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We welcome the recent Original Viewpoint paper by Foy et al1, titled
The role of theory in research to develop and evaluate the implementation
of patient safety practices. We strongly support the recommendations in
this paper, and in particular, the application of behavioural change
theory in the design, implementation and evaluation of Patient Safety
However, on rea...
However, on reading this paper, one could be forgiven for believing
that the use of such behavioural theory as the basis for the design,
implementation and evaluation of PSPs is novel. Reference to the
application of the Theory of Planned Behaviour (TPB) in the paper, was
restricted to taking intra-oral radiographs, managing upper respiratory
tract infections with antibiotics and disclosure of dementia: hardly
We are therefore perplexed at the apparent 'blind spot' of the
authors for citing relevant research in this area. Pubmed and even a
simple Google search using search string "TPB and patient safety
behaviours" will produce original published work which has been omitted.
The first article in this Google search is a paper which explored the
use of TPB in understanding hand hygiene behaviour and design of
interventions to improve compliance2. We have been using such theory for
more than ten years, to design, implement and evaluate important PSPs
including the recent pivotal PSP of hand hygiene.2,3 As hand hygiene was
used as a core example of PSP by Foy et al1, we were left wondering why
such relevant and highly cited3 research was not included.
Another citation on page one of the Google search related to an
original research paper published in 2010 in Quality and Safety in Health
Care (the same journal now called BMJ Quality and Safety). This paper
titled Patient Safety Culture: factors that influence clinician
involvement in patient safety behaviours4, applied TPB to a range of
patient safety behaviours including incident reporting and speaking up
when witnessing a colleague making a mistake. This paper has for the
first time in the literature identified predictive factors for these PSPs,
establishing unique models for differing professional sub-groups such as
junior and senior doctors; junior and senior nurses; and, allied health
practitioners. Again, it is hard to understand why such research,
published in the same journal, was not cited.
For the past decade behavioural theory has been successful in
predicting patients' non compliant antiviral therapy to prevent wide-
spread resistance8 as well as other central public safety issues of the
Perhaps the root cause of the issues identified by Foy et al, is that
the focus has been on identifying an evidence base for what PSPs to
implement, rather than how best to change behaviour and practice. The
former, is founded in traditional biosciences, reductionist research
paradigms and pedagogy, wheras the latter is far more the domain of public
health, behavioural and social sciences. Perhaps if we were to re-state
the problem of patient safety as public health, then we would start to
employ the appropriate scientific endeavours to design, implement and
Finally, we welcome the increased focus on behavioural theory driven
interventions in patient safety, and congratulate the authors and journal
for shining a light on this important issue. However, we believe that the
authors have been selective in their review of the relevant literature on
the use of behavioural theory applied to PSPs, both at a general level,
and in relation to specific examples in the paper.
1. Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. BMJ Qual Saf bmjqs.2010.047993Published Online First: 11 February 2011 doi:10.1136/bmjqs.2010.047993.
2. Whitby M, McLaws ML, Ross MW. Why healthcare workers don't wash their hands: a behavioural explanation. Infect Control Hosp Epidemiol 2006; 27:
3. Whitby M, Pessoa-Silva CL, McLaws ML, Allegranzi B, Sax H, Larson E, Seto WH, Donaldson L, Pittet D. Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2006; 65(1):1-8.
4. Wakefield J, McLaws ML, Whitby M, Patton L, Blake S. Patient Safety Culture: Factors that influence clinician involvement in patient safety behaviour. Quality and Safety in Healthcare 2010 Aug 19 (6): 585-91.
5. Begely K, McLaws ML, Ross MW, Gold J. Adherence behavior of patients on long term protease inhibitor therapy: insight for the treating clinician.
Clinical Psychologist 2008;12(1):9-17.
6. McLaws ML, Irwig LM, Oldenburg B, Mock P, Ross MW. Predicting intention to use condoms in homosexual men: an application and extension of the theory of reasoned action. Psychol Health 1996;11(5):745-55.
7. McLaws ML, Oldenburg B, Ross MW. Application of the Theory of Reasoned Action to measurement of condom use among gay men. In: The Theory of Reasoned Action: Its Application to AIDS-Preventive Behaviour. Terry DJ,
Gallois C, McCamish M (Eds). Chapter 10. Pergamon Press. Oxford, 1993.
8. Ross MW, McLaws ML. Attitudes towards condoms and the Theory of Reasoned Action. In: The Theory of Reasoned Action: Its Application to AIDS-Preventive Behaviour. Terry DJ, Gallois C, McCamish M (Eds). Chapter 5. Pergamon Press. Oxford, 1993.
9. Ross MW, McLaws ML. Subjective norms about condoms are better predictors of use and intention to use than attitudes. Health Educ Research 1992; 7 (3): 335-339.