A toolkit for complex interventions and health technologies using normalization process theory
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A toolkit for complex interventions and health technologies using normalization process theory

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A toolkit for complex interventions and health technologies using normalization process theory A toolkit for complex interventions and health technologies using normalization process theory Presentation Transcript

  • A toolkit for evaluating health technologies and complex interventions using Normalization Process Theory Carl May, Tracy Finch, Luciana Ballini, Anne MacFarlane, Elizabeth Murray, Frances Mair, Shaun Treweek, Tim Rapley www.normalizationprocess.org © The authors 2010/ contact berg206@gmail.com
  • 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 reflexive Monitoring : defines and organizes assessment of the outcomes of a practice cognitive Participation : defines and organizes the people implicated in a complex intervention collective Action : defines and organizes the enacting of a practice coherence : defines and organizes the components 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
    • [participants] distinguish the [intervention] from current ways of working
    • [participants] collectively agree the purpose of the [intervention]
    • [participants] individually understand what the [intervention] requires of them?
    • [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
    • [participants] work to initiate the [intervention]
    • [participants] agree that the [intervention] is a legitimate part of their work
    • [participants] join in delivering the [intervention]
    • [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
    • [participants] perform the tasks required by the [intervention]
    • [participants] maintain trust in each others’ work and expertise through the [intervention]
    • the work of the [intervention] is allocated appropriately to [participants]
    • 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
    • [participants] access information about the effects of the [intervention]
    • [participants] collectively appraise the [intervention] as worthwhile for others
    • [participants] individually appraise the [intervention] as worthwhile for themselves
    • [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 May
    • Professor of Healthcare Innovation
    • Faculty of Health Sciences
    • University of Southampton
    • Southampton, UK
    • [email_address]