Thinking about implementation using normalization process theory

Thinking through ‘implementation’ using normalization process theory to understand the dynamics of complex interventions in health services research Carl May Ph.D www.normalizationprocess.org July 2010: Summer Institute on Health Services Research, University of Victoria, British Columbia

co-investigators
Luciana Ballini (Bologna)
Tracy Finch (Newcastle)
Anne Macfarlane (Galway)
Elizabeth Murray (London)
Frances Mair (Glasgow)
Tim Rapley (Newcastle)
Shaun Treweek (Dundee)
work described in this presentation is funded by the UK Economic and Social Research Council

health services research
“ a field of inquiry that examines the impact of the organization, financing and management of health care services on the delivery, quality, cost, access to and outcomes of such services” (WHO 2007).

health services research
core problems:
identifying and evaluating new and modified ways of organizing and delivering healthcare
identifying and understanding the relationships between measurable inputs (investments) and outputs (effectiveness)
need for structured rigorous research in messy contexts

complex interventions
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.

complex interventions
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)
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)
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
NPT is a middle range theory that can underpin process evaluations of complex interventions in health care

normalization process theory
explains how material practices become routinely embedded in their contexts
explains the routine embedding practices by reference to four generative mechanisms (coherence; cognitive participation; collective action; reflexive monitoring).
explains how the work, (individually and collective), of implementing practices requires continuous investment in ensembles of action that carry forward in time and space.

normalization process theory focuses on the work that people do
generative processes of individual and communal sense making .
driven by investments in meaning .
generative processes of cognitive participation .
driven by investments in commitment
generative processes of collective action .
driven by investments in effort .
generative processes of individual and communal reflexive monitoring .
driven by investments in appraisal .

it’s all about the work
what is it?
who does it?
how does it get done?
why did it happen like that?

NPT simplified
theories are abstract and need to be translated for everyday users
constructs and components of NPT can be translated them into simple statements for managers, clinicians, and researchers
heuristic devices to think through implementation problems not to measure them

example: falls prevention initiative (FPI) in hospital definition: a fall is an unplanned descent to the floor intervention: identify and monitor patients at risk of falling

falls prevention: coherence work
nurses distinguish the FPI from current ways of working
nurses collectively agree the purpose of the FPI
nurses individually understand what the FPI requires of them?
nurses construct potential value of the FPI for their work

falls prevention: participation work
key nurses initiate the FPI
nurses agree that the FPI is a legitimate part of their work
nurses join in delivering the FPI
nurses continue supporting the FPI

falls prevention: enacting work
nurses perform the tasks required by the FPI
nurses maintain their trust in each others’ work and expertise through the FPI
the work of the FPI is allocated appropriately to nurses
the FPI is supported adequately by its host organization

falls prevention: appraisal work
nurses access information about the effects of the FPI
nurses collectively assess the FPI as worthwhile work for patients
nurses individually assess the FPI as worthwhile work for themselves
nurses modify their work in response to their appraisal of the FPI

can 16 questions kill an intervention?
our work is aimed at more than theoretical understanding
we seek to develop modeling techniques that will help forecast emergent implementation problems and identify techniques to solve them
if 16 questions could kill an intervention, would that be a good thing?

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 .

thank you

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Thinking about implementation using normalization process theory

by Carl May on Jul 30, 2010

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