by Karen Sutherland RN BScN
MSN Student, Memorial University of Newfoundland and Labrador
In today’s rapidly changing healthcare environment, technological advancements and computer assisted devices can challenge nurses in many ways. Implementing a change in practice within these environments can produce anxiety or fear of failure in nurses, leading to a resistance to change practice. Medication errors in hospital settings lead to devastating consequences for both nurse and patient that can be reduced significantly through the use of technology that improves patient care and saves time for busy nurses. Bar-coded medication administration is one type of technology that uses a scanning device to compare bar codes on patient identification bands with bar codes on prescribed medications, electronically verifying the medications against the medication records, thereby reducing medication errors significantly. This paper will examine the applicability of using Kurt Lewin’s change management theory as a framework to introduce bar-coded medication technology at a large psychiatric facility. Lewin’s theory can lead to a better understanding of how change affects the organization, identify barriers for successful implementation and is useful for identifying opposing forces that act on human behviour during change, therefore overcoming resistance and leading to acceptance of new technologies by nurses.
Change management, Lewin change theory, Medication errors, Bar-coded Medication Administration
Medication safety has been identified by the Institute for Safe Medication Practices Canada (ISMPC) as a priority among hospitals and long term care facilities since medication errors in hospitals are a serious threat to patient safety. Several studies (Carroll, 2003; Dennison, 2007; DeYoung, Vanderkooi, & Barletta, 2009) indicated that the rates of fatalities associated with medication errors in the United States were greater than 7000 deaths annually, and affected three to five percent of in-hospital patients. The ramifications of medication errors affect all healthcare organizations, resulting in consumer mistrust, increased healthcare costs, and patient injury or death (Carroll, 2003). Medication errors can occur at any stage of the dispensing and administration process but only an estimated five percent are noted in nursing documentation, suggesting that many errors that have not led to serious results are unreported (Wilkins & Shields, 2008).
Several strategies have been introduced to lessen the likelihood of error in the dispensing and/or administration process, including patient identification and electronic medication records. Bar coded medication administration is one such tool that has the potential to reduce medication errors significantly, when used correctly (Carroll, 2003; Dennison, 2007). Patient safety is one of health care’s top priorities and safe medication delivery is an important aspect of total patient care. The current system of medication delivery and administration at our facility involves old medication carts in poor repair and relies on manual checks to ensure the right drug is given to the right patient at the right time, route, site and dosage by the nurse. The psychiatric facility in question is now planning a complete overhaul of the pharmacy system and is incorporating automated dispensing machines, along with electronic medication records and bar coding of medications to modernize their care and improve patient safety. This large project will have the greatest impact on front line nurses, many of whom are skeptical of change or lack confidence in their ability to adapt to new technologies, therefore careful implementation of this project is imperative.
The purpose of this paper is to discuss how Lewin’s Change Management theory can guide the process of implementing bar-coding medication administration (BCMA) at this large psychiatric facility. Several studies (Bozak, 2003; Lehman, 2008; Spetz, Burgess & Phibbs, 2012) expounded the need for a concise plan and clear communication between nurses and management when implementing a change of this nature. The use of Lewin’s Change Management theory can support nurses through the transitions and identify areas of strengths and resistances prior to implementing change. Without a framework for guidance, new technologies can result in workarounds that threaten patient safety.
The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”. Medication errors are a common occurrence in healthcare facilities around the globe, with serious consequences resulting in death or harm, increased inpatient days in hospital, erosion of trust between consumer and healthcare organizations, and a great deal of economic expense (Carroll, 2003; Dennison, 2007). The economical impact of medication errors is estimated to be around five thousand dollars per error unless there is legal litigation, when the costs can skyrocket into the millions (Dennison, 2007). No less important, but certainly less discussed, is the harm to nurse morale after being involved in a medication error, potentially leading to lost time from work (Dennison, 2007). While medication errors can occur at any stage in the process, the nurse is often the last line of defense for catching mistakes due to the nature of the administration of meds at the bedside. This can translate into the onus of responsibility being shifted onto the nurse to not only catch drug errors before they occur, but take the blame if they do occur (Wilkins & Shields, 2008).
The ISMPC has worked closely with hospitals, pharmacies and drug companies to address many preventable occurrences ranging from medication reconciliation programs to the standardization of drug names and labeling. The introduction of automated pharmacy dispensing machines, bar-coding and scanning of medications is a national project throughout Canada, aimed at reducing medication errors and ultimately improving patient safety. The technology involved in bar-code scanning also integrates electronic medication records (EMR) and computerized physician order entry (CPOE) into practice, thereby reducing paper documents and the possibility of transcription errors, ineligible handwriting or missed signatures. BCMA technology consists of bar coded medication packets and bar codes on patient identification bands as well as a scanner attached to a medication cart. The process begins when the nurse uses the scanning device to scan the patient’s identification band then scans the packet of medication being administered. At that time the cart communicates wirelessly with the patient’s electronic medication administration record (MAR) and verifies several elements; that the medication is the correct one ordered for that patient and that the dose, time, route, frequency are correct. Without bar-coding this process is completed manually by the nurse by checking against the paper MAR, verifying these same elements and has been estimated to take up to thirty minutes per patient (Foote & Coleman, 2008) in extreme cases.
With added distractions, complexities of care, and faced paced environments, nurses may inadvertently overlook inconspicuous errors or fail to catch packaging errors, leading to medication mishaps that could have serious consequences. When used correctly, BCMA systems can lessen the chance of medication errors – sometimes reducing medication errors by as much as eighty percent (Carroll, 2003; Foote & Coleman, 2008; Young, Slebodnik & Sands, 2010). The introduction of BCMA technology at our psychiatric facility can improve patient safety and also decrease time spent on medication administration, thereby allowing more time for patient contact. Currently nurses use old medication carts that have worn wheels, broken drawers and some are health and safety hazards. The nurses use paper medication records and must double check medications against the MAR sheets before administering. The facility has recently introduced new computerized swipe access carts that are bar code scanner friendly with the intent to introduce bar coding once the pharmacy department converts to electronic medication dispensing and electronic medication records. While many nurses will welcome this time-saving change, others will feel overwhelmed by the magnitude of the change; therefore careful planning and support on the part of the organization will lessen the stress associated with the implementation.
In today’s busy healthcare environment, nurses are expected to keep up with modern integrated technology, often with little say as to how it affects them. As with any new change, ‘buy in’ by front line nurses is essential to a smooth transition of any informatics project, as many nurses can be unsure and resistive to new computer aided devices in practice (Bozak, 2003). Managing change has always been challenging in health care facilities, and new technologies often incite resistance from nurses who already cannot find enough time in their shift to complete patient related tasks. Several common barriers have been identified when implementing a change in procedure of this magnitude including lack of cooperation amongst staff, fear of using new techniques, and resistance to change in hopes that the new technology would just disappear (Spetz, Burgess & Phibbs, 2012). One barrier that could impact the implementation at our psychiatric hospital is the possibility of a patient refusing to wear identification bands, which are necessary for BCMA to work. Other barriers include short cuts that some nurses have adopted to save time, such as pre pouring medications, which contravenes Canadian nursing standards of practice. Several studies identified barriers to successful implementation of BCMA through the use of ‘workarounds”. In one study, researchers found “15 types of BCMA-related workarounds and 31 separate probable causes of the identified workarounds” (Koppel, Wetterneck, Telles & Karsh, 2012).
Workarounds are common and are a unprofessional attempts to circumvent computer failures or save time. They come about through frustration on the part of the nurses when they are unable to find a solution to an immediate problem. Some common workarounds in BCMA include administering medications without scanning the patient’s wristband, placing the wristband on a stationary object such as the end of the bed, scanning medication packages after delivery and administering medications without scanning the medication bar code. For successful implementation of a project as large as bar-coding, careful planning and identification of all barriers are imperative. Not all nurses are comfortable with technology in the work environment, thus they may be resistant to changing practice, or be afraid of failure (Bozak, 2003). It is important to recognize the different educational needs of the various nurses and acknowledge the varying attitudes and stresses the nurses might have. Using Lewin’s Change Management Theory as a framework can strengthen the probability of successful BCMA implementation.
Many health care organizations have used Kurt Lewin’s theory to understand human behaviour as it relates to change and patterns of resistance to change. Also referred to as Lewin’s Force Field Analysis, the model encompasses three distinct phases known as unfreezing, moving and freezing or refreezing (Bozak, 2003). The intention of the model is to identify factors that can impede change from occurring; forces that oppose change often called restraining or ‘static forces’ and forces that promote or drive change, referred to as ‘driving forces’. When health care organizations fully understand what behaviours drive or oppose change, then work to strengthen the positive driving forces, change can occur successfully (Bozak, 2003).
In Lewin’s first ‘unfreezing’ stage, an understanding of the difficulties related to the identified problem are sought and “strategies are developed to strengthen the driving forces and weaken or reduce the restraining forces” (Bozak, 2003, p. 81). Unfreezing involves identifying key players that will be affected by the change and gathering them together to communicate ideas and create lists of all driving and static forces that will affect the project. The second ‘moving’ stage is where the actual change in practice takes place as a result of equalization of the opposing forces, thereby allowing the driving forces to support the change. In this stage, implementation of the project produces the change desired, so it is important to continue to keep lines of communication with the nursing staff open. Finally, once the desired change has occurred, the ‘refreezing’ stage can be used to evaluate the stability of the change and the overall effectiveness within practice.
The first step of Lewin’s Analysis involves identifying the change focus; specifically, implementing a bar-code scanning system of medication delivery at a large psychiatric facility. Key components of this step are communicating with all stakeholders including frontline nurses, managers and administration. Bozak (2003) asserted that it was important that lines of communication remain open and honest, which creates a “sense of security and trust in all those involved with the proposed change” (p. 83). The inclusion of front line staff in planning groups and key decision – making processes promotes a feeling of empowerment that helps to overcome their resistance to the change and enables them to understand the importance of the project and how it will beneficially affect client care.
During the unfreezing stage, round table discussions with the purpose of teasing out the driving and restraining forces will help identify barriers that may need to be overcome. In this facility some restraining forces might be; staff resistance to using computerized devices, the possibility of workarounds, lack of computer experience, lack of trust in the organization, and aversion to using a new system. Driving forces would be the forces that will help move the project to completion such as; adequate financial investment, support from upper level management, potential for ease of use and better time management. The important point here is that this exercise actively engages all parties to work towards accentuating the positive driving forces and diminishing the restraining forces so that BCMA is successfully adopted without the use of dangerous workarounds with full nursing investment in the outcome.
The moving stage represents the period of actual change including the planning and implementation stages of the project. Implementing bar coding across the facility will require sustained effort from various teams, some of which include; information technology (IT), pharmacy, clinical information services (CIS), nursing, program managers, clinical nurse educators and administrators. A project of this magnitude will affect all of these departments in different ways, so planning an effective roll out with the assistance and inclusion of all stakeholders is imperative. Bozak (2003) recommended actively involving nursing staff, to create a feeling of ownership of the success of the project. Some areas to consider at this facility are implementation timelines, reliability of the equipment, educational training needs, effects on workflow, organizational culture and leadership (Spetz, Burgess & Phibbs, 2012). It is also important to have a project leader to oversee and monitor a project of this magnitude through all phases. Challenges in this stage may include discovering the use of workarounds that can be resolved through further education.
In this final stage of Lewin’s theory, the process of freezing or refreezing the changed practice occurs and leads to a time of “stability and evaluation” (Bozak, 2003, p. 84). Ongoing support of the nurses on the frontline and technology support to all stakeholders should continue until the change is deemed complete and all users are comfortable with the technology. Once completed and fully operational, an evaluation and summary of problems encountered, successes realized, and challenges encountered throughout the project should be done, for future reference.
With any project of this magnitude, it is imperative to have a complete plan in place for ultimate success. Using Lewin’s Change Management theory to guide the implementation of BCMA at this large psychiatric facility can help to promote acceptance by frontline nurses by involving them in all aspects of the planning and implementation. Creating this ‘buy in’ from frontline nurses builds autonomy and ownership of the project, ultimately leading to success. The use of brainstorming round table discussions to identify driving and resisting forces is a first step in this process. Addressing restraining forces helps to promote adoption to ensure the smooth implementation of the BCMA resulting in reduced medication errors. Often, nurses are forced to change practice without having the opportunity to give input, which has eroded their trust of the organization over time. By using Lewin’s theory, we can help reduce stakeholder resistance and fear of change through the development of a well thought plan and active participation in the change process.
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Karen Sutherland RN BScN CPMHN(C) is a first year Masters of Nursing Student at Memorial University. She works at a large psychiatric hospital in Ontario as a nurse educator/practice lead, specializing in forensic mental health nursing. She completed her post RN BScN degree at Laurentian University in Ontario in 2009 and her RN diploma from George Brown College, Toronto Ontario in 1983. Most recently, she obtained her Canadian Nurses Association Specialty Certificate in Psychiatric and Mental Health Nursing.