Our study focused on cases of CIS implementation in hospitals where physicians represented the focal group. To further validate the model, it would be instructive to see how, in similar settings, the resistance of other groups (e.g., nurses) evolve. Also, the model's external validity would be improved by studying CIS implementation in different settings.
We found that, although staff may be enthusiastic about a CIS implementation, the dynamics of resistance during the implementation may lead to system rejection. The 3 cases we analyzed showed the importance of the roles played by implementers and users in determining the outcomes of a system implementation. In particular, antagonistic responses from implementers to users' resistance behaviours appear to have reinforced these behaviours. When resistance was ignored, there were similarly pernicious effects. Moreover, even when implementers' reactions were supportive of users, targeting the wrong object of resistance led resisters to remain oblivious to any proposed improvement. The study also suggests, however, that implementers are not the only ones accountable for explaining resistance behaviours, their origins and consequences. Physicians, as users, cannot afford to retreat into a belligerent position or engage in a dynamic that causes a potentially useful CIS to become a pawn in a power struggle. They ought to recognize the object of their resistance and modulate their behaviours accordingly.
These results are in line with those of previous studies of the implementation of information systems in hospital settings. First, although numerous studies have reported that CIS use translates into benefits (e.g., fewer medication errors,26–29
increased financial gain,30
better quality of care,31,32
improved practitioners' performance,33–35
enhancement of diagnostic accuracy36
and increased safety3,37
), computer systems that satisfy users and that actually contribute to the quality and safety of patient care are rare.4–6,38–42
By depicting the dynamics of the implementation process, our study helps to explain why this is so. Second, previous research has shown that, although a system's technical factors (e.g., it “fits the workflow,” augments physicians' judgment rather than replaces it,43
is user friendly, is flexible38,44,45
and has an innovative design45,46
) may be crucial in determining the success or failure of a CIS implementation, organizational factors (e.g., supportive leadership and championship,38,43,44,46,47
and physician empowerment38
) are paramount. Our study examined the dynamics between 2 major stakeholders in CIS implementation — users and implementers — and showed how critical a factor it can be in the outcome of an implementation.
A number of lessons can be learned from the cases in our study. If the object of resistance is the computer system itself and when the system is seen to impair productivity or threaten quality of care, physicians have a responsibility to bring this to the attention of the hospital's administration so that problems can be fixed. However, if the object of resistance is the system's significance, the real targets are often the organization of work and political issues between groups of users. The CIS implementation may be revealing pre-existing problems. In these cases, users and implementers should engage in introspection, evaluate their roles in these problems and look beyond modifications to the system for solutions. Finally, if the implementers are the object of resistance, the computer system becomes extraneous to the problem. There is then a high risk that users will enter a spiralling trajectory of resistance caused by political struggles that will lead to disruption and even system abandonment. In these instances, physician resistance is costly and can negatively affect quality of care.
@ See related article page 1583