Implementation Toolkit: using Normalization Process Theory to implement and evaluate complex interventions and new technologies in healthcare

The NPT Toolkit for evaluating health technologies and complex interventions

Carl May, Tracy Finch, Luciana Ballini, Anne MacFarlane, Elizabeth Murray, Frances Mair, Shaun Treweek, Tim Rapley

www.normalizationprocess.org

© The authors 2010/ contact [email protected]

this presentation

introduces basic concepts of Normalization Process Theory (NPT) and the NPT Toolkit

purpose of the NPT toolkit is to provide managers, clinicians and researchers with a robust conceptual model of implementation and integration processes around new health technologies and complex interventions

quick introduction to NPT

normalization process theory

explains factors that promote and inhibit implementation, and explains how complex interventions in health care become embedded and integrated in practice

theory lite?

theories are abstract and need to be translated for everyday users

constructs and components of NPT can be translated into simple statements for managers, clinicians, and researchers

simplified statements are heuristic devices to think through implementation problems, not to measure them

what is a complex intervention?

a complex intervention is any deliberately initiated attempt to introduce new, or modify existing, patterns of collective action in health care or some other formal organizational setting.

deliberate initiation means that an intervention is: institutionally sanctioned; formally defined; consciously planned; and intended to lead to a changed outcome.

initiators of a complex intervention may seek to modify the ways that people think, act and organize themselves in health care, or they may seek to initiate a process with the intention of creating a new outcome.

complex interventions

elements of complex interventions directed at actors often seek to change behaviour and its intended outcomes (e.g. strategies for making ‘expert patients’; or new professional roles)

elements of complex interventions aimed at objects often seek to change expertise and actions (e.g. novel therapeutic agents and medical devices; or decision-making tools and clinical guidelines)

elements of complex interventions aimed at contexts often to seek to change the procedures enacted to achieve goals. (e.g. digital delivery, or organisational structures)

most complex interventions engage with multiple actors, objects, and contexts simultaneously

normalization process theory

• explains how interventions become routinely embedded in their contexts

• explains routine embedding by reference to four mechanisms (coherence; cognitive participation; collective action; reflexive monitoring).

• explains how the work, (individually and collective), of implementing interventions requires investment in action.

four constructs of NPT

coherence: defines and organizes the components of a practice

collective Action: defines and organizes the enacting of a practice

cognitive Participation: defines and organizes the people implicated in a complex intervention

reflexive Monitoring: defines and organizes assessment of the outcomes of a practice

normalization process theory focuses on the work that people do

processes of individual and communal coherence and sense making.

processes of cognitive participation.

processes of collective action. processes of individual and

communal reflexive monitoring.

it’s all about the work

what is the work? who does the work? how does the work get get done? why did the work happen like that?

quick introduction to the NPT toolkit

www.normalizationprocess.org

is an on-line resource to help clinicians, managers, and researchers think through problems of implementation, embedding, and integration

is not a validated survey instrument is a resource that can be used when planning

or appraising the implementation and integration of a new technology or complex

intervention

www.normalizationprocess.org provides clinicians, managers, and researchers with

a toolkit to think through key issues around implementation, embedding, and

integration

components of coherence work

differentiation defines an [intervention] and organises its relationships with other practices and contexts;

communal specification or co-ordination forms and organises shared beliefs and knowledge about the purpose of the [intervention];

individual specification forms and organises personal beliefs and knowledge about the demands of the [intervention];

internalization defines the value of the [intervention] to its users.

toolkit items assessing coherence work

1. [participants] distinguish the [intervention] from current ways of working

2. [participants] collectively agree the purpose of the [intervention]

3. [participants] individually understand what the [intervention] requires of them?

4. [participants] construct potential value of the [intervention] for their work

toolkit users can use slide-bars to begin to work through their subjective assessment of

coherence work

components of participation work

initiation brings an [intervention] into practice;

legitimation forms and organises shared beliefs about the legitimacy of participating in the [intervention];

enrolment forms and organises the ways that participants join in the [intervention]

activation forms and organises the ways that participants continue to support the [intervention]

toolkit items assessing participation work

5. [participants] work to initiate the [intervention]

6. [participants] agree that the [intervention] is a legitimate part of their work

7. [participants] join in delivering the [intervention]

8. [participants] continue supporting the [intervention]

toolkit users can use slide-bars to begin to work through their subjective

assessment of participation work

components of collective action

skill-set work of allocation and performance of the tasks related to an [intervention];

relational integration in which confidence and accountability of an [intervention] are formed and organised;

interactional work in which the [intervention] is a vehicle for deciding and disposing of operational problems;

contextual integration in which material and interpersonal resources are realised and policies and procedures executed to support the [intervention].

toolkit items assessing enacting work

9. [participants] perform the tasks required by the [intervention]

10. [participants] maintain trust in each others’ work and expertise through the [intervention]

11. the work of the [intervention] is allocated appropriately to [participants]

12. the [intervention] is supported adequately by its host organization

toolkit users can use slide-bars to begin to work through their subjective

assessment of collective action

components of appraisal work

systematizing forms and organises knowledge about the effects of the [intervention]

communal appraisal people work together to assess whether the effects of the [intervention] are worthwhile for others

individual appraisal people assess whether the effects of an [intervention] are worthwhile for themselves

reconfiguration organizes changes in the ways that the [intervention] is enacted

questions assessing appraisal work

13. [participants] access information about the effects of the [intervention]

14. [participants] collectively appraise the [intervention] as worthwhile for others

15. [participants] individually appraise the [intervention] as worthwhile for themselves

16. [participants] modify their work in response to their appraisal of the [intervention]

toolkit users can use slide-bars to begin to work through their subjective

assessment of monitoring work

interpreting results

interpreting the report reports consist of a primary graph that

represents all 16 items, and four graphs that describe responses for each of the theory's four constructs. 

to properly interpret graphic results users need to familiarize themselves with the core constructs of NPT.

health warning the toolkit is not a scientific instrument. The bars

do not provide objective scores for variables. they are heuristic tools to think through an

implementation or integration process. instruments to measure NPT constructs need to

be constructed using a different set of techniques.

the results page provides a global picture of

implementation work in relation to NPT

the results page provides specific feedback on implementation and embedding – relating these to the

four constructs of NPT

www.normalizationprocess.org

NPT focuses attention on factors already empirically demonstrated to be important in promoting or inhibiting implementation, embedding, and integration of complex interventions the toolkit provides a simplified version of NPT suitable for use as an aid to critical thinking

key papers

May C, Finch T. Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology 2009; 43:535-54. Available here

May C, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science 2009; art4. Available here.

normalization process theory

This work was supported by the UK Economic and Social Research Council (Grant 189250003)

.

Carl MayProfessor of Healthcare InnovationFaculty of Health SciencesUniversity of SouthamptonSouthampton, UK

[email protected]