University of West LondonTheoretical Assessment Submission by TurnItin

NOTE TO ALL STUDENTS: Please complete section 1 of thisform as indicated. Please ensure that all relevant boxesare completed, otherwise assignments cannot be processedefficiently.

Section 1 (Student to complete) Please type clearly in the boxes provided

AssignmentTitle A Change to Electronic Medication in Mental

Health Hospitals using Kurt Lewin’s Change Management Theory

Student No 21183883

Module TitleDeveloping Innovative Practice

Module Code Module 3: AY2013-2014

Attempt 1st X 2nd

Programme Post graduate Diploma in Mental Health

Branch (IfApplicable)

Paragon House London

Intake September 2012 Group PGDip

Tutor Deborah Taylor

Word Count 3 3 3 2 Due Date 2 3 0 6 1 4

ExtensionAgreed

Yes No X (If YES provide Reference Number below)

Date ofextension

Student with Yes No X (If YES provide Reference Number below)Disability

Declaration: I confirm that I understand theUniversity's policy on plagiarism and I understand that Iwill be penalised if this assignment infringes that policy.I am also aware of the regulations governing claims formitigation, which should normally be submitted within 10

1

X

working days of the date of the examination/submission. Iunderstand it is my responsibility to keep a copy of thework submitted (Please refer to student Handbook for furtherdetails).I also accept that by my act of Submitting this of assignment, I agree with above Declaration

A change to Electronic Medication in MentalHealth Hospitals

Using Lewin’s Change Management Theory

Introduction Technological revolution in the area of computer

electronic services has changed the way healthcare

services are being delivered. The introduction of the

computer and computer networking system in health care

services have meant that the traditional paper works and

paper filing systems are giving way to electronic

services in the healthcare system. One obvious reason

why some areas of the healthcare services are reluctant

to embrace technological changes is the challenges it

will pose to the healthcare practitioners during

implementation. There is a hidden fear that a switch to

the digital system could produce anxiety which can lead

to resistance to adopt the new changes. Electronic

medication system will reduce medication errors which

often lead to fatal consequences. There are a surveys

that shows that nurses spent more than thirty minutes of

every hour of patient care on paper work

(PricewaterhouseCoopers, , 2001) and another that says

2

that three hours of a nurse shift is spent on documenting

clinical information (Poissant et al. 2005). Electronic

Medication system will save time that can be spent on

other areas of patient’s care delivery. Electronic

medication will also reduce the possibility of lost or

damaged to information which is common in manual

documentation (Curtis, 2011) and will facilitate

information transfer between professional without the

need to schedule meetings for the purpose of exchanging

documents. (Saranto & Kinnunen, 2008). This essay will

show how electronic medication system can be implemented

in our mental health hospitals using the framework of

Kurt Lewin’s “change management theory”.

Medication errors in our hospitals include: being

administered the wrong type or dose of medicine, placing

a patient on the same medication for too long,

administration of a medication for which a patient is

allergic to, prescription of a group of medication that

should not be taken together, giving a medication meant

for one patient to another and the administration of

incomplete course of medication to a patient. (MMD, 2008)

In a review of reported medication errors incidents

between 2005 and 2010 carried by Medicines and

Healthcare Products Regulatory Agency (MHRA) and NHS

England, 525, 1860 medication error incidents were

reported. Of this number, 86,821 (16%) reported actual

3

patient harm and 822 (0.9%) resulted in death or severe

harm (MHRA, 2013). It must be emphasised that there are

many unreported cases of medication errors in our

hospitals because cases are mostly reported when harm is

involved or when there is a courageous whistle blower at

the point of incident.

Many strategies and ideas have been developed and put

forward to reduce the possibility of prescribing,

dispensing and administering medication in error. The

American Society of Hospital Pharmacists (ASHP, 1993) has

suggested that to reduce medication errors:

..effective systems for ordering, dispensing,

and administering medications should be

established with safeguards to prevent the

occurrence of errors. These systems should

involve adequately trained and supervised

personnel, adequate communications, reasonable

workloads, effective drug handling systems,

multiple procedural and final product checks by

separate individuals, quality management, and

adequate facilities, equipment, and supplies

(ASHP, 1993).

Even with these checks in place, current medication

procedure in our mental health hospitals which involves

the use ledgers and charts to manually checks and

document medication administration is prone to errors.

4

This paper will discuss how electronic medication such as

bar coded medication, automated dispensing machine and

electronic medication recording can significantly reduce

medication errors. The paper will show how Kurt Lewin’s

change management theory can be used to guide the process

of implementing this change in a mental health setting.

We will discuss how Kurt Lewin’s change management theory

can be use to support staff especially nurses many of

whom are sceptical, or lack confidence in the face of new

technologies and transitions. Through a careful planned

change, the theory will be used to identify areas of

strength, weakness and resistance prior to implementation

of the change to ensure that mistakes that could have

adverse effects on the patients are not made.

The Importance of Electronic MedicationThe National Patient safety Agency (NPSA) define

medication errors as “incidents in which there has

been an error in the process of prescribing,

dispensing, preparing, administering, monitoring, or

providing medicine advice, regardless of whether any

harm occurred” (NPSA_NHS, 2007. p. 9). Medication

error occurs in healthcare establishments all over

the world and can result in serious harm or death,

longer stay of patients in hospital, increase in

5

cost of treatment and the lost of public confidence

on healthcare practitioners. The department of

health estimates that 4.7 percent of the total

admissions in NHS hospitals, England are due to

avoidable (definitely preventable) harm from

medicines and medication errors. It estimates the

financial cost of these admissions to be in the

ranged of £200- £400 million annually (NPSA_NHS,

2007). The department of health also estimates that

around 7% of inpatients experience adverse drug

reactions (ADRs), in NHS England (NPSA_NHS, 2007).

Assuming that a similar percentage of inpatient

medication incidents were preventable, it will add

up to an annual cost of £410 million to NHS England

(NPSA_NHS, 2007). If what is known about litigation

cost was added to the costs mentioned above, we

could say that the cost of preventable harm from

medicines to NHS England exceeds £750 million a year

(NPSA_NHS, 2007). We must also add that very little

is know about preventable harm from medicines at

community level in NHS England where most drugs are

prescribed and administered by the GPs and the

community health care system (NHS_NPSA 2007, p. 12).

The less recognised and discussed aspect of

medication error is the harm to morale, lost of work

time or very often lost of job suffered by nurses

who are the last line of defence against error

medication error. The nurse is expected to combine

6

the knowledge and work of the doctor and pharmacist,

recognise any potential harm from a medication and

stop the administration otherwise she faces the

consequences of administering the medication in

error because according to the NMC ‘Standards for

medicines management’, medication “is not solely amechanistic task to be performed in strict compliance

with the written prescription of a medical

practitioner…... It requires thought and the exercise

of professional judgement...” (NMC, 2007 p. 3)

The technology involved in medication that have been

tested and are being used in different countries of the

world and in some NHS hospitals are: bar coding scanning

medication administration (BCMA), electronic medication

recording (EMR), computerised physician order entry

(CPOE) and automated pharmacy dispensing machines (APDM)

(Appari, et al, 2011). Bar coding (BCMA) technology

involves the scanning of bar codes on medicine packets,

patients’ wrist bands and codes on the medication charts

(Appari, et al, 2011). Mental health patients may not

like to wear a hand band as inpatients in general

hospital but the bar code on the medicine packets and the

patient’s chart will fill that vacuum. The computerised

physician order entry (CPOE) will save the amount of

papers needed for medication documentation, reduce

transcription errors from bad or ineligible handwriting

and remove the problem of missed signature. Electronic

7

medication recording (EMR) will save documentation

resources, ensure that the time, date and signature of

the person who administered the medication are visible

and accurate and that the record is available to all

departments of the hospital who might need them in real

time. The automated pharmacy dispensing machines (APDM)

will reduce the error of dispensing underdose or overdose

and will also reduce the chances of wastage through

medication slipping from the fingers to the floor. In

all, electronic medication system verifies several

elements of the patient to make sure that the right

medicine is being administered to the right patient at

the right time, dose, route and frequency and it does so

in speed and accuracy thereby saving time and error that

could occur through manually flipping through piles of

paper work.

Change Management: Lewin’s Change ManagementTheory

In any healthcare system, nurses are major players in the

implementation of health policies and are therefore

expected to be up to date and embrace developments that

will lead to improvement in health care delivery.

Unfortunately however, once it is agreed that change is

necessary by the policy makers, nurses are expected to

buy into it without given enough chance to say how they

are affected by the new change. Managing change is

challenging and it is even more challenging in a hospital

environment where such a change involves lives. According

8

to (Bozak, 2003) nurses ‘buy in’ is vital to a successful

transition of technological project in hospitals because

many of them can be unsure or just simply resistive to

new technological devices. Other barriers that have been

identified when implementing technological changes in an

hospital environment are lack of cooperation from staff

and even patients, lack of confidence and fear of using

the new technique, slow implementation of the change and

the technique with the believe and hope that the new

technological will not last (Spetz, et al. 2012). In a

mental health hospital, there may be cases of some

patients refusing to wear the bar coded hand band; this

problem can simply be solved by sticking the bar code

onto the patient’s chart. Other challenges that could

face the implementation of electronic medication are

‘short cuts’ like pre-pouring of medication and

‘workarounds’ which bypasses technological failures. Any

technology that involves computer networking will at some

point experience a break down as we do often experience

in clients’ software applications like Rio and Jade.

Fortunately, networking technology has evolved to a level

that stability is becoming very reliable. “Backbone”

which backups networking application software now exists

to take care of breakdowns and networking computers have

been upgraded to operate as “stand alone” in the event of

a network outage.

Lewin’s Field Analysis of the Electronic Medication System in Mental Hospitals

9

The process of using Kurt Lewin’s theory frame work to

understanding human behaviour as it would react to change

is known as ‘Kurt Luwin’s Field analysis’(Bozak, 2003).

The model involves three phases: unfreezing, moving stage

and refreezing phase. The aim of the model is to

identify: factors that can prevent change from taking

place; factors that oppose change from occurring often

referred to as ‘static force’; and factors that promote

change also referred to as ‘driving forces’. In other to

implement a change, the work force must recognise theses

forces. When the positive driving forces are promoted and

strengthened against the restraining forces, a change can

be implemented successfully (Bozak, 2003).

10

The unfreezing stage involves a thorough understanding of

the identified problems and formulation of strategies to

overcome them. A meeting is held with the individuals

that will be affected by the change and lists of the

driving and static forces that will affect the change are

created. Individuals during this stage recognise that

change is coming and are prepared for it (Bozak, 2003).

There may be a feeling of apprehension and stress during

this period among staff involve in the change process.

The second stage is the moving stage where the actual

change takes place. The opposing forces, that is the

restraining forces and the driving forces meet. The

moving force is strengthened to propel the change until

it occurs successfully. The last stage is the unfreezing

stage. This is the stage in which change that occurred is

incorporated in the routines practices of the

organization. To prevent retrogression and falling back

to previous ways of doing things, staffs are supported

with training, rewards and policy updates to make the a

part of the culture of the organization (Kaminski, 2011).

Application of the Change Management Theory

Unfreezing Stage

The first step in Kurt Lewin’s change process is

unfreezing the change which involves identifying the

change focus. In our case, it means implementation

electronic medication in NHS mental health hospitals.

This stage step involves communicating and holding

11

meetings with stakeholders such as the doctors, nurses,

pharmacists, managers and administrators. According to

(Bozak, 2003), it is important that lines of

communication are kept open to build trust and a sense of

security during this stage. Frontline staffs have to be

involved in the planning and decision making process and

they should be taking place. Round table discussions are

held during this stage and the driving and restraining

forces are identified and listed. Some of the restraining

forces likely to be face by this change will be: poor

computer experience across members of staffs, reluctance

to learning new technology, workarounds and shortcuts to

bypass procedures, and lack of trust in the change. The

driving forces are those that will make the change takes

place such as: availability of finance, support from the

upper management level, a good a training to support

staff and make the system easy to use. Briefly, this

stage involves engaging staff that will be using the

system to work together using the driving forces to

overcome the restraining forces.

Moving Stage

This is the stage in which the actual change takes place.

It involves perusing the plans that were put in place in

step one and implemented them (Sassen, 2009). The various

hospital teams particularly those involved clinical

service will be part of this implementation stage.

Nursing staff play a vital role in the medication chain

12

hence and in the view of Bozak (2003) they must be give

prominent role and should be made to realise that the

success or failure of the scheme depends on them. There

should be a timeline that must be adhere to and executed

during this phase, equipment should be tested for

reliability, continuing education program should be

planned to support staff and a project leader should be

appointed to oversee the implementation of the change.

Refreezing StageThis is the stage in which the mental health hospitals

are now using electronic medication system to prescribe

order and administer medication to patients. This is a

time of stability and re-evaluation of the change that

has taken place. Continue education is provided for

support, functional equipment with necessary literatures

guides and other resources are made available to support

end users, staff training program for old and newly

recruited staff should be put in place and policy

guideline regarding and regulating electronic medication

should be drawn up by the hospital management.

Medication error will always occur but it is the view of

this essay that electronic medication system will reduce

it.

Criticism of Lewin Change Management Theory

The third stage of Lewin’s model has provoked much

criticism. Many people argue that changes in modern

13

business is too fast to allow room and time for

refreezing after a change process have taken place. But

Lewin himself according to Longo (2011) anticipated this

criticism and wrote in 1757 that : “The refreezing stage

is not intended as a final, conclusive and stable point,

but as the point necessary to determine from which point

and/or state the following process of change starts”.

Clinical Governance Framework and Change Management

Clinical governance was introduced into the NHS in 1997

in the aftermath of many failures in NHS in the 1990s

(Braine, 2006). According to the Department of Health,

the elements and framework of Clinical governance is

important to improve the quality of services in NHS (DOH,

1997). Where and when a change is necessary in the way a

service is delivered, adopting the framework of clinical

governance helps to maximise the quality of care. The

basic themes of clinical governance are: patient

involvement and experience, clinical audit, education and

training, use of information, staff and staff management

(Leadership), clinical effectiveness and research

(Nicholls et al 2000, Starey 2001).

Clinical governance emphasises clinical audit; which in

the context of our change to electronic medication system

mean a system is put in place to evaluate progress. Is

the electronic medication being implement accurately? Are

there any shortcomings against what we ought to be doing?

14

What has worked and what has not worked? Nurses must not

see auditing as a job for the quality control commission

(CQC) alone. When it is well carried out, clinical audit

according to Wilson (1998) “provides reassurance to

patients, practitioners and managers that an agreed

quality of service is being provided within the resources

available”.

Leadership

Change is a process and at every level of that process

leadership is important to harness the efforts of the

workers and achieve a desired goal (Ajmal, et al, 2014).

And in order to survive according to Ajmal, et al. (2014)

every establishment must respond to local, national and

international need for change in technology or other

fields of life. Leaders are the “Champions of Change”.

They keep the process of any change in an establishment

going and maintain operational reliability (Ajmal, et al

2014). Leadership means having the vision, enthusiasm and

the desire to meet challenges (Bishop 2009). It is about

having the ability to get the best out of other people

and not simple contended with the tag of being the boss

(Frampton 2009). A leader must have the ability and

patience to listen to others’ opinions and he must be

able to reflect on these opinions and turn them into

durable policy for the progress of the organization

(Manley et al, 2011).

15

The Prime Minister’s commission on the future Nurses and

Midwifes in England have challenged senior nurse managers

to accept full managerial and professional accountability

for high quality care (DOH, 2010). This means statements

like “many nurses can be unsure and resistive to new

computer aided devices in practice” and that “new

technologies often incite resistance from nurses” by

Bozak, (2003) are no longer acceptable because nurses are

not only suppose to be agents of change but must take

charge and lead that change. According to McKenzie

and Manley (2011) ‘Nurses and nursing staff lead by

example develop themselves and other staff, and influence

the way care is given in a manner that is open and

responds to individual needs.’

Leadership Framework

In a change to electronic method of medication for

example, it is the responsibility of the ward manager to

provide the nursing staff the policy guideline and

supervision for the change taking place. The Royal

College of Nursing (RCN) (2009) identifies clinical

16

leadership as “vital for assuring and sustaining quality

care through the supervisory role of the ward sister or

team leader and the creation of an effective workplace

culture”.

Change Management Method

The National Institute for Health and Clinical Excellence

(NICE) offers a three levels structural approach on how

to manage and implement change in a healthcare setting

titled “How to change practice”. The three layers are:

Understand the barriers to change, identify the barriers

to change and overcome the barriers to change. The guide

aims to improve the quality of patients’ care by

encouraging healthcare professionals to use latest

guidance in their practice. (NICE, 2007). The method is

similar to Lewin’s management theory except that, it is

designed for health care setting although it can be

applied to other fields.

Prosci’s Change management methodology

Another very recent Change management methodology is the

Prosci’s research-based method. It is popular in the

business world and like NICE model; it can also be used

in the healthcare setting.

17

(Prosci, 2007)

Conclusion

The healthcare environment is very dynamic and one of

the main driving forces of changes in it is technology.

Technology assists healthcare organizations in which

nurses play a vital role to meet up challenges and

accomplish establishment goals. A change to electronic

medication in mental health hospitals such as bar coded

medication, automated dispensing machine and electronic

medication recording will significantly reduce medication

errors in our mental health hospitals. As we observed in

this course of this essay, although this change is

necessary, implementation of the project is challenging.

Applying a structured model like Kurt Lewin’s change

management to implementing this change makes it possible

to overcome these challenges. Our believe is that

electronic medication will reduce medication error and

improve health care in our mental health hospitals.

ReferencesAjmal, S. (2014) Role of Leadership in Change ManagementProcess: Abasyn Journal of Social Sciences Vol. 5 No. 2 http://64.17.184.140/wp-content/uploads/2013/02/V5I2-8.pdf

Appari, A. et al (2011) Medication administration quality and health information technology: a national study of US hospitals.

18

[Online]. Available at: http://jamia.bmj.com/content/early/2011/10/28/amiajnl-2011-000289.full.html. (Accessed: 02 June, 2014) American Society of Hospital Pharmacists. [ASHP] (1993)guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993; 50:305–14.

Bishop, V. (2009) Leaders of the future. Nursing Standard.24, 10, 62-63.

Bozak, M., (2003) Using Lewin’s force field analysis inimplementing a nursing information system. Computers, Informatics, Nursing, 21(2), pp.80-85.

Braine, M. (2006) Clinical governance: applying theory to practice. Nursing Standard. 20, 20, 56-65. Date of acceptance: November 15 2005.

Curtis, C. (2007). Nursing evaluation of electronic documentation systems. Retrieved from http://healthfieldmedicare.suite101.com/article.cfm/electronic_health_records

Department of Health (2010) Front Line Care: the future of nursing and midwifery in England. Report of the Prime Minister’s Commission on the Future of Nursing and Midwifery in England. London: Department of Health

Frampton, L. (2009) Changing Culture on the Front Line. [Online] Available at: www.clinicalservicesjournal.com/Story.aspx?Story=5857 (Accessed: June 10, 2014)

Getz, L. (2010). The Benefits of Bar Coding: For the Record [Online]. Vol. 22 No. 23 P. 20. Available at: http://www.fortherecordmag.com/archives/122010p20.shtml (Accessed June 02, 2014)

Kaminski, J. (2011) Theory applied to informatics – Lewin’s Change Theory Canadian Journal of Nursing Informatics Volume 6 No 1. 23 Mar 2011

19

Longo, R. (2011), Is Lewin’s change management model still valid?, HR Professionals, [online]. Available at: http://rosariolongo.blogspot.co.uk/2011/05/is-lewins-change-management-model-still.html (Accessed June 18, 2014)

McKenzie, C, Manley, K (2011) Leadership and responsivecare: Principle of Nursing Practice H. Nursing Standard25(35) 4 May pp.35-37 (PDF 94KB)

Manley, K. et al. (2011) Person-centred care: Principleof Nursing Practice D. Nursing Standard. 25, 31, 35-37.

MHRA (2013) Improving Medication Error Incident Reporting and Learning: [Online]. Available at: http://www.mhra.gov.uk/home/groups/comms-po/documents/news/con341187.pdf

(Accessed 28 May 2014)

Mosby's Medical Dictionary, (MMD) (2008) 8th Edition, Elsevier

NHS Leadership Council (2011) NHS Leadership Framework.NHS Leadership Website (http://www.leadershipacademy.nhs.uk/discover/leadership-framework/

NHS England (2013) Information Governance Policy Issue Document Number: POL_1008

NHS Executive (1999) Clinical governance: quality in the new NHS. Health Service Circular. HSC 1999/065. The Stationery Office, London.

Nicholls et al (2000) Clinical governance: its origins and its foundations. Clinical Performance and Quality Health Care. 8, 3,172-178,

NPSA_NHS (2007) Safety in doses: medication safety incidents in the NHS [Online]. Available at: http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61392

(Accessed 27 May 2014)

Nursing and Midwifery Council (NMC), (2007): Standards formedicines management Pg. 3. [Online] Available at: www.nmc-uk.org/.../NMC- Standards-for-medicines - management .pdf (Assessed 15 June 2014)

20

Prosci (2007).Change management methodology overview. http://www.change-management.com/prosci-methodology-overview.pdf

PricewaterhouseCoopers. (2001). Patients or paperwork: The regulatory burden facing America’s hospitals. [Online]. Available at: www.aha.org/content/00-10/Final Paperwork Report.pdf (Accessed: June 08, 14)

Poissant, L. et al. (2005). The impact of electronic health records on time efficiency of physicians and nurses: A systematic review. JAMIA: Journal of the American Medical Informatics Association, 12(5), 505-516. doi: 10.1197/jamia.M1700

Sassen, E. (2009). Love, hate, or indifference: How nurses really feel about the electronic health record system. Computers, Informatics, Nursing, 27(5), 281-287

Spetz, et al. (2012) What determines successful implementation of inpatient information technology systems? The American Journal of Managed Care, 18 (3), 157-162.

Saranto, K. & Kinnunen, U. (2008) Evaluating nursing documentation – research designs and methods: Systematic review. Journal of Advanced Nursing, 65 (3), 464-476. doi:10.1111/j.1365-2648.2008.04914.x

The Royal College of Nursing (RCN) (2009) Breaking Down Barriers, Driving Up Standards: The role of the ward sister and charge nurse [Online]. Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0010/230995/003312.pdf

Wilson, J (1998) Incident reporting, British Journal of Nursing. 7 11. 670-671

21