FACTORS PROMOTING AND HINDERING INFORMATIZATION

OF NURSING INSTITUTIONS FOR THE AGED: A TOE

THEORETIC PERSPECTIVE

Yingzhao He, Key Laboratory of Data Engineering and Knowledge Engineering, and School

of Business, Renmin University of China, Beijing, China, hyz1980@ruc.edu.cn

Meiyun Zuo, Key Laboratory of Data Engineering and Knowledge Engineering, and School

of Information, Renmin University of China, Beijing, China, zuomy@ruc.edu.cn

Jie Chen, Key Laboratory of Data Engineering and Knowledge Engineering, and School of

Information, Renmin University of China, Beijing, China, joanna.chen@ruc.edu.cn

Abstract

This paper uses the theoretic framework of TOE(technology-organization-environment), identifies the

factors promoting and hindering informatization of nursing institutions for the aged. This case study of

six nursing institutions for the aged finds that different ownership institutions have some different

factors promoting and hindering the process of informatization. In general, compared with public

nursing institutions for the aged, private nursing institutions have more both promoting and hindering

factors in technological and organizational aspect, but less hindering factors in the environmental

aspect; and, risk management is an important promoting factor in the application of information

systems for these institutions, it is fewer reported in other industries’ study. These findings extend the

application field of the TOE theory; extend the informatization study in nursing institutions for the

aged. In practical,we suggest that different ownership’s nursing institutions for the aged should take

good advantage of promoting factors considering their own resources, overcome the hindering factors

to ensure the successful implementation of the informatization.

Keywords: Informatization of nursing institutions for the aged, Promoting factors, Hindering factors,

TOE(technology-organization-environment) theory, Multiple cases study.

1. INTRODUCTION

With the aging society coming, problems of nursing for the aged are aroused. Industries related to

nursing for the aged, such as nursing institutions, have increasingly become one focus of attentions of

the whole society. Existing literature has explored a lot of issues associated with nursing institutions for the

aged, such as pain management(Mittelman 1996; Couilliot 2014), medication management(Dwyer 2010;

Briesacher 2013), falls risk management(Tinetti 1997; Broe 2007), etc. However, research on the

informatization of nursing institutions for the aged is scant. Informatization, i.e. the application of

information systems in an organization, is able to help nursing institutions for the aged improve their

service quality and work efficiency(Brynjolfssonand Hitt 2000; Hamet al. 2005).

Existing studies on the application of information systems in nursing institutions for the aged mainly

focus on the implementation of specific systems such as nursing information system(Prijatelj 2006) and

clinical information system(Nazare et al. 2013). Few studies discuss the application of information

technology in daily management, materials management, financial management, and the promoting and

hindering factors in implementation in nursing institutions for the aged. However, it is important to

understand the promoting and hindering factors in order to ensure the implementation of

informatization in nursing institutions for the aged successfully. The purpose of this research is to

address the research question: What factors promote and hinder the informatization of nursing

institutions for the aged?

This paper uses the TOE(technology-organization-environment) theory, though case study of six

nursing institutions for the aged finds that ownership would impact the factors promoting and

hindering the process of informatization. In general, compared with public nursing institutions for the

aged, private nursing institutions have more factors both promoting and hindering in technological and

organizational context, but less hindering factors in the environmental context. Specifically, risk

management is an important promoting factor in the application of information systems for these

institutions; it is fewer reported in other industries’ study. These findings have both theoretical and

practical implications.

The rest of the paper is organized as follows. In the next section, we briefly introduce the TOE theory

and review the factors of adoption of information systems in the existing literature; in the following

section, we present an overview of the cases. Then we analyze and interpret data from the cases, build

the model of factors promoting and hindering the informatization of different ownership’s nursing

institutions for the aged, discuss the findings and their theoretical and managerial implications. At last,

this paper concludes with a discussion about our findings and directions for future research.

2. THEORETICAL BACKGROUND

The framework of TOE integrates the relevant theories of innovation adoption, summaries the factors

affecting organizational innovation adoption as technology, organization and environment(Tornatzky

1990). The technological factors such as the technological expertise, technology portfolio and attributes

of the technology innovation, etc., have been pointed out influencing the adoption decision of an

innovation(Rogers 2010). The organizational factors refer to organization characteristics including

strategies, structure, top management support, and project management capability. The environmental

factors refer to the external arena where the firm conducts its business, its ability to access resources

supplied by others, and interactions with the government and other firms. The three aspects contact and

restrict mutually, co-influencing the innovation adoption behavior and speed of the enterprise

(Zettelmeyer 2000).

TOE theory has been used successfully by IS researchers to understand the key factors that determine

the new IS adoption at the firm level(Baker 2012). However, there is a lack of study in nursing

institutions for the aged. We next classify the influence factors on the technological, organizational,

environmental dimensions, which have previously been identified by the existing literature.

2.1 Technological Factors

The technological factors are important in influencing the adoption and implementation of information

systems. Researchers have combined aspects of the diffusion of innovation theory(DOI) with TOE to

increase understanding of organizational IT adoption (Oliveira et al. 2011); they suggest that the

technological aspect in TOE includes the knowledge of innovation characteristics from DOI(Rogers

1999).

The previous literature indicated that factors such as data accuracy, minimal customization, technology

compatibility and high complexity of system, associated with the adoption decision of information

systems. For example, Nah et al.(2001) and Parr et al.(1999) noted that the smaller rate of system

customization, the more favorable for system implementation. Anderson(2007) and Khalifa(2013)

found that high rate of system customization was a key factor hindering systems’ implementation.

Larsen(2003) noted that the high complexity of system usually hinder the implementation.

2.2 Organizational Factors

The previous literature based on TOE proposed various organizational factors that are significant

determinants of IT adoption (Ein-Doret al. 1978; Raymond 1990; Yanget al. 2013). Examples of these

factors include firm size(Ko et al. 2008; Thonget al. 1995), top management support (Nah et al. 2001;

Parr et al. 1999; Holland 1999; Somerset al. 2001), project management (Amidet al. 2012; Yusuf 2004;

Barker 2003) and business process reengineering(Bingi et al. 1999; Sumner 2000). In addition, change

management was found to be crucial for the adoption and implementation of information systems

(Nahet al. 2001; Parret al. 1999). Moreover, factors related to employee, such as employee’s

involvement(Bingi et al. 1999; Zhe et al. 2005), employee’s education and training(Parret al. 1999;

Somers et al. 2001; Yusof et al. 2008) employee’s resistance(Amidet al. 2012; Umble 2003), may be

influential in the adoption and implementation decision of information systems.

2.3 Environmental Factors

The external environment also plays an important role in organization’s IT adoption and

implementation. Factors which drive adoption and implementation have been identified by prior

studies include government support(Yang et al. 2013), institutional pressure(Liang 2007; Mizruchi

1999), and market competition pressure(Thong et al. 1995; Yang et al. 2013). Meanwhile imperfect

laws and regulations(Khalifa 2013) are main obstacles of adoption and implementation. In addition,

consultants and vendors play important roles in adoption and implementation, whose support will be

critical in promoting organizations’ adoption for information systems(Parr et al. 1999; Somerset al.

2001; Zhang et al. 2003), and whose objection will be a significant hindering factor(Amid 2012;

Umble 2003; Bingi et al. 1999).

In conclusion, although factors’ studies are prevalent in IS, there is a lack of understanding of the

promoting and hindering factors of informatization of nursing institutions for the aged. To address this

gap, we adopt the TOE theoretic perspective to increase our understanding of the factors that can

determine the informatization decision of nursing institutions. This theoretic len will guide us in the

development of our framework through our multiple cases study.

3. RESEARCH METHOD

Multiple cases are referred to obtain information from several entities and study the phenomenon in

natural context using multiple data collection methods(Benbasat et al. 1987). Multiple cases are

effective because they enable collection of comparative data, and so are likely to yield more accurate,

generalizable theory than single case(Eisenhardt 1991; Yin 2009). Inductive studies are especially

useful for developing theoretic insights when research focuses on areas that extant theory does not

address well(Ozcan et al. 2009). Given limited theory about what factors promote and hinder the

informatization of nursing institutions, we conduct a multiple-case, inductive study(Eisenhardt 1989,

1991; Yin 2009).

The setting for our research is a kind of organization, i.e., the nursing institution for the aged with

following 2 characteristics:

First, this kind institutions serve the elderly as a main target and numerous stakeholders who are

involved in the operation, such as the relatives, children of the elderly and so on. Therefore, nursing

institutions need not only serve the elderly well, but also provide good service to elderly’s relatives,

children, as well as handle the relationship with other related units.

Second, nursing for the aged is a high risk industry with large investments and long payback periods.

The average age of elderly who live in the nursing institution is normally more than 75 years. Aging

naturally makes the elderly at high risk of suffering accidents, injuries, and illness outbreak of death.

We chose 6 nursing institutions for the aged in Beijing in China as our research objects, three of them

are public, the others are private, and their brief descriptions are shown in table 1.

Institution

No.

Owner-

ship

Year of

found

Bed

numbers

Start year

ofinform-

atization

Information systems

A public 1987 1100 2001 Emergency call system, Hospital information

system, Office automatic (OA) system

B public 1997 280 2009 Wireless emergency call system, Business

system

C public 1958 756 2010 Wireless emergency call system, Business

system

D private 1988 1000 2000

Wired emergency call system, Apartment

management system, Medical docking system,

E-card system

E private 2008 400 2008 Wireless emergency call system, Business

system

F private 2012 439 2012 Wireless emergency call system, Business

system, Office automatic (OA) system

Table1. Overview of Case institution

Note：Business system mainly includes those subsystems about：The elderly management, daily care, healthcare

administration, staff management, financial management, item management and so on, some organizations just

implement or apply several ones of them.

Table 1 shows that, public nursing institutions for the aged are generally founded earlier than private

ones, the year of implementation of IS also varies, both of the two types institutions have implemented

emergency call system, but part of them also implement the business system. However, these systems

have not yet integrated and comprehensively covered nursing institutions safety, meals, medicine,

nursing and other basic services, and not specifically designed to assist the management and

decision-making. In a whole, the overall nursing institutions information level is still low, and in the

early stage of the informatization process.

3.1 Data Source

We used several data sources: 1) extensive archives, including business publications, news, internet

sources,and organizational materials; 2) Semi-structured interviews with executives, middle-level

managers and employees of the institutions; 3) Informal follow-ups with e-mails, phone calls and

observations. Triangulation of data collected from multiple sources at multiple times strengthens

confidence in the accuracy offindings(Yin 2009; Jick 1979).

An important data source was semi-structured interview. Using an open-ended format we asked the

informants questions such as why do you adopt information systems, what problems have you

encountered before or during informatization, how those existing information systems benefit your

work. We collected data from over 15 interviews with 4 types of informants who are related to the

informatization in our cases, including the top leaders; information officers; directors of nursing or

caregivers or office workers. The interviews ranged from 30 to 120 minutes, we taped and transcribed

the interviews. Table 2 gives the number of interviews conducted at each institution in the sample and

the titles of informants.

Institution

No.

Numbers of

Interviews Title of Focal informants

A 2 Chief of social work department, office worker

B 4 Top leader, director of the administration office, director of the

nursing department, caregiver

C 3 Top leader, director of the administration office, caregiver

D 2 General manager assistant, director of the nursing department

E 3 Manager of the electronic commerce department, director of nursing

department, receptionist

F 1 Chief information officer (CIO)

Table 2. Overview of interviews

We solved potential informant bias in several ways as below:

First, we collected interview data in several ways over 3 months. This process enabled collection of

both current and retrospective longitudinal data. This combination is ideal, with the retrospective data

enabling efficient collection of more observations (thus enabling better grounding) and current data

mitigating retrospective bias(Leonard-Barton, 1990).

Second, we used interview techniques(e.g., “courtroom questioning,” “event tracking,” and

“nondirective questioning”) that prior research has shown to yield accurate information from

informants(Huber, 1985; Huber & Power, 1985).

Third, we relied on informants at multiple levels of hierarchy(e.g., Top leader and front-line staff).

Using these diverse lenses improves the likelihood of gaining a complete, accurate picture.

Fourth,we promised anonymity to institutions and informants to encourage their candor.

Finally, we complemented our interview data with wide-ranging archival and observational data. We

used internet publications and sources, and observational data from three industry conferences and

microblogging, wechat, and so on. No method is perfect, but the steps we took likely mitigated

informant and other biases and provided detailed and accurate accounts as possible as we can.

3.2 Data Analysis

We performed data analysis in three steps: data reduction, data display, and conclusion drawing and

verification(Gersick 1994; Miles et al. 1994). Certainly, these three stages are not independent or

sequentially, but interrelated and interdependent. For example, the process of data display actually

contains a lot of data reduction tasks and in this process some initial conclusions can be given.

3.2.1 Data reduction

Data reduction refers to the process of field work records and selecting, focusing, simplifying and

transforming the interview text(Mileset al. 1994). Because we have collected so many raw

data(including more than 100 pages interviews and 200 pages archives), it is difficult to directly use the

data for analysis, and we have to compress the content of data and texts into simple, refined form. First,

author repeatedly read the interview data and wrote a case summary for each case. Then, we coded the

original interview data of six focal institutions sentence by sentence, created initial constructs from the

raw data. In order to reduce individual biases, we tried to use the informants’ words as labels to explore

the initial constructs. By this method,we received 138 original statements and the corresponding initial

constructs. Because the initial constructs we requite a lot and there exists a certain degree of

redundancy, we further eliminated those constructs that just appear once. Besides, we also incorporated

some similar constructs. Finally, we got 28 factors. Table 3 shows a sample of the extracting process of

constructs.

3.2.2 Data display

Once the transcripts were reduced and coded, the second major task in the analysis is to display the

data so we can get some preliminary conclusions about factors which influence the informatization of

nursing institutions for the aged. We created tables to compare the similarities and differences of the

two kind cases (i.e. public and private). Table 4 shows a sample of the data’s display structure.

Constructs Raw materials

Cost saving

B1：My first thought is to save paper.（paper saving）

E1：Previously, we have a dedicated worker who was responsible for watching the warning

call from the big screen, and shouted: “this room, that room”. Now the situation is different,

we can spare at least one person.（human resource saving）

Improving

service

quality

B2：Previous call system is very noisy; we have to distinguish the room according to the

voice. Since using the system, you can easily know which room in the call as long as the

system runs.（Service targeted）

D2：Every room is equipped with emergency alarms and 24-hour personal servant who can

enter into room to check the situation of elderly at any time, the elderly also can press the

alarm button whatever he/she has any requirements.（Timeliness of service）

Funding

constraints

B1：I need to consider whether it is necessary to spend seventy thousand yuan a year to hire

an IT engineer, because we need to submit profits to our parent authorities every year.

（Funding constraints）

C1：There are, sometimes, companies promoting software to us. But we also consider the

issue of funding.（Funding constraints）

Risk

management

E3：If there is no system, we would not know where the elderly is and what has happened,

especially when the elderly is a self-care man.（Risk management）

F1：Through using the wrist watches, it is easy to find the elderly by the position system

when the elderly is not in sight.（Risk management）

Table 3. Data encoding examples

Note：B1 represents the original words of first interviewee of nursing institution B, same with the others. The

words in parentheses at the end of each sentence are the initial concepts encoding the original statements.

3.2.3 Conclusion Drawing and Verification

The third task of case analysis is conclusion drawing and verification. At this stage, we create the

model of promoting and hindering factors for different ownership’s nursing institutions for the aged. In

order to get a convincing conclusion, we try to use data from multiple sources to verify each other; this

method has been generally considered effective to verify the repeatability of observations or

interpretations(Stake 2013). For example, employees’ lack of basic computer knowledge is a main

hindering factor of organizational context. By checking the record of interviewing nursing institutions’

top leaders, middle managers(such as nursing director) and employees of both public and private

institutions, we are convinced that this factor also resists the informatization of them. Mutual

verification like this can make more comprehensive, general and better background description for

research object(Ghauri 2004).

The process of discovering the factors promoting and hindering the informatization of different

ownership’s nursing institutions for the aged keeps with replication logic; and we tested emerging

factors across institutions, which is similar to the process of repeating experiments in natural science

(Yin 2009; Eisenhardt 1989). For example, risk management is an important promoting factor of the

informatization of nursing institutions. After reducing the record of case F’s interview, we observe that

the factor is a special factor, and rarely mentioned in other industries’ informatization. After comparing

other five cases’ interview data, we are convinced that this factor is indeed a unique promoting factor

for nursing institutions for the aged. Mutual verification like this provides opportunity to improve the

existing theory.

Table4 Display Sample of factors promoting and hindering the informatization of nursing

institutions for the aged

3.2.4 Proposal of models

In the last stage of analysis, we engage in repeated iterations among data, literature, and theory until we

have a strong match between theory and data. And we also sent our extracted constructs respectively to

the top leaders of two public and two private nursing institutions for the aged and two staffs of ministry

of civil affairs bureau to test the theoretical saturation. The results show that our constructs have been

developed very rich, they have not found new factors affecting informatization of nursing institutions

Factors Ownership

Public Private

Promoting

Factors

Technologicalfactors(T) Strong applicability of system

Organizational

factors(O)

Top management support Top management support

Standardized management Standardized management

Risk management Risk management

Cost saving Cost saving

Information sharing Information sharing

Improve service quality Improve service quality

Improve work efficiency Improve work efficiency

Improve the competitiveness

Employee involvement

Environmental

factors(E)

Vendor support Vendor support

government or policy support Pressure of competition

Hindering

Factors

Technological

factors(T)

High complexity of system High complexity of system

Poor expandability of system Poorexpandability of system

System function can't meet the

business needs

System function can't meet the

business needs

High rate of system

customization

Organizational

factors(O)

Funding constraint Funding constraint

Increased workload Increased workload

Employees lack of basic

computer knowledge

Employees lack of basic

computer knowledge

Lack of full-time IT staff Lack of a fulltime and balanced

IT team

Inadequate system planning Misfit between IT and

organizational business

Unstable business processes

Environmental

factors(E)

Poor vendor poor vendor

Lack of support of partners Lack of support of partners

Intervention of parent institution

on decision-making

for the aged. It can be considered that these factors are saturated.

Finally, we propose our models and some findings as follows. It should be emphasized that only those

factors which are verified by multicases can be included in our models.

4 RESEARCH FINDINGS

Through the prior analysis, we identify factors promoting and hindering the informatization of nursing

institutions for aged. We can see that different factors influence the different ownership’s nursing

institutions informatization, so we build two models of factors promoting and hindering the

informatization for them respectively, as shown in Figure 1 and Figure 2. According to previous

research, we mainly have the following findings:

Environment（E）

Poor vendor

Lack of support of partners

Intervention of the parent

institution on decision-making

I

N

F

O

R

M

A

T

I

Z

A

T

I

O

N

of

P

U

B

L

I

C

Organization（O）

Inadequate system planning

Funding constraint

Lack of full-time IT staff

Increased workload

Employees lack of basic

computer knowledge

Technology（T）

High complexity of system

Poor expandability of system

System function can't meet the

business needs

Hindering factors

Organization（O）

Top management support

Standardized management

Risk management

Cost saving

Information sharing

Improving service quality

Improving work efficiency

Environment（E）

Vendor support

Government or policy support

Promoting factors

Technology（T）

Note:These factors dose not

show in case data

Figure 1. Model of factors promoting and hindering informatization of public nursing

institutions for the aged

4.1 Comparison Promoting Factors

4.1.1 Technological aspect: public nursing institutions lack of promoting factors

As shown in Figure 1, public nursing institutions have few promoting factors in the technological

aspect. The main reason maybe lack of technical staff. Because wages of staff are generally low in

public nursing institutions, yet it is difficult to recruit caregivers (MinaXi 2010), let alone the

recruitment of professional IT personnel. Lack of those IT staff directly leads to the deficiency of

technological momentum. However, as shown in Figure 2, strong applicability of system is an

advantage of private institutions, because the information systems of private institutions are cooperated

with suppliers or independently developed by their own IT staff, those systems can better meet the

needs of management and business of nursing institutions for the aged.

4.1.2 Organizational aspect: more promoting factors that the private nursing institutions owned

than those of public institutions

I

N

F

O

R

M

A

T

I

Z

A

T

I

O

N

of

P

R

I

V

A

T

E

Hindering factors

Organization（O）

Top management support

Standardized management

Risk management

Cost saving

Information sharing

Improving service quality

Improving work efficiency

Improving the competitiveness

Employee involvement

Promoting factors

Technology（T）

Strong applicability of system

Environment（E）

Vendor support

Pressure of competition

Organization（O）

Funding constraint

Increased workload

Employees lack of basic computer

knowledge

Lack of a fulltime and balanced IT

team

Misfit between IT and

organizational business

Unstable business processes

Technology（T）

High complexity of system

Poor expandability of system

System function can't meet the

business needs

High rate of system customization

Environment（E）

Poor vendor

Lack of support of partners

Figure 2. Model of factors promoting and hindering informatization of private nursing

institutions for the aged

As shown in the Figure 1 and Figure 2, the common promoting factors of the two ownerships’

institutions include top management support, standardized management, costsaving, information

sharing, improving service quality and improving work efficiency. Specifically, we find that risk

management is an important factor influence the informatization of nursing institutions, which is rarely

reported in other industries. Analyzing the reason, we think it may be related to the characteristics of

servicing the elderly, high risk and involved many stakeholders of nursing institutions. Most of the

elderly are old aged, disabled, unsuitable to live in the household or community, aging makes the

elderly at high risk of falls, injuries and outbreak of death in nursing institutions(Tinetti 1997; Xiaoyi

Zhang et al. 2012). Meanwhile, the present law and regulations of China are not sound and some

judicial process is not fair enough, when some accidents occur in the nursing homes, some problems

such as who should be responsible for the accident, would cause contractions and conflicts between the

old man’s relatives and nursing institution. In this situation, if the nursing institution has not enough

evidence to identify their own responsibility will leave itself at a disadvantage position. Even, some

nursing institutions may suffer the collapse for the high compensation of this incident. While

information technology such as monitoring system, GPS, wireless call system, can effectively prevent

and control these accidents(Arcelus et al. 2007; Kelly 2002; Suzuki 2006). Once accident happened,

those systems could also provide evidence of responsibility for the nursing institutions. Therefore, risk

management becomes an important promoting factor for them adopting information system.

Inaddition, improving the competitiveness and employee involvement is also promoting the

informatization of private nursing institutions. In order to attract the elderly, the private nursing

institutions usually use information systems as a sign of specific organization management, completed

security measures and high quality service to enhance themselves competitiveness(Thong et al. 1995).

Moreover, private institutions can offer higher wages to recruit young, highly educated and with more

knowledge of computer skills staff, who often actively participate in the implementation of information

systems, so employee involvement becomes an important promoting factor of private institutions to

carry out the informatization.

4.1.3 Environmental aspect: promoting factors of two ownership’s institutions are slightly different

Vendor support is the common promoting factor for both ownerships’ nursing institutions

informatization. The specific kinds of vendor support include suppliers’ door-to-door selling,

co-developing software with customers or customized software, after-sales maintenance and software

upgrades and other services. But on the whole, vendor provides more support to private institutions

than public institutions. In our interview, we find that the software vendor often sell their products to

private institutions but seldom sell software to public ones. The reason for this phenomenon maybe that

private institutions have greater decision-making autonomy and ability to pay.

In addition, government or policy support is an important promoting factor of public institutions

informatization because government has provided such as fixed investment, and a lot of government

subsidies to public institutions. While pressure of competition is important to private institutions, for

they usually apply information systems to get competition advantage(Thong et al. 1995).

4.2 Comparison Hindering Factors

4.2.1 Technological aspect: private nursing institutions have more hindering factors than public

institutions

As shown in the Figure 1 and Figure 2, the common hindering factors of two ownerships’ institutions

include high complexity of system, poor expandability of system and system function can not meet the

business needs. In addition, high rate of system customization is a factor hindering informatization of

private institutions. According to our interview, the main reason is that, those existing information

systems are mostly derived from simply function modification of other industry IS, so these systems

cannot meet the needs of care and management of nursing institutions, and should be customized a lot.

So the majority of private nursing institutions feel the process of informatization is very difficult and

complex for them.

4.2.2 Organizational aspect: the private nursing institutions have more hindering factors than

public institutions

The common hindering factors in the organizational context include funding constraint, increased

workload and the employees’ lack of basic computer knowledge. Increased workload is because, in the

start stage, the employees are not familiar with the systems application, and they need to invest more

time to complete their original work and new work on information systems.

Besides, inadequate system planning is a factor hindering public nursing institution’s informatization.

The reason is that public institutions informatization is often driven by external forces, such as

government or suppliers, and it is very hard to make long-term effective plan for the information

systems with little motivation. However, the misfit between IT and organizational business is a factor

hindering private institutions’ informatization. According to our interview, the reason maybe that

private institutions’ informatization is often driven by the information department, which often has high

expectation to the IS and neglects the current status of institution.

Furthermore, lack of full-time IT staff would hinder public institutions informatization, because

personnel’s salary is low and there is lack of a reasonable position promotion mechanism, so the staffs

are difficult to get promotion. At the same time, although the private institutions can recruit IT staff by

offering higher wages, the little future development also makes it difficult to retain staff, and lead to the

lack of a stable IT team. In addition, unstable business processes also is an important resistance of

private institutions’ informatization. Because the establishment of private nursing institutions is late,

mostly institutions have the problem that the market positioning is not clearly leading to non-standard

and unstable business process.

4.2.3 Environmental aspect: public institutions have more hindering factors than private

institutions

In the environmental aspect, the common hindering factors which the two ownership’s institutions are

faced with poor vendor and lack the support of partners. Poor vendor is referred to, vendor selling

nursing institutions’ information systems are mainly converted from ERP vendors, they lack of

understanding of business and management of nursing institutions, so that their modified software

cannot meet the demand of the nursing institutions and they are unable to provide qualified software

system for nursing institutions. Lack the support of partners is mainly reflected in the partners such as

hospital, home service companies, do not share and interchange information with nursing institutions.

Particularly, hospitals not accepting medical records of nursing institutions is a major hindrance for

nursing institutions to implement electronic medical records system.

In addition, because public institutions implementing informatization need parent institutions’ support,

in another side, the parent institutions’ intervention has also become an important hindering factor of

public institutions informatization.

5 DISCUSSION

Based on our analysis of six cases, we identify the promoting and hindering factors of informatization

of nursing institutions for the aged, and find several different factors between public and private

nursing institutions.

5.1 Theoretical Contributions

This study makes contributions to IS research by expanding the application fields of the TOE.

Although the existing research has successfully applied TOE framework to understand technology

adoption in many kinds of organizations, the research on IT adoption of nursing institutions is scarcely.

This paper uses TOE to study nursing institutions’ informatization, and expands the application field of

the TOE.

Moreover, this paper enriches the theoretical research of informatization in the nursing institutions. At

present, nursing institutions in China generally believe that IT can't solve their main problems and

difficulties, or informatization is not important. However, the promoting factors that this paper

identified provide helpful reference for nursing institutions to implement informatization. Moreover,

this paper finds the informatization can effectively deal with some problems of nursing institutions,

such as work inefficiency and cost saving, and particularly provide important support for the

operational risk management and control. These findings provide sufficient theoretical support for the

nursing institutions’ applications of information technology.

5.2 Practical Implications

In practical, our findings suggest that different ownership’s nursing institutions should consider

different measures to make use of promoting factors and overcome hindering factors based on their

respective resource conditions to ensure the smooth implementation of the informatization. Specifically,

our suggestions show as follows.

First, public nursing institutions should focus on recruitment and cultivation of the IT technological

personnel. Through the analysis of cases, we find that the public institutions lack of promoting factors

in the technological aspect in the implementation of the informatization. The key cause of this problem

is lack of technical staff, lack of information knowledge, experienceand technology (Thong et al. 1995).

Therefore, the public institutions should set reasonable salary compensation and promotion mechanism

to attract professional technical staff and develop their IT capability(Premkumar etal. 1999).

Second, private nursing institutions should normalize their operation management mode and business

processes as soon as possible. Through the analysis of cases, we find that most of private institutions

are still in its uncertainty exploratory stage of operations management mode, and their business

processes are still instability and non-standard. Those problems seriously restrict the implementation of

information systems(Raymond 1990). Therefore, we suggest that private institutions should explore a

set of suitable operation management mode and business processes as soon as possible, and then

normalize them to overcome the resistance of the instability of business processes and accelerate the

implementation of information systems.

Third, all nursing institutions should strengthen the IT-related training of employees. Whether for

public or private institutions, employee’s resistance is an important hindering factor of the

informatization. While they are lack of computer knowledge, they believe the systems implementation

would increase their workload, and then resist the implementation. However, our interviews also find

that when employees are familiar with the operation and function of systems, they believe that IT could

improve their work efficiency, service timeliness, and etc., and they would be willing to accept IT

applications. Therefore, nursing institutions should design and adopt a set of effective IT training

mechanisms, improve the staff's computer skills and knowledge level(Zhanget al. 2003).

6 CONCLUSION

In this paper, we adopt multiple cases study based on the TOE framework, identify the promoting and

hindering factors that influence the informatization of nursing institutions for the aged. We find that

different ownership’s nursing institutions have some different promoting and hindering factors during

the informatization. Overall, compared with public institutions, private institutions have more

promoting and hindering factors in terms of technology and organization aspects, while have less

hindering factors in terms of environment aspect. In addition, we find that risk management is an

important promoting factor for nursing institutions’ information system applications. All these findings

not only expand the application field for TOE, but also enrich the theoretical research of nursing

institutions’ informatization. We also provide some suggestions for different ownership’s nursing

institutions.

There are two main limitations in our paper. First, our study was done in only one city, Beijing in

China.We haven’t investigated nursing institutions for the aged in other cities or countries. Second, the

research object of this study involves only the nursing institutions for the aged that have implemented

information systems, and those haven't yet adopted IT has not involved.

In future, we will extend investigation sample to better understand the status and problems of the

informatization of the nursing institutions for the aged. Moreover, we would compare the promoting

and hindering factors of those institutions that have implemented information systems with those have

not implemented information systems.

Acknowledgement

This work was supported in part by the Fundamental Research Funds for the Central Universities, the

Research Funds of Renmin University of China under Grant 10XNJ065, National Natural Science

Foundation of China under Grant 71273265, part by National Social Science Foundation of China

Major Program under Grant 13&ZD184, and part by Program for New Century Excellent Talents in

University. The second author is the corresponding author, and his e-mail address is

zuomy@ruc.edu.cn.

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