assumed 1.241 .275 .871 28 .391 .35204 .40440 -.47634 1.18042 Equal variances not assumed .852 23.501 .403 .35204 .41304 -.50139 1.20547 Confidence Pre Equal variances assumed 1.821 .188 3.475 28 .002 1.33571 .38443 .54825 2.12318 Equal variances not assumed 3.388 22.472 .003 1.33571 .39431 .51897 2.15246 Confidence Post Equal variances assumed 2.056 .163 1.567 28 .128 .62500 .39890 -.19210 1.44210 Equal variances not assumed 1.518 20.990 .144 .62500 .41161 -.23101 1.48101 Understanding Pre Equal variances assumed 2.764 .108 4.497 28 .000 2.07143 .46068 1.12778 3.01508 Equal variances not assumed 4.334 19.631 .000 2.07143 .47800 1.07313 3.06973 Understanding Post Equal variances assumed 4.012 .055 3.384 28 .002 1.69345 .50040 .66843 2.71847 Equal variances not assumed 3.270 20.238 .004 1.69345 .51793 .61389 2.77301

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109 Appendix G : Informed Consent Social and Behavioral Sc iences University of South Florida The following information is being presented to help you decide whether or not you want to take part in a minimal risk research study. Please read this carefully. If you do not understand anything, ask the person in charge of the study. Title of Study: Organizational Communication and Change: A case study on the implementation of an innovation at Florida Medical Clinic Principal Investigator: Erika G. Llenza Study Location(s): Florida Medical Clinic You are being asked to participate to help gather information on the effects communication on organizational change efforts. General Information about the Research Study The purpose of this research study is to investigat e the possible effects communication efforts have on the adoption or rejection of organizational change initia tives. Two survey questionnaires will be distributed before and after your scheduled training program. Plan of Study Each respondent will take part in a survey before an d after the scheduled training program. The survey questionnaires will include a series of items to rate on a scale of 1 to 7 and a question and answer section. Each survey should take no longer than 20 minutes to complete. Payment for Participation You will not be paid for your participation in this study. Benefits of Being a Part of this Research Study By taking part in this research study you will be providing information that is of interest to many researchers and professional on the effects of comm unication efforts on organizational change initiatives. Your participation will provide further insight into an area of research that is continually developing. Risks of Being a Part of this Research Study There are no anticipated risks for par ticipation in this research study. Confidentiality of Your Records Individual Responses : Individual responses to the survey will be anonymous and coded in a way to ensure respondent identity is not revealed. Only the researcher will have a ccess to participant responses. Summary Results: A summary of the results of this study will be provided to Florida Medical Clinic. The data obtained from you will be combined with data from others. The summary results will not include your name or any other information that would personally identify you in any way. Volunteering to Be Part of this Research Study Your decision to participate in this research study is completely voluntary. You are free to withdraw at any time. Questions and Contacts If you have any questions about this research study, contact Erika G. Llenza at (813) 598-9988.

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110 If you have questions about your rights as a person who is taking part in a research study, you may contact the Division of Research Compliance of the University of South Florida at (813) 9745638. Consent to Take Part in This Research Study By participating in this study I agree that: I have fully read or have had read and explained to me this informed consent form describing this research project. I have had the opportunity to question one of the persons in charge of this research and have received satisfactory answers. I understand that I am being asked to participate in research. I understand the risks and benefits, and I freely give my consent to participate in the research project outlined in this form, under the conditions indicated in it. I have been given a signed copy of this informed consent form, which is mine to keep. _________________ _____ _________________________ _______________ Signature of Participant Printed Name of Participant Date Investigator Statement I have carefully explained to the subject the nature of the above research study. I hereby certify that to the best of my knowledge the subject signing this consent form understands the nature, demands, risks, and benefits involved in participating in this study. ___________________ ________________________ _______________________ Signature of Investigator Printed Name of Investigator Date Of authorized research investigator designated by the Principal Investigator Investigator Statement: I certify that participants have been provided with an informed consent form that has been approved by the University of South Florida’s Institutional Review Boar d and that explains the nature, demands, risks, and benefits involved in participating in this study. I further certify that a phone number has been provided in the event of additional questions. _____________ ______ __________________ ____ ____________ Signature of Investigator Printed Name of Investigator Date


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ABSTRACT: This study examined how employees at a Florida medical facility felt regarding the upcoming change to a paperless system and whether a training program administered by the organization was effective in reducing anxiety, increasing understanding of the need for the change, increasing employee confidence using the new computer system, changing employee perceptions of the new system, and helping employees view the change as an organizational improvement. The results indicated that the training program marginally reduced anxiety, but did not significantly increase user confidence or understanding of the need for the change. While participants viewed the change as an organizational improvement, this view was only superficial. When means were examined by occupation, age group and gender, pre-training results indicated that the medical staff and older participants exhibited the most anxiety, understood the reason for the change the least and had the lowest confidence in their ability to use the practice management system. These same participants appeared to benefit the most from the training program. They reported reduced anxiety and increased confidence using the innovation. Post-training, younger participants and those who identified their occupation as "other" indicated increased anxiety levels and slight reductions in their confidence using the practice management system. The medical staff and older participants appeared to benefit the most from the training program.
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