The World Health Organization’s (WHO) surgical checklist is an effective intervention
to decrease morbidity and mortality in surgical procedures 1]–4] and, thus, to increase patient safety. The checklist is now strongly recommended
for adoption by international experts as an effective, yet economically simple intervention
5]. One important aspect in implementing the checklist has recently and repeatedly been
stated: Simply implementing the checklist does not necessarily lead to improvements
in patient safety 6]. The essential requirement for the checklist to be effective is staff compliance
1], 4]. However, compliance rates are often far below 100 % 7]–9]. A multitude of possible reasons on organisational as well as individual level have
been proposed to explain low compliance rates, for example lack of knowledge 10] and the way the checklist is implemented in the first place and how it is accompanied
by supportive activities 11].
Individual-centred explanations draw on psychological antecedents of intentions to
either use or not to use the surgical checklist. A widely used theory to explain motivation
of individuals to engage in health related behaviour is the “the theory of planned
behaviour†(TPB) 12], 13]. To date, the TPB seems to be the most popular theoretical framework in order to
explain determinants and antecedents of health-related behaviour. It has been used
in different health behaviour contexts such as smoking, dieting, or exercising 12], 14]–16]. More recently, the theory has been applied to engagement in patient safety-related
behaviours, for example, patients’ involvement in error-preventing behaviours in Chemotherapy
and infection prevention 17]–19]. However, the TPB has not only been applied in the context of general health-related
behaviour but also in terms of explaining facilitators and barriers of behaviour change
of health-care workers concerning patient safety. The theoretical domains framework
(TDF) tries to provide a theoretical framework to understand and explain behavioural
change of individuals in the health-care domain 20]. Different theoretical approaches (e.g. TPB) have been combined in the TDF in order
to explain, when and how and why individuals engage in patient safety behaviour. In
a study by Taylor et al. 21] the TDF has been applied to explain the mechanisms and barriers underlying behavioural
change concerning the positioning of nasogastric tubes prior to feeding. Aspects that
added to the understanding were, amongst others, borrowed from the TPB. The TPB, hence,
seems to be a reasonable construct to apply when trying to explain possible behaviour
changes in health-care workers behaviour. In brief, the TPB states that intentions
to perform a behaviour are influenced by three major factors: a) attitudes towards
the behaviour, that is whether it is evaluated as favourable or unfavourable, b) subjective
norms, that is the social pressure that is perceived concerning the performance or
not-performance of the behaviour, and c) perceived behaviour control, that is to which
extent individuals perceive themselves as being capable to successfully perform the
behaviour 12]. All three components affect the formation of intentions to perform the behaviour
or not (see Fig. 1). The TPB has also been applied to patient safety related behaviours: Schwappach
and Wernli 17] studied the relationship between patients’ attitudes, norms, and perceived behaviour
control, as well as patients’ intentions to contribute to drug administration safety
during chemotherapy. They found that attitudes, norms, and perceived behaviour control
significantly contributed to the patients’ intentions. Luszczynska and Gunson 19], for example, found a significant relation between perceived behaviour control and
the intention to ask staff about hand washing in patients with MRSA. O’Boyle et al.
found the TPB variables to predict health care workers’ intention to handwash, and
their intention was related to self-reported hand hygiene 22]. Outside healthcare, Fogarty and Shaw used the TPB to model procedural violation
behaviours in aircraft maintenance which are often associated with incidents and accidents
23]. Their model highlighted the importance of management attitudes and group norms as
direct and indirect predictors of violation behaviour.
Fig. 1. Conceptual model of the theory of planned behaviour 38]
Generally, the more favourable the attitudes, the stronger subjective norms and the
greater the perceived behavioural control, the more likely intentions in favour of
the behaviour are built. Regarding the antecedents of intentions, Ajzen and Manstead
12] summarized different studies concerning a broad range of health-care related behaviour.
In studies on physical exercise, the use of illicit drugs, eating a low-fat diet,
consuming dietary products, and performing breast self-examinations, they found correlations
between attitudes and intentions of .42 and .70, between subjective norms and intentions
of .33 and 55, and between perceived behaviour control and intentions of .48 and 80.
These studies indicate that all three components serve as a valuable predictor of
intentions to perform a specific behaviour.
Intentions in turn are predictive of actual behaviour, though the strength of this
relationship varies over situations and is influenced by different other aspects 12], 24]. It has been argued that intentions and actual behaviour can only be consistent if
beliefs are the same across both, the hypothetical and the real situation. Although
perceived behaviour control, attitudes and norms contain a stable core, that is, invariant
across situations, they are still influenced by different contextual cues. Depending
on the situation, different aspects of perceived behaviour control and attitudes become
more salient than others and may, hence, determine the actual behaviour. Hypothetical
and actual situations are qualitatively different and trigger different facets of
attitudes, norms, and perceived behaviour control. The more closely related perceived
behaviour control and attitudes are to the real situation, the greater the predictive
value of the TPB 24]. That is the closer attitudes and perceived behaviour control contentually resemble
the real situation, the greater the predictive power. If individuals voice attitudes
and perceived behaviour control that do not closely match the situation under study,
the predictive value of this self-reporting decreases. A meta-analysis of the intention-behaviour
relationship suggests that a medium-to-large change in intention is needed to achieve
a small-to-medium change in behaviour. Behaviours are performed in “social contextâ€
and intentions usually exert less strong influence when there is potential for social
reaction 25]. However, concerning intention-building, the TPB has proven to be of predictive value
12].
To the best of our knowledge, the TPB has not been applied to the context of determinants
of surgical checklist use. With checklist use as behaviour of interest, the TPB would
predict that positive beliefs about the usefulness of the checklist and its value
for patient safety would positively influence intentions to use the surgical checklist.
If individuals perceive strong subjective norms that their co-workers and/or superiors
expect the use of the checklist and individuals highly value these expectations, intentions
to use the checklist should be positively influenced. Finally, if individuals perceive
high levels of control over the target behaviour to be successfully conducted, intentions
to use the checklist should be positively influenced. However, use of the checklist
is embedded in a highly social context. It requires teamwork with co-workers of different
professions, roles, hierarchies and power differentials. Intentions to use the checklist
may therefore be influenced by professional relations and power. Attitudes, norms,
and perceived behaviour control may also be systematically influenced by hierarchical
positions. Individuals holding a leading position within a team usually have greater
decisional power than individuals without an executive position. Perceived behavioural
control describes peoples’ perception of the difficulty to successfully perform the
behaviour of interest. Although perceived behavioural control reflects a person’s
perception of control and not his or her objective level of control, the experience
of being able to make decisions which influence team routines may support a general
feeling of greater behavioural control in a specific environment. Hence, perceived
behaviour control might be more distinct in individuals with managerial function.
Due to greater autonomy of decision that is an inherent aspect of leadership positions,
the perceived capability of successfully conducting a specific behaviour should be
greater. As a consequence, levels of perceived behaviour control should be higher
which should result in stronger intentions. We would hence expect perceived behaviour
control as being more distinct in individuals with managerial function and, ultimately,
being of greater predictive power concerning intentions. Compliance with checklist
use has often been found to vary 1], 26], 27]. However, reasons for the variation are difficult to find. In analysing whether the
general TPB model fits the data of the present study, we present an important prerequisite
for future studies to analyse the relation of behaviour antecedents as described with
the TPB and actual behaviour.
Taken together, the aims of the present study were twofold: First, we used the TPB
to model the relationship between norms, attitudes and perceived behavioural control
on intentions to use the WHO surgical checklist. Second, we examined whether individuals
with and without managerial function differ systematically with respect to the variables
of the TPB.