The use of theory in research

There is a trend of the increasing use of theory within healthcare research generally and pharmacy practice research specifically. Theory is defined as

‘…an explanation of a phenomenon arrived through examination and contemplation of the relevant facts; a statement of one or more laws or principles which are generally held as describing an essential property of something’. (62) Theories can help to explain, predict, and understand

phenomena and, in many cases, to challenge and extend existing knowledge.

Theories can also connect pieces of research data to generate findings which fit into a larger body of other studies.

Two ‘theories’ were used in this research: Reason’s Accident

Causation(63,64) as described in Chapter 1 and the Theoretical Domains Framework (TDF)(65-67), which is an integrative framework developed from other theories hence is not a theory in itself. Reason’s Accident causation model was applied in phases two and three and TDF in phase three.

2.7.1 The Theoretical Domains Framework

Evidence suggests that behavioural change interventions using a theoretical basis are far more effective than those developed using a more pragmatic approach. Whereas many other theories focus on individual factors (such as a belief, motivation etc.), the Theoretical Domains Framework (TDF) is an integrative framework developed from a synthesis of psychological theories aimed to propose interventions aimed at behaviour change. The TDF was developed by a group of psychological theorists, health service researchers and health psychologists. It is derived from 33 theories of behaviour change, comprising 14 domains and 84 constructs that allows synthesis of a

multitude of coherent behavior change theories into a single, integrative framework. TDF allows assessment and explanation of behaviour and associated barriers and enablers and inform the design of appropriately targeted interventions. (65-67)

In the current research TDF was applied to characterise the determinants of a range of behaviours and to identify the barriers and facilitators that

influenced the medication error reporting and causality at HMC.

The TDF domains and their descriptors are given in Table 2.8.

Table 2-8: The Theoretical Domain Framework (adapted from Atkin et al)

Domain Examples

Knowledge An awareness of the existence of something Skills An ability or proficiency acquired through practice Social/Professional role and

identity A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting Beliefs about capabilities Acceptance of the truth, reality, or validity about an

ability, talent, or facility that a person can put to constructive use

Optimism The confidence that things will happen for the best or that desired goals will be attained

Beliefs about consequences Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation

Reinforcement Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus

Intentions A conscious decision to perform a behaviour or a resolve to act in a certain way

Goals Mental representations of outcomes or end states that an individual wants to achieve

Memory, attention and

decision processes The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives

Environmental context and

resources Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour Social influences Those interpersonal processes that can cause

individuals to change their thoughts, feelings, or behaviours

Emotion A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event

Behavioural regulation Anything aimed at managing or changing objectively observed or measured actions

2.7.2 James Reason’s Accident Causation Model

The historical person-centred approach to error used in healthcare and other industries is based on the philosophy that errors occur due to human

weakness. (68-70) This approach was widely criticised for being blame oriented, wherein an individual is deemed completely responsible for errors and not providing attention to system-related issues. In 1990, James Reason introduced the ‘accident causation model’, a system centred model focusing on the principle that errors occur due to flaws in the much larger system and that humans are just a small part. (64) Prior to its use in the healthcare, this model was initially used in nuclear industry, aviation industry etc. (69)

Several studies have previously adapted the accident causation model to understand medication errors and medication non-adherence. (70-74) According to this model, a system is compared to a knife that has a sharp end (active failures) and a blunt end (latent failures). Active failures mostly occur due to frontline workers, they are unsafe acts that are conducted by people who are in direct contact with the patients or the system itself. Active failures are subcategorised as slips, lapses, mistakes and violations. While

‘slips’ and ‘lapses’ occur when a right plan is executed incorrectly, ‘mistakes’

and ‘violations’ happen when an incorrect plan is formulated and then

followed. Active failures do not occur in isolation, but instead are believed to have a casual history and occur due to error provoking conditions that lie deep rooted within the system (latent failures). Error provoking conditions such as lack of knowledge among the staff, busy working environment etc.

are anticipated to occur due to latent failures such as poor organisational policies or lack of budget for training and development. Latent failures are considered as inevitable and they lie dormant within the system, these mostly occur due to wrong strategic decisions, incorrect planning at top level management. Understanding such errors are important as they lead to proactive management and prevent errors and thus promote patient safety.

(64,69,70)

Table 2-9: James Reason’s Accident Causation model, with descriptions of types of failures

Reasons Accident Causation model with illustrations

Slips When a step of the plan is performed wrongly, e.g. choosing a wrong medication from the shelf during dispensing

Lapse When a step of a plan is missed or omitted, e.g. omitting prescribing a medication following reconciliation

Mistakes Occurs due to misapplication of rules or lack of knowledge, e.g. prescribing a wrong dose or medication due to lack of knowledge

Violations

Occurs when a person intentionally chooses not to follow the rule or policy (may not be with a purpose to cause harm, but to save time or achieve something more easily), e.g.

prescribing an unauthorised medication to save time; not following the hospital policy/guideline while prescribing, dispensing or administering a medication

Error provoking

conditions Active failures result from the error provoking conditions such as patient factors, individual, team, environment etc.

Latent failures

Error provoking conditions are hidden within the

organisational and surrounding culture, e.g. lack of budget to hire staff and provide training, lack of transparency among the healthcare professionals and patients, lack of resources to manage drug information questions etc.

Figure 2-2 James Reason’s Swiss Cheese Model illustrating the consequences of failures aligning.