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Understanding the nutrition care needs of patients newly
diagnosed
with type 2 diabetes: a need for open communication
and patient-focussed consultations
Lauren BallA,C, Ruth DavmorA, Michael LeverittB, Ben
DesbrowA, Carolyn EhrlichA
and Wendy ChaboyerA
AMenzies Health Institute Queensland, Griffith University,
Gold Coast 4222, Qld, Australia.
BSchool of Human Movement and Nutrition Sciences, The
University of Queensland,
Brisbane 4072, Qld, Australia.
CCorresponding author. Email: [email protected]
Abstract. Patients who are newly diagnosed with type 2 diabetes
mellitus (T2DM) commonly attempt to modify their
dietary intake after receiving nutrition care from primary health
professionals. Yet, adherence to dietary recommendations
is rarely sustained and factors influencing adherence are poorly
understood. This study exploredT2DMpatients’ experiences
of dietary change and their views on how primary health
professionals can best support long-term maintenance of dietary
change.Apurposive sample of 10 individuals recently
diagnosedwithT2DMparticipated in three individual semi-
structured
qualitative telephone interviews: at baseline, then at 3 and 6
months after recruitment. Interview questions were modified
from the initial interview inorder to investigate
emergingfindings.A two-step data analysis process occurred
throughcontent
analysis of individual interviews andmeta-synthesis of findings
over time. Participants initiallymadewide-ranging attempts
to improve dietary behaviours, butmost experienced negative
emotions from the restraint required tomaintain a healthy diet.
Participants felt confused by the conflicting advice received
from health professionals and other sources such as friends,
family, internet and diabetes organisations. Participants
frequently reported feeling rushed and not heard in
consultations,
resulting in limited ongoing engagement with primary
healthcare services. These findings suggest that there is
opportunity
for primary health professionals to enhance the dietary support
provided to patients by: acknowledging the challenges of
sustained improvements in dietary intake; open communication;
and investing in patient relationships through more
patient-focussed consultations.
Additional keywords: chronic disease, general practice, primary
care, nutrition therapy, nutritional management.
Received 28 April 2015, accepted 18 August 2015, published
online 5 October 2015
Introduction
Type 2 diabetes mellitus (T2DM) is a lifestyle-related chronic
disease and leading cause of morbidity andmortality in
Australia
(Australian Institute of Health andWelfare 2007). Over 5%of
the
Australian population has been diagnosed with T2DM, and an
additional 0.9% is predicted to be diagnosed annually
(Australian
Bureau of Statistics (ABS) 2012). T2DM is typically diagnosed
and managed in the primary healthcare setting, and patients
with
T2DM receive health care from a variety of primary health
professionals (Diabetes Australia 2012). Importantly, the health
outcomes of patients with T2DM are influenced by their dietary
intake (Coppell et al. 2010). Therefore, facilitating patients
to have a healthy dietary intake is a key component of T2DM
management (Diabetes Australia, Royal Australian College of
General Practitioners (RACGP) 2008; National Health and
Hospitals Reform Commission 2009).
Patients who are newly diagnosed with T2DM commonly
attempt to modify their dietary intake after receiving nutrition
care from primary health professionals (Castro-Sánchez and
Avila-Ortiz 2013). In the first 6 months after diagnosis, patients
often experience changes to their enjoyment of food while
trying
to follow a recommended diet, and most report only temporarily
adherence to dietary recommendations (Castro-Sánchez and
Avila-Ortiz 2013). The United Kingdom Prospective Diabetes
Study was the largest clinical research study into diabetes
management (n = 3867 participants), and has shown that
establishing short-term optimal glycaemic control in the early
stages after diagnosis reduces the risk of macro- and micro-
vascular complications, as well as all-cause mortality 10 years
after diagnosis (Murray et al.2010).Given the influenceofdietary
intake on glycaemic control of patientswith T2DM,
investigating
ways to further support patients to maintain healthy dietary
behaviours in the early stages after diagnosis is important.
Exploring patients’ experiences and perceptions is crucial
to understanding how to provide patient-centred care. Patient-
centred care is an approach to health care that meets the specific
Journal compilation � La Trobe University 2016
www.publish.csiro.au/journals/py
CSIRO PUBLISHING
Australian Journal of Primary Health, 2016, 22, 416–422
Research
http://dx.doi.org/10.1071/PY15063
mailto:[email protected]
needs, values and beliefs of patients (McMillan et al. 2013) and
is
regarded as imperative to the optimal management of chronic
disease, including T2DM (Holman and Lorig 2000). Many
primary health professionals, such as GPs, practice nurses and
dietitians, report providing ‘nutrition care’ to patients, referring
to
anypractice conducted to support patients to improve their
dietary
intake (Ball et al. 2010; Ball et al. 2012). Recent investigations
into the nutrition care provided by primary health professionals
indicate that patient-centred care is not always achieved, and
this
may be hindering the efficacy of nutrition care for chronic
disease
management (Ball et al. 2012; Ball et al. 2013; Ball et al. 2014).
Given the importance of optimal dietary intake in T2DM self-
management, it is necessary for primary health professionals
to better understand the experiences, challenges and needs of
patients attempting to improve their dietary behaviours in order
to provide effective patient-centred nutrition care.
The aim of this study was to examine the perceptions of
patientswho have been recently diagnosedwith T2DMregarding
nutrition care provided by primary healthcare professionals.
Specifically, the study explored patients’ experience of dietary
change and their views on how primary health professionals
could best support long-termmaintenance of dietary change.
This
understanding can be used to facilitate health professionals to
provide nutrition care that addresses the needs and experiences
of patients.
Methods
This study utilised a longitudinal, qualitative design to describe
the perceptions and experiences of patients who have recently
been diagnosed with T2DM. The study was approved by
the Griffith University Human Research Ethics Committee
(reference number PBH/09/14/HREC).
Participant recruitment
A purposive sample of individuals with T2DM (<4 months since
diagnosis) was recruited via e-newsletters and social media
pages of Diabetes Australia, and state branches of Diabetes New
SouthWales,DiabetesQueensland,Diabetes SouthAustralia and
Diabetes Tasmania. The sampling strategy aimed to recruit a
combination of male and female, young and old, employed and
unemployed/retired participants. Potential participants who
contacted the research team were provided with a plain
language
information sheet, before being asked to provide consent and
attend an initial interview.
Data collection
Each participant was involved in three individual semi-
structured
telephone interviews; at baseline, and then at 3 and 6months
after
recruitment into the study.A semi-structured interviewguidewas
developed for each round of interviews. Interviews included
questions such as: ‘How has your recent diagnosis influenced
your feelings about food?’; ‘Describe your interactions with
health professionals regarding food and healthy eating’; and ‘At
this moment, how could health professionals be most helpful
in supporting you in healthy eating?’ Elaboration probing,
clarification probing and attention probing were utilised to
gain a deeper understanding of the participants’ perceptions
(Liamputtong 2010). Interview questions were modified from
the initial interview in order to investigate emerging findings
(Thomson and Holland 2003).
All interviewswere conducted by one investigator (RD), were
30–60min in length and were digitally recorded and transcribed
verbatim. Immediately after each interview, an entrywasmade in
a reflective journal that outlined the impressions of the
interview.
Data collection and analysis were conducted concurrently;
recruitment and data collection continued until data saturation
was considered to have been achieved. In practical terms,
saturation was considered to have been reached when no new
responses and subsequent preliminary categoriesweredetectedas
interviews progressed (Strauss and Corbin 2007).
Data analysis
A two-step data analysis process was used for this study. First,
content analysis was used to analyse the verbatim transcripts
because it allows an in-depth understanding of the participants’
nutrition care needs (Graneheim and Lundman 2004; Hsieh and
Shannon 2005). Analysis of verbatim transcripts involved an
iterative process of reading the transcripts to become familiar
with the data, generating initial subcategories, searching for
categories, reviewing the categories and, finally, labelling the
categories (Graneheim and Lundman 2004; Hsieh and Shannon
2005). Triangular analysis was conducted by two investigators
(LB andRD), who independently generated initial subcategories,
and then compared and discussed to reach agreement. Second,
a meta-synthesis approach was undertaken to synthesise and
interpret the data across the three time points (Sandelowski and
Barroso 2007). The process involved extracting the
subcategories
and interpreting them in order to identify higher order
categories
that transcend findings from each period. Regular meetings
were
held with the whole research team in which emerging findings
were critically reviewed, ensuring that the identified and
defined
subcategories accurately reflected the data for transferability
and
credibility.
Results
Ten individuals participated in the study, each completing three
interviews. The participants consisted of three males and seven
females, and their ages ranged from 27 to 74 years. A summary
of
the three categories and subcategories that emerged from the
analysis are displayed in Table 1.
What is known about the topic?
* Patients newly diagnosed with type 2 diabetes
commonly attempt to modify their dietary intake after
receiving nutrition-related care. Adherence to dietary
recommendations is rarely sustained and factors
influencing adherence are poorly understood.
What does this paper add?
* The results suggest that there is opportunity to enhance
the dietary support provided to patients by investing
in patient relationships through more patient-focussed
consultations and open communication.
Nutrition care for type 2 diabetes mellitus Australian Journal of
Primary Health 417
Adjusting to diagnosis
The first category encompassed the impact of being diagnosed
with T2DM on participants’ perceptions about the food they eat
and their broader dietary intake. The adjustment process
involved
considerable emotional adaptation, which occurred at different
rates among participants. Initially, participants reported feeling
shocked and surprised at being diagnosed with T2DM. Most
considered their usual dietary intake to be healthy, and this
added
to the challengeof coming to termswith having a long-
termhealth
condition:
I’ve always considered [that] we ate healthy . . . It never
entered my mind that I would have sugar diabetes.
(Participant 7, Interview 1)
The diagnosis of T2DM appeared to have an immediate
negative impact on participants’ views about dietary intake in
general, particularly in social situations when others reacted to
the news:
All the sad faces, they say, ‘Oh, you’ve got diabetes.’
People are now scared to cook for me. It’s actually
intimidated them to think they can’t actually cook normal
food. (Participant 8, Interview 1)
Three and six months after the initial interview, participants
began to adapt to the diagnosis of T2DM, generally moving on
from the initial shock and feelingmore in control, as the
following
statements from the same participant in successive interviews
demonstrate:
I keep saying tomyself, ‘I’mnot depressed, I’mnot allowed
to be depressed.’ I got so depressedwhen I was diagnosed,
of course, and I don’t feel quite as black as that, but I don’t
feel that I’m in control of myself at the moment, either.
(Participant 7, Interview 2)
I’ve accepted it now, and just have a little swear and curse
every now and then. It’s been a little bit easier lately, I’m
handling it better. (Participant 7, Interview 3)
After adjusting to thediagnosis, participantswantedcontinued
improvement in their management of T2DM, even beyond the
goals suggested by their supporting health professionals:
The doctor said she was really happy with my BGL [blood
glucose level] at 6.5, but I think maybe below 6 is better.
I know it’s quite difficult, but I want to try anyway.
(Participant 5, Interview 3)
Modifying dietary behaviours
The second category related to participants’ experiences of
modifying their dietary behaviours in order to improve their
blood glucose management and other health outcomes. These
experiences ranged from logistical considerations of food
preparation to broad emotional adaptation to having different
dietary behaviours compared with before diagnosis.
Initially,wide-ranging attempts to improvedietary behaviours
were undertaken by participants. Participants experienced an
emotional impact of restricting their diet, as well as managing
ongoing changes:
I’vemade somewholesale changes to theway I vieweating,
what I eat and [now I pay] particular attention, like stuff
like food labels . . .making sure I eat three meals a day and
don’t skip meals. (Participant 2, Interview 1)
As time progressed, participants had differing experiences
of sustaining dietary changes, with some finding that
monitoring
blood sugar levels provided useful feedback on food choices:
I’ve got to the stage now where I don’t think too much
about the diet because . . . you’re just in the habit of
eating healthy meals. I know now what I should be
eating, and what are ‘sometimes’ foods. (Participant 2,
Interview 2)
You know you’ve eaten the right thing because the [blood
sugar] reading is lower. (Participant 6, Interview 2)
Table 1. Categories and subcategories emerging from the
interviews
Category Definition Subcategories
Adjusting to diagnosis Impact of being diagnosed with T2DM
on perceptions
about food and dietary intake
*Shocked and surprised at being diagnosed with T2DM
*Immediate negative views about dietary intake
*Beginning to move on from the initial shock of diagnosis
*Wanting continued improvement beyond suggested goals
Modifying dietary
behaviours
Patient experiences of modifying their dietary behaviours
in an attempt to improve management of blood glucose
levels and other health outcomes, ranging from
logistical considerations of food preparation to broad
emotional adaptation to eating differently to before
diagnosis
*Wide-ranging attempts to improve dietary behaviours
*Emotional impact of restricting diet and managing ongoing
changes
*Differing experiences of sustaining dietary changes
*Maintaining a healthy dietary intake continues to be a
challenge
*Monitoring blood sugar levels provides useful feedback on
food choices
*Feeling aware of the consequences of not eating healthy foods
Receiving support from
health professionals
Experiences of interacting with health professionals and
discussing food and dietary intake
*Receiving overwhelming, conflicting nutrition information
*Receiving initial directives from dietitians is challenging
*Ongoing engagement with primary care services is limited
and not highly valued
*Feeling rushed and not heard in consultations
418 Australian Journal of Primary Health L. Ball et al.
However, formany participants,maintaining a healthy dietary
intake continued to be a challenge as time progressed, mostly
because it felt restrictive:
It’s a challenge . . . I’ve beenputting abitmore onmyplate,
having a second serve of something . . . It’s the old habits
. . . It’s not something I could maintain. (Participant 3,
Interview 2)
I’m getting to the point where I’m cheesed off with always
having to have diabetic biscuits and other things. You get
bored with them. I’m feeling I’mhaving tomake a sacrifice
that other people don’t have to. (Participant 9, Interview 3)
Despite the challenge of maintaining a healthy dietary intake,
some participants reported feeling aware of the consequences of
not eating healthy foods:
I can’t see myself drifting back to eating the same way as
I was, because I know what the consequences are.
(Participant 2, Interview 3)
Receiving support from health professionals
The third category related to participants’ experiences of
receiving nutrition care from health professionals. Participants’
perceptions extended beyond the content of advice provided by
health professionals to broader experiences of support and
communication in healthcare consultations.
When participants were initially diagnosed with T2DM, they
received an overwhelming amount of conflicting nutrition
information. The information came from health professionals as
well as dietary advice from friends, family, online sources and
T2DM organisations:
I kept finding somuch controversy it mademyhead spin . . .
They say you have protein, you have carbs, and you have
your veggies and stuff. Well, then you read no meat, no
animal protein, none of this . . . Who is right and who is
wrong? I found it confusing. (Participant 2, Interview 1)
Participants found their initial interactions with dietitians to
be challenging because of the direct, instructional nature of
the nutrition care provided:
A few days after I was diagnosed, I went to a dietitian and
she laid it all out . . . I wasn’t impressed. This woman was
just there to purposefully lay down a diet . . . to put me in
line and show me this, that and that. (Participant 1,
Interview 1)
I’d had a nice lead-in with the educator and then, all of a
sudden, I saw the dietitian and shewas laying down the law
and I was thinking, ‘This is a bit of a turnaround!’
(Participant 2, Interview 2)
Participants found that aside from the support provided by
dietitians, other health professionals, aswell as family and
friends
and online support, were helpful on occasions:
The diabetes educator . . . she handled me very well and I
felt different when I came out of there . . . They put it in
perspective, which is sort of what I needed. (Participant 2,
Interview 1)
There’s one lady at work, her husband has type 2 diabetes
and she tells me what she does with him, so yeah, that is
really good. (Participant 3, Interview 2)
Overall, participants had limited ongoing engagement with
primary healthcare services. This appeared to be a result of
limited
understanding about how the primary care system operated, and
the role of different health professionals, as well as the limited
value patients placed on the services provided in this setting:
TheGPgavemeoneof those ‘goand seefive people a year’
diabetes plans but I haven’t organised any of it . . . It’s not
a big deal, it’s just something I probably need to tick off
to keep everybody happy and then I can relax again for
another year. (Participant 8, Interview 2)
I didn’t quite understand what diabetes educators did or
the dietitians. (Participant 2, Interview 2)
Most participants thought that the support provided by primary
health professionals had considerable room for improvement
because they felt rushedandnotheard inconsultations,
andbecause
open communication was not always achieved:
They get you in there, they tell you you’ve got type 2 and
you’ve got to make these changes, and it always feels like
[they’re in] a rush to finish with you and get you out the
back door and start with a new case. (Participant 2,
Interview 3)
You’re talking to someone and they go, ‘Your half hour’s
up, I’ve got another patient waiting’. Nobody has got the
time to sit and take the time to talk. I find that very
frustrating and annoying. You just start to say something
and then you’ve got to leave.’ (Participant 1, Interview 3)
Differences in accommodating new dietary behaviours
The collective experiences of participants over time suggest that
individuals have different experiences in accommodating new
dietary behaviours after being diagnosed with T2DM. The
experiences of participants in this study appeared to be
influenced
by contextual conditions such as immediate family support and
responsibilities, confidence in existing food knowledge, and
familiarity with health professionals and the healthcare system.
Three archetypical experiences were apparent in this study.
First, some individuals appeared to take a factual and directive
approach to adjusting to their diagnosis and modifying their
dietary behaviours. In order to achieve this, they preferred clear
instructions from health professionals and felt most comfortable
eating in accordance with a predetermined plan. Positive
feedback from continued healthy eating (such as improved
blood
glucose management and weight loss) outweighed the negative
emotions felt from being restricted in their food choices, and
this
motivated continued adherence to the point of sustained
improvement in dietary behaviours.
Second, some individuals appeared to take an adaptive
approach to adjusting to their diagnosis, modifying their dietary
behaviours and seeking support from health professionals. The
initial shock of diagnosis reduced their confidence in making
dietary choices, and they placed considerable importance on
Nutrition care for type 2 diabetes mellitus Australian Journal of
Primary Health 419
guidance from health professionals and other sources of dietary
information (such as family, friends, internet and diabetes
organisations). Early improvements in dietary intake were not
considered sustainable because of the negative emotional
impact dietary restrictions had on their quality of life. However,
over time, adjustments to dietary intake that were considered
reasonable and achievable were made. These individuals
perceived themselves as having made general improvements in
their dietary behaviours that had positive impacts on blood
glucose management and other health outcomes. However, these
individuals also experienced regular occasions of making food
choices that were not viewed as ideal, and risked having a poor
dietary intake over time.
Third, some individuals experienced persistent negative
emotions after diagnosis and did not makemeaningful
adaptations
to their dietary behaviours over time. These individuals felt
overwhelmed by the conflicting information received from
health
professionals and other sources of dietary information, which
caused them to withdraw from the experience of making dietary
choices and receiving support. Improvements in blood glucose
management and other health outcomes appeared to be a result
of
undereating and avoiding social eating situations, which was not
identified in consultations with health professionals. These
individuals perceived themselves as requiring considerably
more
support thanwhat they feltwas available, andwere frustratedby
the
lack of immediate success when following guidelines provided
by
primary health professionals.
Discussion
This study contributes new information on patients’ experiences
of dietary change after being diagnosed with T2DM and their
views on howprimary health professionals can best support
long-
term maintenance of dietary change. Participants’ insights
resulted in the generation of three categories: adjusting to
diagnosis, modifying dietary behaviours and receiving support
from health professionals. This information is important
because
of the relationship that exists between healthcare experiences,
chronic disease self-management practices (including dietary
behaviours) and healthcare outcomes (Sequist et al. 2012).
Participants in this study experienced challenges in adjusting
to their recent diagnosis of T2DM; this had a direct negative
impact on their views about their dietary intake. Being
diagnosed
with T2DM is recognised as a particularly alarming and
emotional time for patients because it is viewed as a
transformation point from a healthy person to one who is aware,
frightened and sometimes embarrassed by having a long-term
health condition (Histock et al. 2001; Hillson 2014). The impact
of thediagnosis onparticipants’ attitude to foodwas
considerable,
including reduced confidence in what to eat, reduced enjoyment
of eating, and feeling uncomfortable eatingwith others,
including
family, peers and friends. These factors have the potential to
influence the effectiveness of nutrition care provided by
primary
health professionals, and health professionals should be aware
of
this when providing nutrition care to patients.
Previous studies investigating dietary changes after diagnosis
with T2DM report that following initial dietary changes,
patients
often move into an accommodation-adaptation phase regarding
their dietary intake (Castro-Sánchez and Avila-Ortiz 2013).
However, this finding was not apparent in all participants in the
current study, even6months after recruitment into the study (up
to
10 months after diagnosis). While some participants did report
positive perceptions about their dietary intake as time
progressed,
many participants continued to experience negative emotions
as a result of the restraint required to maintain a healthy diet,
and
the conflict between diet-related social activities and necessary
self-management behaviours. The three archetypical experiences
apparent in this study and the individual timelines in which
participants adjusted to changes in dietary intake highlight the
importance of flexible and tailored support for patients in
the months after diagnosis.
Participants in this study reported that they have received an
overwhelming amount of contradictory nutrition information
from health professionals and other sources. A recent survey of
Australian adults who self-identified as needing to improve
their
dietary behaviours suggested that nutrition information sources
perceived as most trustworthy, credible and effective included
dietitians, nutritionists and GPs, but the most frequently utilised
sources were the internet, friends, family and magazines (Cash
et al. 2014). The use of family as a source of information aligns
with family systems theory, which conceptualises families as a
system of interrelated parts that influence each other and
contribute to the growth or detriment of others (Bowen 1966).
Further, the participants in the current study reported limited
ongoing engagement with health professionals such as dietitians
and GPs, despite these sources being described in the recent
survey as the most trusted, credible and effective (Cash et al.
2014). Further understanding about how patients decide which
nutrition information sources to use is clearly required.
The support provided by primary health professionals to the
participants in this study was generally reported as requiring
significant improvement. Interestingly, the factors that
weremost
influential in patients’ experiences of receiving nutrition care
appeared to be open communication, not feeling rushed
andbeing
genuinely supported, rather than any specific nutrition advice or
approach. This appeared to be important for all participants but
particularly those who experienced persistent negative emotions
after diagnosis. Open communication and genuine support are
considered critical for building relationships with patients with
T2DM, and the way this is displayed is influenced by a health
professional’s own personality and the emotions they are
experiencing (Kowitt et al. 2015). Similar factors that influence
patients’ experiences of health care have been identified in
other
Australian population groups, such as new mothers, whose
perceptions of their healthcare quality were reduced when they
felt unsupported and hurried in consultations (Corr et al. 2015).
Collectively, this suggests that primary health professionals
could enhance the delivery of their care by investing in patient
relationships through longer, more patient-focussed
consultations
and open communication.
Study participants described situations in which health
professionals provided nutrition care that did not meet their
needs. FacilitatingAustralian primary healthcare professionals
to
provide nutrition care in a patient-centred manner is important
to optimise self-management of T2DM and reduce the risk of
complications. It has been suggested that compassion fatigue –
a
gradual lessening of compassion over time as a result of being
regularly exposed to patients’problems– is occurring amongGPs
420 Australian Journal of Primary Health L. Ball et al.
and other primary health professionals in Australia (Shrestha
and Joyce 2011). This lack of empathy from health
professionals
has been associated with significantly increased metabolic
complications in patients with T2DM (Canale et al. 2012).
Given
this association, strategies to reduce compassion fatigue and
subsequently enhance patient-centred care appear to …
IT STraTegy:
ISSueS and PracTIceS
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IT STraTegy:
ISSueS and PracTIceS
T h i r d E d i t i o n
James D. McKeen
Queen’s University
Heather A. Smith
Queen’s University
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Saddle River
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Copyright © 2015, 2012 and 2009 by Pearson Education, Inc.,
Upper Saddle River, New Jersey, 07458. Pearson
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permission(s), write to: Rights and Permissions Department.
Library of Congress Cataloging-in-Publication Data
McKeen, James D.
IT strategy: issues and practices/James D. McKeen, Queen’s
University, Heather A. Smith,
Queen’s University.—Third edition.
pages cm
ISBN 978-0-13-354424-4 (alk. paper)
ISBN 0-13-354424-9 (alk. paper)
1. Information technology—Management. I. Smith, Heather A.
II. Title.
HD30.2.M3987 2015
004.068—dc23
2014017950
ISBN–10: 0-13-354424-9
ISBN–13: 978-0-13-354424-4
10 9 8 7 6 5 4 3 2 1
CoNTENTS
Preface xiii
About the Authors xxi
Acknowledgments xxii
Section I Delivering Value with IT 1
Chapter 1 DeVelopIng anD DelIVerIng on The IT Value
propoSITIon 2
Peeling the Onion: Understanding IT Value 3
What Is IT Value? 3
Where Is IT Value? 4
Who Delivers IT Value? 5
When Is IT Value Realized? 5
The Three Components of the IT Value Proposition 6
Identification of Potential Value 7
Effective Conversion 8
Realizing Value 9
Five Principles for Delivering Value 10
Principle 1. Have a Clearly Defined Portfolio Value
Management
Process 11
Principle 2. Aim for Chunks of Value 11
Principle 3. Adopt a Holistic Orientation to Technology Value
11
Principle 4. Aim for Joint Ownership of Technology Initiatives
12
Principle 5. Experiment More Often 12
Conclusion 12 • References 13
Chapter 2 DeVelopIng IT STraTegy for BuSIneSS Value 15
Business and IT Strategies: Past, Present, and Future 16
Four Critical Success Factors 18
The Many Dimensions of IT Strategy 20
Toward an IT Strategy-Development Process 22
Challenges for CIOs 23
Conclusion 25 • References 25
Chapter 3 lInkIng IT To BuSIneSS MeTrICS 27
Business Measurement: An Overview 28
Key Business Metrics for IT 30
v
vi Contents
Designing Business Metrics for IT 31
Advice to Managers 35
Conclusion 36 • References 36
Chapter 4 BuIlDIng a STrong relaTIonShIp
wITh The BuSIneSS 38
The Nature of the Business–IT Relationship 39
The Foundation of a Strong Business–IT
Relationship 41
Building Block #1: Competence 42
Building Block #2: Credibility 43
Building Block #3: Interpersonal Interaction 44
Building Block #4: Trust 46
Conclusion 48 • References 48
Appendix A The Five IT Value Profiles 50
Appendix B Guidelines for Building a Strong Business–IT
Relationship 51
Chapter 5 CoMMunICaTIng wITh BuSIneSS ManagerS 52
Communication in the Business–IT Relationship 53
What Is “Good” Communication? 54
Obstacles to Effective Communication 56
“T-Level” Communication Skills for IT Staff 58
Improving Business–IT Communication 60
Conclusion 61 • References 61
Appendix A IT Communication Competencies 63
Chapter 6 BuIlDIng BeTTer IT leaDerS froM
The BoTToM up 64
The Changing Role of the IT Leader 65
What Makes a Good IT Leader? 67
How to Build Better IT Leaders 70
Investing in Leadership Development: Articulating the Value
Proposition 73
Conclusion 74 • References 75
MInI CaSeS
Delivering Business Value with IT at Hefty Hardware 76
Investing in TUFS 80
IT Planning at ModMeters 82
Contents vii
Section II IT governance 87
Chapter 7 CreaTIng IT ShareD SerVICeS 88
IT Shared Services: An Overview 89
IT Shared Services: Pros and Cons 92
IT Shared Services: Key Organizational Success Factors 93
Identifying Candidate Services 94
An Integrated Model of IT Shared Services 95
Recommmendations for Creating Effective IT
Shared Services 96
Conclusion 99 • References 99
Chapter 8 a ManageMenT fraMework for
IT SourCIng 100
A Maturity Model for IT Functions 101
IT Sourcing Options: Theory Versus Practice 105
The “Real” Decision Criteria 109
Decision Criterion #1: Flexibility 109
Decision Criterion #2: Control 109
Decision Criterion #3: Knowledge Enhancement 110
Decision Criterion #4: Business Exigency 110
A Decision Framework for Sourcing IT Functions 111
Identify Your Core IT Functions 111
Create a “Function Sourcing” Profile 111
Evolve Full-Time IT Personnel 113
Encourage Exploration of the Whole Range
of Sourcing Options 114
Combine Sourcing Options Strategically 114
A Management Framework for Successful
Sourcing 115
Develop a Sourcing Strategy 115
Develop a Risk Mitigation Strategy 115
Develop a Governance Strategy 116
Understand the Cost Structures 116
Conclusion 117 • References 117
Chapter 9 The IT BuDgeTIng proCeSS 118
Key Concepts in IT Budgeting 119
The Importance of Budgets 121
The IT Planning and Budget Process 123
viii Contents
Corporate Processes 123
IT Processes 125
Assess Actual IT Spending 126
IT Budgeting Practices That Deliver Value 127
Conclusion 128 • References 129
Chapter 10 ManagIng IT- BaSeD rISk 130
A Holistic View of IT-Based Risk 131
Holistic Risk Management: A Portrait 134
Developing a Risk Management Framework 135
Improving Risk Management Capabilities 138
Conclusion 139 • References 140
Appendix A A Selection of Risk Classification
Schemes 141
Chapter 11 InforMaTIon ManageMenT: The nexuS
of BuSIneSS anD IT 142
Information Management: How Does IT Fit? 143
A Framework For IM 145
Stage One: Develop an IM Policy 145
Stage Two: Articulate the Operational
Components 145
Stage Three: Establish Information Stewardship 146
Stage Four: Build Information Standards 147
Issues In IM 148
Culture and Behavior 148
Information Risk Management 149
Information Value 150
Privacy 150
Knowledge Management 151
The Knowing–Doing Gap 151
Getting Started in IM 151
Conclusion 153 • References 154
Appendix A Elements of IM Operations 155
MInI CaSeS
Building Shared Services at RR Communications 156
Enterprise Architecture at Nationstate Insurance 160
IT Investment at North American Financial 165
Contents ix
Section III IT-enabled Innovation 169
Chapter 12 InnoVaTIon wITh IT 170
The Need for Innovation: An Historical
Perspective 171
The Need for Innovation Now 171
Understanding Innovation 172
The Value of Innovation 174
Innovation Essentials: Motivation, Support,
and Direction 175
Challenges for IT leaders 177
Facilitating Innovation 179
Conclusion 180 • References 181
Chapter 13 BIg DaTa anD SoCIal CoMpuTIng 182
The Social Media/Big Data Opportunity 183
Delivering Business Value with Big Data 185
Innovating with Big Data 189
Pulling in Two Different Directions: The Challenge
for IT Managers 190
First Steps for IT Leaders 192
Conclusion 193 • References 194
Chapter 14 IMproVIng The CuSToMer experIenCe:
an IT perSpeCTIVe 195
Customer Experience and Business value 196
Many Dimensions of Customer Experience 197
The Role of Technology in Customer Experience 199
Customer Experience Essentials for IT 200
First Steps to Improving Customer Experience 203
Conclusion 204 • References 204
Chapter 15 BuIlDIng BuSIneSS InTellIgenCe 206
Understanding Business Intelligence 207
The Need for Business Intelligence 208
The Challenge of Business Intelligence 209
The Role of IT in Business Intelligence 211
Improving Business Intelligence 213
Conclusion 216 • References 216
x Contents
Chapter 16 enaBlIng CollaBoraTIon wITh IT 218
Why Collaborate? 219
Characteristics of Collaboration 222
Components of Successful Collaboration 225
The Role of IT in Collaboration 227
First Steps for Facilitating Effective Collaboration 229
Conclusion 231 • References 232
MInI CaSeS
Innovation at International Foods 234
Consumerization of Technology at IFG 239
CRM at Minitrex 243
Customer Service at Datatronics 246
Section IV IT portfolio Development and Management 251
Chapter 17 applICaTIon porTfolIo ManageMenT 252
The Applications Quagmire 253
The Benefits of a Portfolio Perspective 254
Making APM Happen 256
Capability 1: Strategy and Governance 258
Capability 2: Inventory Management 262
Capability 3: Reporting and Rationalization 263
Key Lessons Learned 264
Conclusion 265 • References 265
Appendix A Application Information 266
Chapter 18 ManagIng IT DeManD 270
Understanding IT Demand 271
The Economics of Demand Management 273
Three Tools for Demand management 273
Key Organizational Enablers for Effective Demand
Management 274
Strategic Initiative Management 275
Application Portfolio Management 276
Enterprise Architecture 276
Business–IT Partnership 277
Governance and Transparency 279
Conclusion 281 • References 281
Contents xi
Chapter 19 CreaTIng anD eVolVIng a TeChnology
roaDMap 283
What is a Technology Roadmap? 284
The Benefits of a Technology Roadmap 285
External Benefits (Effectiveness) 285
Internal Benefits (Efficiency) 286
Elements of the Technology Roadmap 286
Activity #1: Guiding Principles 287
Activity #2: Assess Current Technology 288
Activity #3: Analyze Gaps 289
Activity #4: Evaluate Technology
Landscape 290
Activity #5: Describe Future Technology 291
Activity #6: Outline Migration Strategy 292
Activity #7: Establish Governance 292
Practical Steps for Developing a Technology
Roadmap 294
Conclusion 295 • References 295
Appendix A Principles to Guide a Migration
Strategy 296
Chapter 20 enhanCIng DeVelopMenT
proDuCTIVITy 297
The Problem with System Development 298
Trends in System Development 299
Obstacles to Improving System Development
Productivity 302
Improving System Development Productivity: What we
know that Works 304
Next Steps to Improving System Development
Productivity 306
Conclusion 308 • References 308
Chapter 21 InforMaTIon DelIVery: IT’S eVolVIng role 310
Information and IT: Why Now? 311
Delivering Value Through Information 312
Effective Information Delivery 316
New Information Skills 316
New Information Roles 317
New Information Practices 317
xii Contents
New Information Strategies 318
The Future of Information Delivery 319
Conclusion 321 • References 322
MInI CaSeS
Project Management at MM 324
Working Smarter at Continental Furniture International 328
Managing Technology at Genex Fuels 333
Index 336
PREFACE
Today, with information technology (IT) driving constant
business transformation,
overwhelming organizations with information, enabling 24/7
global operations, and
undermining traditional business models, the challenge for
business leaders is not
simply to manage IT, it is to use IT to deliver business value.
Whereas until fairly recently,
decisions about IT could be safely delegated to technology
specialists after a business
strategy had been developed, IT is now so closely integrated
with business that, as one
CIO explained to us, “We can no longer deliver business
solutions in our company
without using technology so IT and business strategy must
constantly interact with
each other.”
What’s New in This Third Edition?
• Six new chapters focusing on current critical
issues in IT management, including
IT shared services; big data and social computing; business
intelligence; manag-
ing IT demand; improving the customer experience; and
enhancing development
productivity.
• Two significantly revised chapters: on delivering
IT functions through different
resourcing options; and innovating with IT.
• Twonew mini cases based on real companies
and real IT management situations:
Working Smarter at Continental Furniture and Enterprise
Architecture at Nationstate
Insurance.
• A revised structure based on reader
feedback with six chapters and two mini cases
from the second edition being moved to the Web site.
All too often, in our efforts to prepare future executives to deal
effectively with
the issues of IT strategy and management, we lead them into a
foreign country where
they encounter a different language, different culture, and
different customs. Acronyms
(e.g., SOA, FTP/IP, SDLC, ITIL, ERP), buzzwords (e.g.,
asymmetric encryption, proxy
servers, agile, enterprise service bus), and the widely adopted
practice of abstraction
(e.g., Is a software monitor a person, place, or thing?) present
formidable “barriers to
entry” to the technologically uninitiated, but more important,
they obscure the impor-
tance of teaching students how to make business decisions about
a key organizational
resource. By taking a critical issues perspective, IT Strategy:
Issues and Practices treats IT
as a tool to be leveraged to save and/or make money or
transform an organization—not
as a study by itself.
As in the first two editions of this book, this third edition
combines the experi-
ences and insights of many senior IT managers from leading-
edge organizations with
thorough academic research to bring important issues in IT
management to life and
demonstrate how IT strategy is put into action in contemporary
businesses. This new
edition has been designed around an enhanced set of critical
real-world issues in IT
management today, such as innovating with IT, working with
big data and social media,
xiii
xiv Preface
enhancing customer experience, and designing for business
intelligence and introduces
students to the challenges of making IT decisions that will have
significant impacts on
how businesses function and deliver value to stakeholders.
IT Strategy: Issues and Practices focuses on how IT is changing
and will continue to
change organizations as we now know them. However, rather
than learning concepts
“free of context,” students are introduced to the complex
decisions facing real organi-
zations by means of a number of mini cases. These provide an
opportunity to apply
the models/theories/frameworks presented and help students
integrate and assimilate
this material. By the end of the book, students will have the
confidence and ability to
tackle the tough issues regarding IT management and strategy
and a clear understand-
ing of their importance in delivering business value.
Key Features of This Book
• A focus on IT management issues as opposed to
technology issues
• Critical IT issues explored within their
organizational contexts
• Readily applicablemodels and frameworks for
implementing IT strategies
• Mini cases to animate issues and focus
classroom discussions on real-world deci-
sions, enabling problem-based learning
• Proven strategies and best practices from leading-edge
organizations
• Useful and practical advice and guidelinesfor
delivering value with IT
• Extensive teaching notes for all mini cases
A Different ApproAch to teAching it StrAtegy
The real world of IT is one of issues—critical issues—such as
the following:
• How do we know if we are getting
value from our IT investment?
• How can we innovate with IT?
• What specific IT functions should we seek
from external providers?
• How do we buildan IT leadershipteam that is
a trusted partner with the business?
• How do we enhance IT capabilities?
• What is IT’s role in creating an intelligent
business?
• How can we best take advantage of new
technologies, such as big data and social
media, in our business?
• How can we manage IT risk?
However, the majority of management information systems
(MIS) textbooks are orga-
nized by system category (e.g., supply chain, customer
relationship management, enterprise
resource planning), by system component (e.g., hardware,
software, networks), by system
function (e.g., marketing, financial, human resources), by
system type (e.g., transactional,
decisional, strategic), or by a combination of these.
Unfortunately, such an organization
does not promote an understanding of IT management in
practice.
IT Strategy: Issues and Practices tackles the real-world
challenges of IT manage-
ment. First, it explores a set of the most important issues facing
IT managers today, and
second, it provides a series of mini cases that present these
critical IT issues within the
context of real organizations. By focusing the text as well as the
mini cases on today’s
critical issues, the book naturally reinforces problem-based
learning.
Preface xv
IT Strategy: Issues and Practices includes thirteen mini cases—
each based on a real
company presented anonymously.1 Mini cases are not simply
abbreviated versions of
standard, full-length business cases. They differ in two
significant ways:
1. A horizontal perspective. Unlike standard cases that develop
a single issue within
an organizational setting (i.e., a “vertical” slice of
organizational life), mini cases
take a “horizontal” slice through a number of coexistent issues.
Rather than looking
for a solution to a specific problem, as in a standard case,
students analyzing a mini
case must first identify and prioritize the issues embedded
within the case. This mim-
ics real life in organizations where the challenge lies in
“knowing where to start” as
opposed to “solving a predefined problem.”
2. Highly relevant information. Mini cases are densely written.
Unlike standard
cases, which intermix irrelevant information, in a mini case,
each sentence exists for
a reason and reflects relevant information. As a result, students
must analyze each
case very carefully so as not to miss critical aspects of the
situation.
Teaching with mini cases is, thus, very different than teaching
with standard cases.
With mini cases, students must determine what is really going
on within the organiza-
tion. What first appears as a straightforward “technology”
problem may in fact be a
political problem or one of five other “technology” problems.
Detective work is, there-
fore, required. The problem identification and prioritization
skills needed are essential
skills for future managers to learn for the simple reason that it
is not possible for organi-
zations to tackle all of their problems concurrently. Mini cases
help teach these skills to
students and can balance the problem-solving skills learned in
other classes. Best of all,
detective work is fun and promotes lively classroom discussion.
To assist instructors, extensive teaching notes are available for
all mini cases. Developed
by the authors and based on “tried and true” in-class experience,
these notes include case
summaries, identify the key issues within each case, present
ancillary information about the
company/industry represented in the case, and offer guidelines
for organizing the class-
room discussion. Because of the structure of these mini cases
and their embedded issues, it
is common for teaching notes to exceed the length of the actual
mini case!
This book is most appropriate for MIS courses where the goal is
to understand how
IT delivers organizational value. These courses are frequently
labeled “IT Strategy” or
“IT Management” and are offered within undergraduate as well
as MBA programs. For
undergraduate juniors and seniors in business and commerce
programs, this is usually
the “capstone” MIS course. For MBA students, this course may
be the compulsory core
course in MIS, or it may be an elective course.
Each chapter and mini case in this book has been thoroughly
tested in a variety
of undergraduate, graduate, and executive programs at Queen’s
School of Business.2
1 We are unable to identify these leading-edge companies by
agreements established as part of our overall
research program (described later).
2 Queen’s School of Business is one of the world’s premier
business schools, with a faculty team renowned
for its business experience and academic credentials. The
School has earned international recognition for
its innovative approaches to team-based and experiential
learning. In addition to its highly acclaimed MBA
programs, Queen’s School of Business is also home to Canada’s
most prestigious undergraduate business
program and several outstanding graduate programs. As well,
the School is one of the world’s largest and
most respected providers of executive education.
xvi Preface
These materials have proven highly successful within all
programs because we adapt
how the material is presented according to the level of the
students. Whereas under-
graduate students “learn” about critical business issues from the
book and mini cases
for the first time, graduate students are able to “relate” to these
same critical issues
based on their previous business experience. As a result,
graduate students are able to
introduce personal experiences into the discussion of these
critical IT issues.
orgAnizAtion of thiS Book
One of the advantages of an issues-focused structure is that
chapters can be approached
in any order because they do not build on one another. Chapter
order is immaterial; that
is, one does not need to read the first three chapters to
understand the fourth. This pro-
vides an instructor with maximum flexibility to organize a
course as he or she sees fit.
Thus, within different courses/programs, the order of topics can
be changed to focus on
different IT concepts.
Furthermore, because each mini case includes multiple issues,
they, too, can be
used to serve different purposes. For example, the mini case
“Building Shared Services
at RR Communications” can be used to focus on issues of
governance, organizational
structure, and/or change management just as easily as shared
services. The result is a
rich set of instructional materials that lends itself well to a
variety of pedagogical appli-
cations, particularly problem-based learning, and that clearly
illustrates the reality of IT
strategy in action.
The book is organized into four sections, each emphasizing a
key component of
developing and delivering effective IT strategy:
• Section I: Delivering Value with IT is designed to
examine the complex ways that
IT and business value are related. Over the past twenty years,
researchers and prac-
titioners have come to understand that “business value” can
mean many different
things when applied to IT. Chapter 1 (Developing and
Delivering on the IT Value
Proposition) explores these concepts in depth. Unlike the
simplistic value propo-
sitions often used when implementing IT in organizations, this
chapter presents
“value” as a multilayered business construct that must be
effectively managed at
several levels if technology is to achieve the benefits expected.
Chapter 2 (Developing
IT Strategy for Business Value) examines the dynamic
interrelationship between
business and IT strategy and looks at the processes and critical
success factors
used by organizations to ensure that both are well aligned.
Chapter 3 (Linking IT
to Business Metrics) discusses new ways of measuring IT’s
effectiveness that pro-
mote closer business–IT alignment and help drive greater
business value. Chapter
4 (Building a Strong Relationship with the Business) examines
the nature of the
business–IT relationship and the characteristics of an effective
relationship that
delivers real value to the enterprise. Chapter 5 (Communicating
with Business
Managers) explores the business and interpersonal competencies
that IT staff will
need in order to do their jobs effectively over the next five to
seven years and what
companies should be doing to develop them. Finally, Chapter 6
(Building Better IT
Leaders from the Bottom Up) tackles the increasing need for
improved leadership
skills in all IT staff and examines the expectations of the
business for strategic and
innovative guidance from IT.
Preface xvii
In the mini cases associated with this section, the concepts of
delivering
value with IT are explored in a number of different ways. We
see business and
IT executives at Hefty Hardware grappling with conflicting
priorities and per-
spectives and how best to work together to achieve the
company’s strategy. In
“Investing in TUFS,” CIO Martin Drysdale watches as all of the
work his IT depart-
ment has put into a major new system fails to deliver value. And
the “IT Planning
at ModMeters” mini case follows CIO Brian Smith’s efforts to
create a strategic
IT plan that will align with business strategy, keep IT running,
and not increase
IT’s budget.
• Section II: IT Governance explores key concepts in how
the IT organization is
structured and managed to effectively deliver IT products and
services to the orga-
nization. Chapter 7 (IT Shared Services) discusses how IT
shared services should be
selected, organized, managed, and governed to achieve
improved organizational
performance. Chapter 8 (A Management Framework for IT
Sourcing) examines
how organizations are choosing to source and deliver different
types of IT functions
and presents a framework to guide sourcing decisions. Chapter 9
(The IT Budgeting
Process) describes the “evil twin” of IT strategy, discussing
how budgeting mecha-
nisms can significantly undermine effective business strategies
and suggesting
practices for addressing this problem while maintaining
traditional fiscal account-
ability. Chapter 10 (Managing IT-based Risk) describes how
many IT organizations
have been given the responsibility of not only managing risk in
their own activities
(i.e., project development, operations, and delivering business
strategy) but also
of managing IT-based risk in all company activities (e.g.,
mobile computing, file
sharing, and online access to information and software) and the
need for a holistic
framework to understand and deal with risk effectively. Chapter
11 (Information
Management: The Nexus of Business and IT) describes how new
organizational
needs for more useful and integrated information are driving the
development of
business-oriented functions within IT that focus specifically on
information and
knowledge, as opposed to applications and data.
The mini cases in this section examine the difficulties of
managing com-
plex IT issues when they intersect substantially with important
business issues.
In “Building Shared Services at RR Communications,” we see
an IT organiza-
tion in transition from a traditional divisional structure and
governance model
to a more centralized enterprise model, and the long-term
challenges experi-
enced by CIO Vince Patton in changing both business and IT
practices, includ-
ing information management and delivery, to support this new
approach. In
“Enterprise Architecture at Nationstate Insurance,” CIO Jane
Denton endeavors
to make IT more flexible and agile, while incorporating new and
emerging tech-
nologies into its strategy. In “IT Investment at North American
Financial,” we
show the opportunities and challenges involved in prioritizing
and resourcing
enterprisewide IT projects and monitoring that anticipated
benefits are being
achieved.
• Section III: IT-Enabled Innovation discusses some of the
ways technology is
being used to transform organizations. Chapter 12 (Innovation
with IT) examines
the nature and importance of innovation with IT and describes a
typical inno-
vation life cycle. Chapter 13 (Big Data and Social Computing)
discusses how IT
leaders are incorporating big data and social media concepts and
technologies
xviii Preface
to successfully deliver business value in new ways. Chapter 14
(Improving the
Customer Experience: An IT Perspective) explores the IT
function’s role in creating
and improving an …
TOPIC : Interventions to improve nutritional status: What type
of interventions improve adherence to recommendations on
nutritional intake?
Example Study:
· Interventions to enhance adherence to dietary advice for
preventing and managing chronic diseases in adults.
WRITTEN ASSIGNMENT:
· Read the study and answer the required questions for each
category
· Must write the paper using provided Summary Paper Format
on page #3.
· Grading Rubric/Description on page 4-5
ATI #3: Skills Module Contents: Summary Paper Format
· Bold for each Heading and Subheading
· Include in-text citations for all information/contents as needed
· Summary paper MUST be written in this format
Introduction and Key Points
Define the Topic and Question
· How do you interpret and/or understand the topic and question
you selected?
Overview/Significance of Problem
· Describe Overview and Significance of Problem of the topic
and question you selected
· Include in-text citations
Article Search
Current and credible resources: List Chamberlain library
Database(s) used
Database search-terms and methods
Number of articles located
List additional sources outside of ATI module: List all sources
you used for article search outside of ATI (CDC, American
Diabetic Association, etc.)
Article Findings
Why this article chosen?
How it addresses the topic? State the “Purpose/Aim of Study”
as the author stated in article
Type of Research conducted:
· Quantitative, Qualitative, Descriptive, or Mixed-Method
study?
· Briefly describe what was done (sample, methods,
measurement tools used)
Findings of Research: Comprehensively describe ALL Findings
in the article.
Evidence for Practice
Summary of Evidence
· Briefly summarize the overall purpose and findings.
How will this evidence improve current practice?
· Briefly describe what the current practice is.
· Describe how this evidence improve current practice?
How will this evidence decrease a gap in current practice?
· Briefly describe difference between the current knowledge,
skills, competence, practice, performance or patient outcomes
and the ideal or desirable state
· Describe how this evidence decrease a gap in the practice?
Any concerns or weaknesses in the evidence/finding? (Found in
Discussion)
Sharing of Evidence
Who would you share the information with? (colleagues, other
disciplines, patients, families)
How would you share this information? (in-services, health fair
for patients, educate healthcare professionals)
What resources would you need to accomplish this sharing of
evidence?
· List resources you may need for sharing the evidence as you
stated in above 2 questions (who and how) (i.e. administrator,
manager, support for materials….etc.)
Why would it be important to share this evidence with the
nursing profession?
Conclusion
· Summarizes the Theme of Paper, Findings, and Key points.
· Do NOT include Conclusion/Implication on the article

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Understanding the nutrition care needs of patients newly diagn.docx

  • 1. Understanding the nutrition care needs of patients newly diagnosed with type 2 diabetes: a need for open communication and patient-focussed consultations Lauren BallA,C, Ruth DavmorA, Michael LeverittB, Ben DesbrowA, Carolyn EhrlichA and Wendy ChaboyerA AMenzies Health Institute Queensland, Griffith University, Gold Coast 4222, Qld, Australia. BSchool of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane 4072, Qld, Australia. CCorresponding author. Email: [email protected] Abstract. Patients who are newly diagnosed with type 2 diabetes mellitus (T2DM) commonly attempt to modify their dietary intake after receiving nutrition care from primary health professionals. Yet, adherence to dietary recommendations is rarely sustained and factors influencing adherence are poorly understood. This study exploredT2DMpatients’ experiences of dietary change and their views on how primary health professionals can best support long-term maintenance of dietary change.Apurposive sample of 10 individuals recently diagnosedwithT2DMparticipated in three individual semi- structured qualitative telephone interviews: at baseline, then at 3 and 6 months after recruitment. Interview questions were modified from the initial interview inorder to investigate emergingfindings.A two-step data analysis process occurred
  • 2. throughcontent analysis of individual interviews andmeta-synthesis of findings over time. Participants initiallymadewide-ranging attempts to improve dietary behaviours, butmost experienced negative emotions from the restraint required tomaintain a healthy diet. Participants felt confused by the conflicting advice received from health professionals and other sources such as friends, family, internet and diabetes organisations. Participants frequently reported feeling rushed and not heard in consultations, resulting in limited ongoing engagement with primary healthcare services. These findings suggest that there is opportunity for primary health professionals to enhance the dietary support provided to patients by: acknowledging the challenges of sustained improvements in dietary intake; open communication; and investing in patient relationships through more patient-focussed consultations. Additional keywords: chronic disease, general practice, primary care, nutrition therapy, nutritional management. Received 28 April 2015, accepted 18 August 2015, published online 5 October 2015 Introduction Type 2 diabetes mellitus (T2DM) is a lifestyle-related chronic disease and leading cause of morbidity andmortality in Australia (Australian Institute of Health andWelfare 2007). Over 5%of the Australian population has been diagnosed with T2DM, and an additional 0.9% is predicted to be diagnosed annually (Australian Bureau of Statistics (ABS) 2012). T2DM is typically diagnosed
  • 3. and managed in the primary healthcare setting, and patients with T2DM receive health care from a variety of primary health professionals (Diabetes Australia 2012). Importantly, the health outcomes of patients with T2DM are influenced by their dietary intake (Coppell et al. 2010). Therefore, facilitating patients to have a healthy dietary intake is a key component of T2DM management (Diabetes Australia, Royal Australian College of General Practitioners (RACGP) 2008; National Health and Hospitals Reform Commission 2009). Patients who are newly diagnosed with T2DM commonly attempt to modify their dietary intake after receiving nutrition care from primary health professionals (Castro-Sánchez and Avila-Ortiz 2013). In the first 6 months after diagnosis, patients often experience changes to their enjoyment of food while trying to follow a recommended diet, and most report only temporarily adherence to dietary recommendations (Castro-Sánchez and Avila-Ortiz 2013). The United Kingdom Prospective Diabetes Study was the largest clinical research study into diabetes management (n = 3867 participants), and has shown that establishing short-term optimal glycaemic control in the early stages after diagnosis reduces the risk of macro- and micro- vascular complications, as well as all-cause mortality 10 years after diagnosis (Murray et al.2010).Given the influenceofdietary intake on glycaemic control of patientswith T2DM, investigating ways to further support patients to maintain healthy dietary behaviours in the early stages after diagnosis is important. Exploring patients’ experiences and perceptions is crucial to understanding how to provide patient-centred care. Patient- centred care is an approach to health care that meets the specific
  • 4. Journal compilation � La Trobe University 2016 www.publish.csiro.au/journals/py CSIRO PUBLISHING Australian Journal of Primary Health, 2016, 22, 416–422 Research http://dx.doi.org/10.1071/PY15063 mailto:[email protected] needs, values and beliefs of patients (McMillan et al. 2013) and is regarded as imperative to the optimal management of chronic disease, including T2DM (Holman and Lorig 2000). Many primary health professionals, such as GPs, practice nurses and dietitians, report providing ‘nutrition care’ to patients, referring to anypractice conducted to support patients to improve their dietary intake (Ball et al. 2010; Ball et al. 2012). Recent investigations into the nutrition care provided by primary health professionals indicate that patient-centred care is not always achieved, and this may be hindering the efficacy of nutrition care for chronic disease management (Ball et al. 2012; Ball et al. 2013; Ball et al. 2014). Given the importance of optimal dietary intake in T2DM self- management, it is necessary for primary health professionals to better understand the experiences, challenges and needs of patients attempting to improve their dietary behaviours in order to provide effective patient-centred nutrition care. The aim of this study was to examine the perceptions of patientswho have been recently diagnosedwith T2DMregarding
  • 5. nutrition care provided by primary healthcare professionals. Specifically, the study explored patients’ experience of dietary change and their views on how primary health professionals could best support long-termmaintenance of dietary change. This understanding can be used to facilitate health professionals to provide nutrition care that addresses the needs and experiences of patients. Methods This study utilised a longitudinal, qualitative design to describe the perceptions and experiences of patients who have recently been diagnosed with T2DM. The study was approved by the Griffith University Human Research Ethics Committee (reference number PBH/09/14/HREC). Participant recruitment A purposive sample of individuals with T2DM (<4 months since diagnosis) was recruited via e-newsletters and social media pages of Diabetes Australia, and state branches of Diabetes New SouthWales,DiabetesQueensland,Diabetes SouthAustralia and Diabetes Tasmania. The sampling strategy aimed to recruit a combination of male and female, young and old, employed and unemployed/retired participants. Potential participants who contacted the research team were provided with a plain language information sheet, before being asked to provide consent and attend an initial interview. Data collection Each participant was involved in three individual semi- structured
  • 6. telephone interviews; at baseline, and then at 3 and 6months after recruitment into the study.A semi-structured interviewguidewas developed for each round of interviews. Interviews included questions such as: ‘How has your recent diagnosis influenced your feelings about food?’; ‘Describe your interactions with health professionals regarding food and healthy eating’; and ‘At this moment, how could health professionals be most helpful in supporting you in healthy eating?’ Elaboration probing, clarification probing and attention probing were utilised to gain a deeper understanding of the participants’ perceptions (Liamputtong 2010). Interview questions were modified from the initial interview in order to investigate emerging findings (Thomson and Holland 2003). All interviewswere conducted by one investigator (RD), were 30–60min in length and were digitally recorded and transcribed verbatim. Immediately after each interview, an entrywasmade in a reflective journal that outlined the impressions of the interview. Data collection and analysis were conducted concurrently; recruitment and data collection continued until data saturation was considered to have been achieved. In practical terms, saturation was considered to have been reached when no new responses and subsequent preliminary categoriesweredetectedas interviews progressed (Strauss and Corbin 2007). Data analysis A two-step data analysis process was used for this study. First, content analysis was used to analyse the verbatim transcripts because it allows an in-depth understanding of the participants’ nutrition care needs (Graneheim and Lundman 2004; Hsieh and Shannon 2005). Analysis of verbatim transcripts involved an iterative process of reading the transcripts to become familiar with the data, generating initial subcategories, searching for
  • 7. categories, reviewing the categories and, finally, labelling the categories (Graneheim and Lundman 2004; Hsieh and Shannon 2005). Triangular analysis was conducted by two investigators (LB andRD), who independently generated initial subcategories, and then compared and discussed to reach agreement. Second, a meta-synthesis approach was undertaken to synthesise and interpret the data across the three time points (Sandelowski and Barroso 2007). The process involved extracting the subcategories and interpreting them in order to identify higher order categories that transcend findings from each period. Regular meetings were held with the whole research team in which emerging findings were critically reviewed, ensuring that the identified and defined subcategories accurately reflected the data for transferability and credibility. Results Ten individuals participated in the study, each completing three interviews. The participants consisted of three males and seven females, and their ages ranged from 27 to 74 years. A summary of the three categories and subcategories that emerged from the analysis are displayed in Table 1. What is known about the topic? * Patients newly diagnosed with type 2 diabetes commonly attempt to modify their dietary intake after receiving nutrition-related care. Adherence to dietary recommendations is rarely sustained and factors influencing adherence are poorly understood.
  • 8. What does this paper add? * The results suggest that there is opportunity to enhance the dietary support provided to patients by investing in patient relationships through more patient-focussed consultations and open communication. Nutrition care for type 2 diabetes mellitus Australian Journal of Primary Health 417 Adjusting to diagnosis The first category encompassed the impact of being diagnosed with T2DM on participants’ perceptions about the food they eat and their broader dietary intake. The adjustment process involved considerable emotional adaptation, which occurred at different rates among participants. Initially, participants reported feeling shocked and surprised at being diagnosed with T2DM. Most considered their usual dietary intake to be healthy, and this added to the challengeof coming to termswith having a long- termhealth condition: I’ve always considered [that] we ate healthy . . . It never entered my mind that I would have sugar diabetes. (Participant 7, Interview 1) The diagnosis of T2DM appeared to have an immediate negative impact on participants’ views about dietary intake in general, particularly in social situations when others reacted to the news: All the sad faces, they say, ‘Oh, you’ve got diabetes.’
  • 9. People are now scared to cook for me. It’s actually intimidated them to think they can’t actually cook normal food. (Participant 8, Interview 1) Three and six months after the initial interview, participants began to adapt to the diagnosis of T2DM, generally moving on from the initial shock and feelingmore in control, as the following statements from the same participant in successive interviews demonstrate: I keep saying tomyself, ‘I’mnot depressed, I’mnot allowed to be depressed.’ I got so depressedwhen I was diagnosed, of course, and I don’t feel quite as black as that, but I don’t feel that I’m in control of myself at the moment, either. (Participant 7, Interview 2) I’ve accepted it now, and just have a little swear and curse every now and then. It’s been a little bit easier lately, I’m handling it better. (Participant 7, Interview 3) After adjusting to thediagnosis, participantswantedcontinued improvement in their management of T2DM, even beyond the goals suggested by their supporting health professionals: The doctor said she was really happy with my BGL [blood glucose level] at 6.5, but I think maybe below 6 is better. I know it’s quite difficult, but I want to try anyway. (Participant 5, Interview 3) Modifying dietary behaviours The second category related to participants’ experiences of modifying their dietary behaviours in order to improve their blood glucose management and other health outcomes. These experiences ranged from logistical considerations of food
  • 10. preparation to broad emotional adaptation to having different dietary behaviours compared with before diagnosis. Initially,wide-ranging attempts to improvedietary behaviours were undertaken by participants. Participants experienced an emotional impact of restricting their diet, as well as managing ongoing changes: I’vemade somewholesale changes to theway I vieweating, what I eat and [now I pay] particular attention, like stuff like food labels . . .making sure I eat three meals a day and don’t skip meals. (Participant 2, Interview 1) As time progressed, participants had differing experiences of sustaining dietary changes, with some finding that monitoring blood sugar levels provided useful feedback on food choices: I’ve got to the stage now where I don’t think too much about the diet because . . . you’re just in the habit of eating healthy meals. I know now what I should be eating, and what are ‘sometimes’ foods. (Participant 2, Interview 2) You know you’ve eaten the right thing because the [blood sugar] reading is lower. (Participant 6, Interview 2) Table 1. Categories and subcategories emerging from the interviews Category Definition Subcategories Adjusting to diagnosis Impact of being diagnosed with T2DM on perceptions about food and dietary intake
  • 11. *Shocked and surprised at being diagnosed with T2DM *Immediate negative views about dietary intake *Beginning to move on from the initial shock of diagnosis *Wanting continued improvement beyond suggested goals Modifying dietary behaviours Patient experiences of modifying their dietary behaviours in an attempt to improve management of blood glucose levels and other health outcomes, ranging from logistical considerations of food preparation to broad emotional adaptation to eating differently to before diagnosis *Wide-ranging attempts to improve dietary behaviours *Emotional impact of restricting diet and managing ongoing changes *Differing experiences of sustaining dietary changes *Maintaining a healthy dietary intake continues to be a challenge *Monitoring blood sugar levels provides useful feedback on food choices *Feeling aware of the consequences of not eating healthy foods Receiving support from health professionals Experiences of interacting with health professionals and discussing food and dietary intake *Receiving overwhelming, conflicting nutrition information *Receiving initial directives from dietitians is challenging *Ongoing engagement with primary care services is limited
  • 12. and not highly valued *Feeling rushed and not heard in consultations 418 Australian Journal of Primary Health L. Ball et al. However, formany participants,maintaining a healthy dietary intake continued to be a challenge as time progressed, mostly because it felt restrictive: It’s a challenge . . . I’ve beenputting abitmore onmyplate, having a second serve of something . . . It’s the old habits . . . It’s not something I could maintain. (Participant 3, Interview 2) I’m getting to the point where I’m cheesed off with always having to have diabetic biscuits and other things. You get bored with them. I’m feeling I’mhaving tomake a sacrifice that other people don’t have to. (Participant 9, Interview 3) Despite the challenge of maintaining a healthy dietary intake, some participants reported feeling aware of the consequences of not eating healthy foods: I can’t see myself drifting back to eating the same way as I was, because I know what the consequences are. (Participant 2, Interview 3) Receiving support from health professionals The third category related to participants’ experiences of receiving nutrition care from health professionals. Participants’ perceptions extended beyond the content of advice provided by health professionals to broader experiences of support and
  • 13. communication in healthcare consultations. When participants were initially diagnosed with T2DM, they received an overwhelming amount of conflicting nutrition information. The information came from health professionals as well as dietary advice from friends, family, online sources and T2DM organisations: I kept finding somuch controversy it mademyhead spin . . . They say you have protein, you have carbs, and you have your veggies and stuff. Well, then you read no meat, no animal protein, none of this . . . Who is right and who is wrong? I found it confusing. (Participant 2, Interview 1) Participants found their initial interactions with dietitians to be challenging because of the direct, instructional nature of the nutrition care provided: A few days after I was diagnosed, I went to a dietitian and she laid it all out . . . I wasn’t impressed. This woman was just there to purposefully lay down a diet . . . to put me in line and show me this, that and that. (Participant 1, Interview 1) I’d had a nice lead-in with the educator and then, all of a sudden, I saw the dietitian and shewas laying down the law and I was thinking, ‘This is a bit of a turnaround!’ (Participant 2, Interview 2) Participants found that aside from the support provided by dietitians, other health professionals, aswell as family and friends and online support, were helpful on occasions: The diabetes educator . . . she handled me very well and I felt different when I came out of there . . . They put it in
  • 14. perspective, which is sort of what I needed. (Participant 2, Interview 1) There’s one lady at work, her husband has type 2 diabetes and she tells me what she does with him, so yeah, that is really good. (Participant 3, Interview 2) Overall, participants had limited ongoing engagement with primary healthcare services. This appeared to be a result of limited understanding about how the primary care system operated, and the role of different health professionals, as well as the limited value patients placed on the services provided in this setting: TheGPgavemeoneof those ‘goand seefive people a year’ diabetes plans but I haven’t organised any of it . . . It’s not a big deal, it’s just something I probably need to tick off to keep everybody happy and then I can relax again for another year. (Participant 8, Interview 2) I didn’t quite understand what diabetes educators did or the dietitians. (Participant 2, Interview 2) Most participants thought that the support provided by primary health professionals had considerable room for improvement because they felt rushedandnotheard inconsultations, andbecause open communication was not always achieved: They get you in there, they tell you you’ve got type 2 and you’ve got to make these changes, and it always feels like [they’re in] a rush to finish with you and get you out the back door and start with a new case. (Participant 2, Interview 3) You’re talking to someone and they go, ‘Your half hour’s
  • 15. up, I’ve got another patient waiting’. Nobody has got the time to sit and take the time to talk. I find that very frustrating and annoying. You just start to say something and then you’ve got to leave.’ (Participant 1, Interview 3) Differences in accommodating new dietary behaviours The collective experiences of participants over time suggest that individuals have different experiences in accommodating new dietary behaviours after being diagnosed with T2DM. The experiences of participants in this study appeared to be influenced by contextual conditions such as immediate family support and responsibilities, confidence in existing food knowledge, and familiarity with health professionals and the healthcare system. Three archetypical experiences were apparent in this study. First, some individuals appeared to take a factual and directive approach to adjusting to their diagnosis and modifying their dietary behaviours. In order to achieve this, they preferred clear instructions from health professionals and felt most comfortable eating in accordance with a predetermined plan. Positive feedback from continued healthy eating (such as improved blood glucose management and weight loss) outweighed the negative emotions felt from being restricted in their food choices, and this motivated continued adherence to the point of sustained improvement in dietary behaviours. Second, some individuals appeared to take an adaptive approach to adjusting to their diagnosis, modifying their dietary behaviours and seeking support from health professionals. The initial shock of diagnosis reduced their confidence in making dietary choices, and they placed considerable importance on
  • 16. Nutrition care for type 2 diabetes mellitus Australian Journal of Primary Health 419 guidance from health professionals and other sources of dietary information (such as family, friends, internet and diabetes organisations). Early improvements in dietary intake were not considered sustainable because of the negative emotional impact dietary restrictions had on their quality of life. However, over time, adjustments to dietary intake that were considered reasonable and achievable were made. These individuals perceived themselves as having made general improvements in their dietary behaviours that had positive impacts on blood glucose management and other health outcomes. However, these individuals also experienced regular occasions of making food choices that were not viewed as ideal, and risked having a poor dietary intake over time. Third, some individuals experienced persistent negative emotions after diagnosis and did not makemeaningful adaptations to their dietary behaviours over time. These individuals felt overwhelmed by the conflicting information received from health professionals and other sources of dietary information, which caused them to withdraw from the experience of making dietary choices and receiving support. Improvements in blood glucose management and other health outcomes appeared to be a result of undereating and avoiding social eating situations, which was not identified in consultations with health professionals. These individuals perceived themselves as requiring considerably more support thanwhat they feltwas available, andwere frustratedby the
  • 17. lack of immediate success when following guidelines provided by primary health professionals. Discussion This study contributes new information on patients’ experiences of dietary change after being diagnosed with T2DM and their views on howprimary health professionals can best support long- term maintenance of dietary change. Participants’ insights resulted in the generation of three categories: adjusting to diagnosis, modifying dietary behaviours and receiving support from health professionals. This information is important because of the relationship that exists between healthcare experiences, chronic disease self-management practices (including dietary behaviours) and healthcare outcomes (Sequist et al. 2012). Participants in this study experienced challenges in adjusting to their recent diagnosis of T2DM; this had a direct negative impact on their views about their dietary intake. Being diagnosed with T2DM is recognised as a particularly alarming and emotional time for patients because it is viewed as a transformation point from a healthy person to one who is aware, frightened and sometimes embarrassed by having a long-term health condition (Histock et al. 2001; Hillson 2014). The impact of thediagnosis onparticipants’ attitude to foodwas considerable, including reduced confidence in what to eat, reduced enjoyment of eating, and feeling uncomfortable eatingwith others, including family, peers and friends. These factors have the potential to influence the effectiveness of nutrition care provided by primary health professionals, and health professionals should be aware
  • 18. of this when providing nutrition care to patients. Previous studies investigating dietary changes after diagnosis with T2DM report that following initial dietary changes, patients often move into an accommodation-adaptation phase regarding their dietary intake (Castro-Sánchez and Avila-Ortiz 2013). However, this finding was not apparent in all participants in the current study, even6months after recruitment into the study (up to 10 months after diagnosis). While some participants did report positive perceptions about their dietary intake as time progressed, many participants continued to experience negative emotions as a result of the restraint required to maintain a healthy diet, and the conflict between diet-related social activities and necessary self-management behaviours. The three archetypical experiences apparent in this study and the individual timelines in which participants adjusted to changes in dietary intake highlight the importance of flexible and tailored support for patients in the months after diagnosis. Participants in this study reported that they have received an overwhelming amount of contradictory nutrition information from health professionals and other sources. A recent survey of Australian adults who self-identified as needing to improve their dietary behaviours suggested that nutrition information sources perceived as most trustworthy, credible and effective included dietitians, nutritionists and GPs, but the most frequently utilised sources were the internet, friends, family and magazines (Cash et al. 2014). The use of family as a source of information aligns with family systems theory, which conceptualises families as a
  • 19. system of interrelated parts that influence each other and contribute to the growth or detriment of others (Bowen 1966). Further, the participants in the current study reported limited ongoing engagement with health professionals such as dietitians and GPs, despite these sources being described in the recent survey as the most trusted, credible and effective (Cash et al. 2014). Further understanding about how patients decide which nutrition information sources to use is clearly required. The support provided by primary health professionals to the participants in this study was generally reported as requiring significant improvement. Interestingly, the factors that weremost influential in patients’ experiences of receiving nutrition care appeared to be open communication, not feeling rushed andbeing genuinely supported, rather than any specific nutrition advice or approach. This appeared to be important for all participants but particularly those who experienced persistent negative emotions after diagnosis. Open communication and genuine support are considered critical for building relationships with patients with T2DM, and the way this is displayed is influenced by a health professional’s own personality and the emotions they are experiencing (Kowitt et al. 2015). Similar factors that influence patients’ experiences of health care have been identified in other Australian population groups, such as new mothers, whose perceptions of their healthcare quality were reduced when they felt unsupported and hurried in consultations (Corr et al. 2015). Collectively, this suggests that primary health professionals could enhance the delivery of their care by investing in patient relationships through longer, more patient-focussed consultations and open communication. Study participants described situations in which health
  • 20. professionals provided nutrition care that did not meet their needs. FacilitatingAustralian primary healthcare professionals to provide nutrition care in a patient-centred manner is important to optimise self-management of T2DM and reduce the risk of complications. It has been suggested that compassion fatigue – a gradual lessening of compassion over time as a result of being regularly exposed to patients’problems– is occurring amongGPs 420 Australian Journal of Primary Health L. Ball et al. and other primary health professionals in Australia (Shrestha and Joyce 2011). This lack of empathy from health professionals has been associated with significantly increased metabolic complications in patients with T2DM (Canale et al. 2012). Given this association, strategies to reduce compassion fatigue and subsequently enhance patient-centred care appear to … IT STraTegy: ISSueS and PracTIceS This page intentionally left blank
  • 21. IT STraTegy: ISSueS and PracTIceS T h i r d E d i t i o n James D. McKeen Queen’s University Heather A. Smith Queen’s University Boston Columbus Indianapolis New York San Francisco Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montréal Toronto Delhi Mexico City São Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo Editor in Chief: Stephanie Wall Acquisitions Editor: Nicole Sam Program Manager Team Lead: Ashley Santora Program Manager: Denise Vaughn Editorial Assistant: Kaylee Rotella Executive Marketing Manager: Anne K. Fahlgren Project Manager Team Lead: Judy Leale Project Manager: Thomas Benfatti Procurement Specialist: Diane Peirano Cover Designer: Lumina Datamantics Full Service Project Management: Abinaya Rajendran at Integra Software Services, Pvt. Ltd. Cover Printer: Courier/Westford Composition: Integra Software Services, Pvt. Ltd. Printer/Binder: Courier/Westford
  • 22. Text Font: 10/12 Palatino LT Std Credits and acknowledgments borrowed from other sources and reproduced, with permission, in this textbook appear on appropriate page within text. Copyright © 2015, 2012 and 2009 by Pearson Education, Inc., Upper Saddle River, New Jersey, 07458. Pearson Prentice Hall. All rights reserved. Printed in the United States of America. This publication is protected by Copyright and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or likewise. For information regarding permission(s), write to: Rights and Permissions Department. Library of Congress Cataloging-in-Publication Data McKeen, James D. IT strategy: issues and practices/James D. McKeen, Queen’s University, Heather A. Smith, Queen’s University.—Third edition. pages cm ISBN 978-0-13-354424-4 (alk. paper) ISBN 0-13-354424-9 (alk. paper) 1. Information technology—Management. I. Smith, Heather A. II. Title. HD30.2.M3987 2015 004.068—dc23 2014017950 ISBN–10: 0-13-354424-9 ISBN–13: 978-0-13-354424-4 10 9 8 7 6 5 4 3 2 1
  • 23. CoNTENTS Preface xiii About the Authors xxi Acknowledgments xxii Section I Delivering Value with IT 1 Chapter 1 DeVelopIng anD DelIVerIng on The IT Value propoSITIon 2 Peeling the Onion: Understanding IT Value 3 What Is IT Value? 3 Where Is IT Value? 4 Who Delivers IT Value? 5 When Is IT Value Realized? 5 The Three Components of the IT Value Proposition 6 Identification of Potential Value 7 Effective Conversion 8 Realizing Value 9 Five Principles for Delivering Value 10 Principle 1. Have a Clearly Defined Portfolio Value Management Process 11
  • 24. Principle 2. Aim for Chunks of Value 11 Principle 3. Adopt a Holistic Orientation to Technology Value 11 Principle 4. Aim for Joint Ownership of Technology Initiatives 12 Principle 5. Experiment More Often 12 Conclusion 12 • References 13 Chapter 2 DeVelopIng IT STraTegy for BuSIneSS Value 15 Business and IT Strategies: Past, Present, and Future 16 Four Critical Success Factors 18 The Many Dimensions of IT Strategy 20 Toward an IT Strategy-Development Process 22 Challenges for CIOs 23 Conclusion 25 • References 25 Chapter 3 lInkIng IT To BuSIneSS MeTrICS 27 Business Measurement: An Overview 28 Key Business Metrics for IT 30 v vi Contents Designing Business Metrics for IT 31
  • 25. Advice to Managers 35 Conclusion 36 • References 36 Chapter 4 BuIlDIng a STrong relaTIonShIp wITh The BuSIneSS 38 The Nature of the Business–IT Relationship 39 The Foundation of a Strong Business–IT Relationship 41 Building Block #1: Competence 42 Building Block #2: Credibility 43 Building Block #3: Interpersonal Interaction 44 Building Block #4: Trust 46 Conclusion 48 • References 48 Appendix A The Five IT Value Profiles 50 Appendix B Guidelines for Building a Strong Business–IT Relationship 51 Chapter 5 CoMMunICaTIng wITh BuSIneSS ManagerS 52 Communication in the Business–IT Relationship 53 What Is “Good” Communication? 54 Obstacles to Effective Communication 56 “T-Level” Communication Skills for IT Staff 58 Improving Business–IT Communication 60 Conclusion 61 • References 61
  • 26. Appendix A IT Communication Competencies 63 Chapter 6 BuIlDIng BeTTer IT leaDerS froM The BoTToM up 64 The Changing Role of the IT Leader 65 What Makes a Good IT Leader? 67 How to Build Better IT Leaders 70 Investing in Leadership Development: Articulating the Value Proposition 73 Conclusion 74 • References 75 MInI CaSeS Delivering Business Value with IT at Hefty Hardware 76 Investing in TUFS 80 IT Planning at ModMeters 82 Contents vii Section II IT governance 87 Chapter 7 CreaTIng IT ShareD SerVICeS 88 IT Shared Services: An Overview 89 IT Shared Services: Pros and Cons 92 IT Shared Services: Key Organizational Success Factors 93 Identifying Candidate Services 94
  • 27. An Integrated Model of IT Shared Services 95 Recommmendations for Creating Effective IT Shared Services 96 Conclusion 99 • References 99 Chapter 8 a ManageMenT fraMework for IT SourCIng 100 A Maturity Model for IT Functions 101 IT Sourcing Options: Theory Versus Practice 105 The “Real” Decision Criteria 109 Decision Criterion #1: Flexibility 109 Decision Criterion #2: Control 109 Decision Criterion #3: Knowledge Enhancement 110 Decision Criterion #4: Business Exigency 110 A Decision Framework for Sourcing IT Functions 111 Identify Your Core IT Functions 111 Create a “Function Sourcing” Profile 111 Evolve Full-Time IT Personnel 113 Encourage Exploration of the Whole Range of Sourcing Options 114 Combine Sourcing Options Strategically 114
  • 28. A Management Framework for Successful Sourcing 115 Develop a Sourcing Strategy 115 Develop a Risk Mitigation Strategy 115 Develop a Governance Strategy 116 Understand the Cost Structures 116 Conclusion 117 • References 117 Chapter 9 The IT BuDgeTIng proCeSS 118 Key Concepts in IT Budgeting 119 The Importance of Budgets 121 The IT Planning and Budget Process 123 viii Contents Corporate Processes 123 IT Processes 125 Assess Actual IT Spending 126 IT Budgeting Practices That Deliver Value 127 Conclusion 128 • References 129 Chapter 10 ManagIng IT- BaSeD rISk 130 A Holistic View of IT-Based Risk 131
  • 29. Holistic Risk Management: A Portrait 134 Developing a Risk Management Framework 135 Improving Risk Management Capabilities 138 Conclusion 139 • References 140 Appendix A A Selection of Risk Classification Schemes 141 Chapter 11 InforMaTIon ManageMenT: The nexuS of BuSIneSS anD IT 142 Information Management: How Does IT Fit? 143 A Framework For IM 145 Stage One: Develop an IM Policy 145 Stage Two: Articulate the Operational Components 145 Stage Three: Establish Information Stewardship 146 Stage Four: Build Information Standards 147 Issues In IM 148 Culture and Behavior 148 Information Risk Management 149 Information Value 150 Privacy 150
  • 30. Knowledge Management 151 The Knowing–Doing Gap 151 Getting Started in IM 151 Conclusion 153 • References 154 Appendix A Elements of IM Operations 155 MInI CaSeS Building Shared Services at RR Communications 156 Enterprise Architecture at Nationstate Insurance 160 IT Investment at North American Financial 165 Contents ix Section III IT-enabled Innovation 169 Chapter 12 InnoVaTIon wITh IT 170 The Need for Innovation: An Historical Perspective 171 The Need for Innovation Now 171 Understanding Innovation 172 The Value of Innovation 174 Innovation Essentials: Motivation, Support, and Direction 175
  • 31. Challenges for IT leaders 177 Facilitating Innovation 179 Conclusion 180 • References 181 Chapter 13 BIg DaTa anD SoCIal CoMpuTIng 182 The Social Media/Big Data Opportunity 183 Delivering Business Value with Big Data 185 Innovating with Big Data 189 Pulling in Two Different Directions: The Challenge for IT Managers 190 First Steps for IT Leaders 192 Conclusion 193 • References 194 Chapter 14 IMproVIng The CuSToMer experIenCe: an IT perSpeCTIVe 195 Customer Experience and Business value 196 Many Dimensions of Customer Experience 197 The Role of Technology in Customer Experience 199 Customer Experience Essentials for IT 200 First Steps to Improving Customer Experience 203 Conclusion 204 • References 204 Chapter 15 BuIlDIng BuSIneSS InTellIgenCe 206 Understanding Business Intelligence 207 The Need for Business Intelligence 208
  • 32. The Challenge of Business Intelligence 209 The Role of IT in Business Intelligence 211 Improving Business Intelligence 213 Conclusion 216 • References 216 x Contents Chapter 16 enaBlIng CollaBoraTIon wITh IT 218 Why Collaborate? 219 Characteristics of Collaboration 222 Components of Successful Collaboration 225 The Role of IT in Collaboration 227 First Steps for Facilitating Effective Collaboration 229 Conclusion 231 • References 232 MInI CaSeS Innovation at International Foods 234 Consumerization of Technology at IFG 239 CRM at Minitrex 243 Customer Service at Datatronics 246 Section IV IT portfolio Development and Management 251 Chapter 17 applICaTIon porTfolIo ManageMenT 252 The Applications Quagmire 253
  • 33. The Benefits of a Portfolio Perspective 254 Making APM Happen 256 Capability 1: Strategy and Governance 258 Capability 2: Inventory Management 262 Capability 3: Reporting and Rationalization 263 Key Lessons Learned 264 Conclusion 265 • References 265 Appendix A Application Information 266 Chapter 18 ManagIng IT DeManD 270 Understanding IT Demand 271 The Economics of Demand Management 273 Three Tools for Demand management 273 Key Organizational Enablers for Effective Demand Management 274 Strategic Initiative Management 275 Application Portfolio Management 276 Enterprise Architecture 276 Business–IT Partnership 277 Governance and Transparency 279 Conclusion 281 • References 281
  • 34. Contents xi Chapter 19 CreaTIng anD eVolVIng a TeChnology roaDMap 283 What is a Technology Roadmap? 284 The Benefits of a Technology Roadmap 285 External Benefits (Effectiveness) 285 Internal Benefits (Efficiency) 286 Elements of the Technology Roadmap 286 Activity #1: Guiding Principles 287 Activity #2: Assess Current Technology 288 Activity #3: Analyze Gaps 289 Activity #4: Evaluate Technology Landscape 290 Activity #5: Describe Future Technology 291 Activity #6: Outline Migration Strategy 292 Activity #7: Establish Governance 292 Practical Steps for Developing a Technology Roadmap 294 Conclusion 295 • References 295
  • 35. Appendix A Principles to Guide a Migration Strategy 296 Chapter 20 enhanCIng DeVelopMenT proDuCTIVITy 297 The Problem with System Development 298 Trends in System Development 299 Obstacles to Improving System Development Productivity 302 Improving System Development Productivity: What we know that Works 304 Next Steps to Improving System Development Productivity 306 Conclusion 308 • References 308 Chapter 21 InforMaTIon DelIVery: IT’S eVolVIng role 310 Information and IT: Why Now? 311 Delivering Value Through Information 312 Effective Information Delivery 316 New Information Skills 316 New Information Roles 317 New Information Practices 317 xii Contents
  • 36. New Information Strategies 318 The Future of Information Delivery 319 Conclusion 321 • References 322 MInI CaSeS Project Management at MM 324 Working Smarter at Continental Furniture International 328 Managing Technology at Genex Fuels 333 Index 336 PREFACE Today, with information technology (IT) driving constant business transformation, overwhelming organizations with information, enabling 24/7 global operations, and undermining traditional business models, the challenge for business leaders is not simply to manage IT, it is to use IT to deliver business value. Whereas until fairly recently, decisions about IT could be safely delegated to technology specialists after a business strategy had been developed, IT is now so closely integrated with business that, as one CIO explained to us, “We can no longer deliver business solutions in our company without using technology so IT and business strategy must constantly interact with each other.”
  • 37. What’s New in This Third Edition? • Six new chapters focusing on current critical issues in IT management, including IT shared services; big data and social computing; business intelligence; manag- ing IT demand; improving the customer experience; and enhancing development productivity. • Two significantly revised chapters: on delivering IT functions through different resourcing options; and innovating with IT. • Twonew mini cases based on real companies and real IT management situations: Working Smarter at Continental Furniture and Enterprise Architecture at Nationstate Insurance. • A revised structure based on reader feedback with six chapters and two mini cases from the second edition being moved to the Web site. All too often, in our efforts to prepare future executives to deal effectively with the issues of IT strategy and management, we lead them into a foreign country where they encounter a different language, different culture, and different customs. Acronyms (e.g., SOA, FTP/IP, SDLC, ITIL, ERP), buzzwords (e.g., asymmetric encryption, proxy servers, agile, enterprise service bus), and the widely adopted practice of abstraction (e.g., Is a software monitor a person, place, or thing?) present formidable “barriers to
  • 38. entry” to the technologically uninitiated, but more important, they obscure the impor- tance of teaching students how to make business decisions about a key organizational resource. By taking a critical issues perspective, IT Strategy: Issues and Practices treats IT as a tool to be leveraged to save and/or make money or transform an organization—not as a study by itself. As in the first two editions of this book, this third edition combines the experi- ences and insights of many senior IT managers from leading- edge organizations with thorough academic research to bring important issues in IT management to life and demonstrate how IT strategy is put into action in contemporary businesses. This new edition has been designed around an enhanced set of critical real-world issues in IT management today, such as innovating with IT, working with big data and social media, xiii xiv Preface enhancing customer experience, and designing for business intelligence and introduces students to the challenges of making IT decisions that will have significant impacts on how businesses function and deliver value to stakeholders. IT Strategy: Issues and Practices focuses on how IT is changing
  • 39. and will continue to change organizations as we now know them. However, rather than learning concepts “free of context,” students are introduced to the complex decisions facing real organi- zations by means of a number of mini cases. These provide an opportunity to apply the models/theories/frameworks presented and help students integrate and assimilate this material. By the end of the book, students will have the confidence and ability to tackle the tough issues regarding IT management and strategy and a clear understand- ing of their importance in delivering business value. Key Features of This Book • A focus on IT management issues as opposed to technology issues • Critical IT issues explored within their organizational contexts • Readily applicablemodels and frameworks for implementing IT strategies • Mini cases to animate issues and focus classroom discussions on real-world deci- sions, enabling problem-based learning • Proven strategies and best practices from leading-edge organizations • Useful and practical advice and guidelinesfor delivering value with IT • Extensive teaching notes for all mini cases A Different ApproAch to teAching it StrAtegy The real world of IT is one of issues—critical issues—such as
  • 40. the following: • How do we know if we are getting value from our IT investment? • How can we innovate with IT? • What specific IT functions should we seek from external providers? • How do we buildan IT leadershipteam that is a trusted partner with the business? • How do we enhance IT capabilities? • What is IT’s role in creating an intelligent business? • How can we best take advantage of new technologies, such as big data and social media, in our business? • How can we manage IT risk? However, the majority of management information systems (MIS) textbooks are orga- nized by system category (e.g., supply chain, customer relationship management, enterprise resource planning), by system component (e.g., hardware, software, networks), by system function (e.g., marketing, financial, human resources), by system type (e.g., transactional, decisional, strategic), or by a combination of these. Unfortunately, such an organization does not promote an understanding of IT management in practice. IT Strategy: Issues and Practices tackles the real-world challenges of IT manage- ment. First, it explores a set of the most important issues facing IT managers today, and second, it provides a series of mini cases that present these
  • 41. critical IT issues within the context of real organizations. By focusing the text as well as the mini cases on today’s critical issues, the book naturally reinforces problem-based learning. Preface xv IT Strategy: Issues and Practices includes thirteen mini cases— each based on a real company presented anonymously.1 Mini cases are not simply abbreviated versions of standard, full-length business cases. They differ in two significant ways: 1. A horizontal perspective. Unlike standard cases that develop a single issue within an organizational setting (i.e., a “vertical” slice of organizational life), mini cases take a “horizontal” slice through a number of coexistent issues. Rather than looking for a solution to a specific problem, as in a standard case, students analyzing a mini case must first identify and prioritize the issues embedded within the case. This mim- ics real life in organizations where the challenge lies in “knowing where to start” as opposed to “solving a predefined problem.” 2. Highly relevant information. Mini cases are densely written. Unlike standard cases, which intermix irrelevant information, in a mini case, each sentence exists for a reason and reflects relevant information. As a result, students
  • 42. must analyze each case very carefully so as not to miss critical aspects of the situation. Teaching with mini cases is, thus, very different than teaching with standard cases. With mini cases, students must determine what is really going on within the organiza- tion. What first appears as a straightforward “technology” problem may in fact be a political problem or one of five other “technology” problems. Detective work is, there- fore, required. The problem identification and prioritization skills needed are essential skills for future managers to learn for the simple reason that it is not possible for organi- zations to tackle all of their problems concurrently. Mini cases help teach these skills to students and can balance the problem-solving skills learned in other classes. Best of all, detective work is fun and promotes lively classroom discussion. To assist instructors, extensive teaching notes are available for all mini cases. Developed by the authors and based on “tried and true” in-class experience, these notes include case summaries, identify the key issues within each case, present ancillary information about the company/industry represented in the case, and offer guidelines for organizing the class- room discussion. Because of the structure of these mini cases and their embedded issues, it is common for teaching notes to exceed the length of the actual mini case! This book is most appropriate for MIS courses where the goal is
  • 43. to understand how IT delivers organizational value. These courses are frequently labeled “IT Strategy” or “IT Management” and are offered within undergraduate as well as MBA programs. For undergraduate juniors and seniors in business and commerce programs, this is usually the “capstone” MIS course. For MBA students, this course may be the compulsory core course in MIS, or it may be an elective course. Each chapter and mini case in this book has been thoroughly tested in a variety of undergraduate, graduate, and executive programs at Queen’s School of Business.2 1 We are unable to identify these leading-edge companies by agreements established as part of our overall research program (described later). 2 Queen’s School of Business is one of the world’s premier business schools, with a faculty team renowned for its business experience and academic credentials. The School has earned international recognition for its innovative approaches to team-based and experiential learning. In addition to its highly acclaimed MBA programs, Queen’s School of Business is also home to Canada’s most prestigious undergraduate business program and several outstanding graduate programs. As well, the School is one of the world’s largest and most respected providers of executive education. xvi Preface These materials have proven highly successful within all
  • 44. programs because we adapt how the material is presented according to the level of the students. Whereas under- graduate students “learn” about critical business issues from the book and mini cases for the first time, graduate students are able to “relate” to these same critical issues based on their previous business experience. As a result, graduate students are able to introduce personal experiences into the discussion of these critical IT issues. orgAnizAtion of thiS Book One of the advantages of an issues-focused structure is that chapters can be approached in any order because they do not build on one another. Chapter order is immaterial; that is, one does not need to read the first three chapters to understand the fourth. This pro- vides an instructor with maximum flexibility to organize a course as he or she sees fit. Thus, within different courses/programs, the order of topics can be changed to focus on different IT concepts. Furthermore, because each mini case includes multiple issues, they, too, can be used to serve different purposes. For example, the mini case “Building Shared Services at RR Communications” can be used to focus on issues of governance, organizational structure, and/or change management just as easily as shared services. The result is a rich set of instructional materials that lends itself well to a variety of pedagogical appli-
  • 45. cations, particularly problem-based learning, and that clearly illustrates the reality of IT strategy in action. The book is organized into four sections, each emphasizing a key component of developing and delivering effective IT strategy: • Section I: Delivering Value with IT is designed to examine the complex ways that IT and business value are related. Over the past twenty years, researchers and prac- titioners have come to understand that “business value” can mean many different things when applied to IT. Chapter 1 (Developing and Delivering on the IT Value Proposition) explores these concepts in depth. Unlike the simplistic value propo- sitions often used when implementing IT in organizations, this chapter presents “value” as a multilayered business construct that must be effectively managed at several levels if technology is to achieve the benefits expected. Chapter 2 (Developing IT Strategy for Business Value) examines the dynamic interrelationship between business and IT strategy and looks at the processes and critical success factors used by organizations to ensure that both are well aligned. Chapter 3 (Linking IT to Business Metrics) discusses new ways of measuring IT’s effectiveness that pro- mote closer business–IT alignment and help drive greater business value. Chapter 4 (Building a Strong Relationship with the Business) examines the nature of the
  • 46. business–IT relationship and the characteristics of an effective relationship that delivers real value to the enterprise. Chapter 5 (Communicating with Business Managers) explores the business and interpersonal competencies that IT staff will need in order to do their jobs effectively over the next five to seven years and what companies should be doing to develop them. Finally, Chapter 6 (Building Better IT Leaders from the Bottom Up) tackles the increasing need for improved leadership skills in all IT staff and examines the expectations of the business for strategic and innovative guidance from IT. Preface xvii In the mini cases associated with this section, the concepts of delivering value with IT are explored in a number of different ways. We see business and IT executives at Hefty Hardware grappling with conflicting priorities and per- spectives and how best to work together to achieve the company’s strategy. In “Investing in TUFS,” CIO Martin Drysdale watches as all of the work his IT depart- ment has put into a major new system fails to deliver value. And the “IT Planning at ModMeters” mini case follows CIO Brian Smith’s efforts to create a strategic IT plan that will align with business strategy, keep IT running, and not increase
  • 47. IT’s budget. • Section II: IT Governance explores key concepts in how the IT organization is structured and managed to effectively deliver IT products and services to the orga- nization. Chapter 7 (IT Shared Services) discusses how IT shared services should be selected, organized, managed, and governed to achieve improved organizational performance. Chapter 8 (A Management Framework for IT Sourcing) examines how organizations are choosing to source and deliver different types of IT functions and presents a framework to guide sourcing decisions. Chapter 9 (The IT Budgeting Process) describes the “evil twin” of IT strategy, discussing how budgeting mecha- nisms can significantly undermine effective business strategies and suggesting practices for addressing this problem while maintaining traditional fiscal account- ability. Chapter 10 (Managing IT-based Risk) describes how many IT organizations have been given the responsibility of not only managing risk in their own activities (i.e., project development, operations, and delivering business strategy) but also of managing IT-based risk in all company activities (e.g., mobile computing, file sharing, and online access to information and software) and the need for a holistic framework to understand and deal with risk effectively. Chapter 11 (Information Management: The Nexus of Business and IT) describes how new organizational
  • 48. needs for more useful and integrated information are driving the development of business-oriented functions within IT that focus specifically on information and knowledge, as opposed to applications and data. The mini cases in this section examine the difficulties of managing com- plex IT issues when they intersect substantially with important business issues. In “Building Shared Services at RR Communications,” we see an IT organiza- tion in transition from a traditional divisional structure and governance model to a more centralized enterprise model, and the long-term challenges experi- enced by CIO Vince Patton in changing both business and IT practices, includ- ing information management and delivery, to support this new approach. In “Enterprise Architecture at Nationstate Insurance,” CIO Jane Denton endeavors to make IT more flexible and agile, while incorporating new and emerging tech- nologies into its strategy. In “IT Investment at North American Financial,” we show the opportunities and challenges involved in prioritizing and resourcing enterprisewide IT projects and monitoring that anticipated benefits are being achieved. • Section III: IT-Enabled Innovation discusses some of the ways technology is being used to transform organizations. Chapter 12 (Innovation with IT) examines
  • 49. the nature and importance of innovation with IT and describes a typical inno- vation life cycle. Chapter 13 (Big Data and Social Computing) discusses how IT leaders are incorporating big data and social media concepts and technologies xviii Preface to successfully deliver business value in new ways. Chapter 14 (Improving the Customer Experience: An IT Perspective) explores the IT function’s role in creating and improving an … TOPIC : Interventions to improve nutritional status: What type of interventions improve adherence to recommendations on nutritional intake? Example Study: · Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults. WRITTEN ASSIGNMENT: · Read the study and answer the required questions for each category · Must write the paper using provided Summary Paper Format on page #3. · Grading Rubric/Description on page 4-5 ATI #3: Skills Module Contents: Summary Paper Format · Bold for each Heading and Subheading · Include in-text citations for all information/contents as needed · Summary paper MUST be written in this format
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  • 52. nursing profession? Conclusion · Summarizes the Theme of Paper, Findings, and Key points. · Do NOT include Conclusion/Implication on the article