Applying Lewins Change Management Theory to the

Implementation of Bar-Coded Medication Administration

cjni.net /journal/

by Karen Sutherland RN BScN

MSN Student, Memorial University of Newfoundland and Labrador

Abstract

In todays 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 Lewins change management
theory as a framework to introduce bar-coded medication technology at a large psychiatric facility. Lewins 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.

Keywords
Change management, Lewin change theory, Medication errors, Bar-coded Medication Administration

Introduction
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
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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 cares 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 Lewins 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 Lewins
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 Importance of Bar-Coding

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
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process begins when the nurse uses the scanning device to scan the patients identification band then scans the
packet of medication being administered. At that time the cart communicates wirelessly with the patients 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.

Change Management
In todays 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 patients
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 Lewins Change
Management Theory as a framework can strengthen the probability of successful BCMA implementation.

Lewins Change Management Theory

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Many health care organizations have used Kurt Lewins theory to understand human behaviour as it relates to
change and patterns of resistance to change. Also referred to as Lewins 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 Lewins 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.

Application of the change management theory

Unfreezing Stage
The first step of Lewins 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.

Moving Stage
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

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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.

Refreezing Stage
In this final stage of Lewins 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.

Conclusion
With any project of this magnitude, it is imperative to have a complete plan in place for ultimate success. Using
Lewins 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 Lewins 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.

References
Bozak, M., (2003). Using Lewins force field analysis in implementing a nursing information system. Computers,
Informatics, Nursing, 21(2), pp.80-85.

Carroll P. (2003). Medication errors: The bigger picture. R N, 66(1), 52-58.

Dennison, R. (2007). A medication safety education program to reduce the risk of harm caused by medication errors.
Journal Of Continuing Education In Nursing, 38(4), 176-184.

DeYoung, J., Vanderkooi, M., & Barletta, J. (2009). Effect of bar-code-assisted medication administration on
medication error rates in an adult medical intensive care unit. American Journal of Health-System Pharmacy, 66(12),
1110-1115. doi:10.2146/ajhp080355

Foote, S. O., & Coleman, J. R. (2008). Medication administration: The implementation process of bar-coding for
medication administration to enhance medication safety. Nursing Economics, 26(3), 207-210.

Koppel, R., Wetterneck, T., Telles, J.L., & Karsh, B., (2008). Workarounds to barcode medication administration
systems: Their occurrences, Causes, and threats to patient safety. Journal of American Medical Information
Association, 15, 408-423. doi: 10.1197/jamia.M2616

Institute of Safe Medication Practices Canada, 2012. Retrieved from http://www.ismp-canada.org/index.htm

Lehman, K., (2008). Change management: magic or mayhem. Journal for Nurses in Staff Development, 24(4), 176-
184.
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Rack, L., Dudjak, L., & Wolf, G., (2011). Study of Nurse Workarounds in a Hospital Using Bar Code Medication
Administration System. Journal of Nursing Care Quality. 27(3) 232-239. doi: 10.1097/NCQ.0b013e318240a854

Spetz, J., Burgess, J. F., & Phibbs, C. S. (2012). What determines successful implementation of inpatient
information technology systems? The American Journal of Managed Care, 18 (3), 157-162.

The National Coordinating Council for Medication Error reporting and Prevention, (2012). Retrieved from
http://www.nccmerp.org/

Wilkins, K. & Shields, M., (2008). Correlates of medication error in hospitals. Statistics Canada. Retrieved from
http://www.statcan.gc.ca/pub/82-003-x/2008002/article/10565-eng.htm

Author Biography
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.

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