Dear Editor,

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 Practices (PSPs).

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 mainstream PSPs.

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 time.5-9

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 evaluate interventions.

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: 484-492.

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.

Conflict of Interest:

None declared