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Master Class 
‘Getting new ideas into practice: 
normalising the implementation of 
complex interventions across the 
heal...
Programme 
09:30 Welcome, Ian Renwick, Chair of the ‘Collaborating for Better Care Partnership’ 
09.35 Introduction, Dr Tr...
Welcome 
Ian Renwick 
Chair, Collaborating for Better Care Partnership 
(Chief Executive, Gateshead Health NHS 
Foundation...
Wi-fi access 
@AHSN_NENC 
#NPTmaster 
Network: NUFC guest 
Password: newcastle 
Takes you to loading page- enter following...
Introduction 
Dr Tracy Finch 
Senior Lecturer in Psychology of Healthcare, 
Newcastle University 
Dr Tim Rapley 
Lecturer ...
Today 
• Introduction to Normalization Process Theory as one 
approach within Implementation Science 
• Very interactive –...
Pre-MasterclassSurvey 
Response rate: between 29-38 of 60 (48% -63%) across the survey. 
0 
2 
4 
6 
8 
10 
12 
Healthcare...
Familiar with NPT? 
0 2 4 6 8 10 12 14 16 
Never heard of before 
Heard of it but don't 
know about it 
Heard presentation...
Hoping to take away from the day? 
• Practical knowledge to apply in practice (11/23) 
• Develop implementation strategy (...
Interventions appraised 
using the survey 
45% (17/38) used ‘own example’: 
• Electronic monitoring 
systems 
• self-care ...
A brief background on ‘Implementation’ 
• Problem of getting ‘proven’ interventions and 
therapies into practice – ‘implem...
Why is ‘implementation’ so difficult? 
Complex interventions: 
“Conventionally defined as interventions with several inter...
Normalization Process Theory 
• Theory of how new technologies and practices become ‘normalised’ 
• Focuses on how impleme...
The key theory papers….
What is NPT? 
A way of thinking about implementation problems that focuses on: 
How interventions can become part of ever...
What is NPT useful for? 
We suggest that the NPT can act as a 
sensitising tool, enabling researchers to think 
through is...
Summary of NPT literature 
• Qualitative review of 29 studies that used NPT, between 
2006 & 2012 
• Mixed methods, but mo...
Decision Support Technologies 
Telecare services 
Mental Health 
COPD 
Infertility 
Depression 
Chronic Constipation 
TB 
...
NPT Projects & Collaborators 
ESRC ‘Toolkit’ Grant 189-25-0003: ‘Normalizing new health 
technologies - building a web-ena...
Task One: WHAT is NPT? 
Dr Tim Rapley
• Think with NPT via practical examples … 
• Not a sacred object - use, adapt, tailor …
NPT launch
• Participants distinguish the intervention from 
current ways of working 
• Whether the intervention is easy to describe ...
• Who are the participants? 
– Technology of LIFELAX intervention 
• Trial team - intervention deliverers 
• General Pract...
• Participants distinguish the intervention from current ways 
of working 
– Technology of LIFELAX intervention 
• Trial t...
Task One: Group Work 
• 5 minutes … 
– Read scenario; 
– Focus on one group of participants; 
– Discuss potential implemen...
What is NPT? 
A way of thinking about implementation problems that focuses on: 
How interventions can become part of ever...
Introducing NPT 
Carl May 
Professor of Healthcare Innovation, 
University of Southampton
Individual behaviour, practice implementation, and organizational integration: introducing Normalization Process Theory 
C...
Acknowledgements: Frances Mair, Tracy Finch, Catherine Pope, Anne MacFarlane, Shaun Treweek, Tim Rapley, BieNioOng, Mark J...
There is nothing so practical as a good theory 
Kurt Lewin 
43
It’s all about the work 
•What is the work? (How is a practice made coherent by its users?) 
•Who does the work? (How do p...
TRANSLATIONAL GAPS MATTER IN HEALTHCARE 
45
T1research seeks to move a basic discovery into a candidate health application; 
T2research assesses the value of T1applic...
47 
Picture: courtesy of Prof KJ Pienta
1. CROSSING THE GAPS AT T3AND T4 
48
What is implementation? 
•Implementation includes anydeliberately initiated attempt to introduce new, or modify existing, ...
What is implemented? 
Interventions 
–may be intended to change behaviour and its intended outcomes (e.g. strategies for m...
A technology is nota ‘thing’ 
•It is an ensemble of beliefs, techniques, artefacts, behaviours, interactions, and relation...
2. THEORY IS A PRACTICAL TOOL FOR THINKING ACROSS GAPS 
52
Theories are the basic building blocks of Science 
•Theories are structured rational explanations of structures, relations...
Processes are changes in state over time 
•Implementation is the process that takes place after a decision to adopt a new ...
More than 60 theories, models, and frameworks relevant to implementation are available to practitioners and researchers* 
...
•Why is it so difficult to implement new technologies in practice? 
•Need to understand how new ways of thinking, acting a...
Capability: How users interact with interventions*May C: A rational model for assessing and evaluating complex interventio...
Screening for intimate partner violence in NSW 
•Interactional workability: Intervention impacts on interactions between h...
Hoberg, A. et al., Feasibility evaluation of Interpersonal and Social Rhythm GroupTherapyDelivery Model Archives of Psychi...
Contribution: the work that people do to implement complex interventions 
Coherence:defines and organizes the components o...
Quality improvement collaborative for depression (13 primary care MDTs, Netherlands) 
•Coherence: The stepped-care model o...
Collective Action: What do I need to do to use the decision aid? 
Coherence Does it make sense to use a decision aid to do...
Relationships between capability, contribution and context* 
65 
(Context 1) Capacity: social structural resources (norms,...
key papers 
May C, Finch T. Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociol...
68 
Thank you!
Normalisation for whom? 
• Back to complexity – different roles, different perspectives: 
– Front end clinical staff ‘ v ’...
Example: Teledermatology 
Specialist Dermatology Nurses 
Consultant Dermatologists 
Patient Advocacy 
Coherence 
‘Yes’ as ...
Task Two: Group work 
• Focusing on your ‘ ase study’ and within small groups: 
– Agree at least 2 or 3 roles whose perspe...
Task Two: Group Feedback 
• Discussion: 
– What were the challenges of taking different 
perspectives? 
– Any roles that w...
Using NPT within different 
methodological approaches 
Different purposes, 
different methods 
Dr Tracy Finch
Applying NPT 
Two ways of thinking about this: 
1) What is the objective you want to achieve? 
– Designing an intervention...
NPT: Developing, evaluating, 
implementing….. 
• NPT has a role in developing, evaluating and implementing 
complex interv...
Developing an intervention 
E.g. ImPACT – support of low back pain management in Primary 
Care using physiotherapists 
• D...
NPT: Optimising evaluation of a 
complex intervention 
• Example: WISE (Whole System Informing Self-management 
Engagement...
NPT: Planning implementation 
E.g. Robotic Urological Surgery – NPT used by commissioning agency to 
plan implementation a...
Regional Implementation of Robotic Surgery
NPT Users’ Manual: Methodological 
Guidance 
‘Advice’ Sections on: 
• Reviews 
• Surveys 
• Qualitative research 
• Trials...
Using NPT in Systematic Reviews 
1) Determine research questions and overall design of 
a systematic review; 
2) Serve as ...
Example: NPT based review of e-Health 
• Systematic ‘review of reviews’ to understand barriers and 
facilitators to e-Heal...
Using NPT in Qualitative Research 
• Majority of NPT studies have used qualitative 
approaches 
• Useful for identifying, ...
Using NPT in Qualitative 
Research 
Consider: 
• NPT is not a methodology or a method, and should be 
used in a flexible a...
Example: NPT & implementing 
interpreters 
Context: Uptake of language interpreter services within primary 
care, Ireland....
NPT & Qual
Using NPT in Surveys 
• The ‘How much?’ question: 
– Structured surveys have the potential to collect data 
efficiently, a...
NPT in Survey research: 
Examples 
• Development of NPT based instrument (TARS) for 
normalisation of e-health. 
• NoMAD s...
NPT in Survey research: Some 
considerations 
• Usually useful for giving ‘breadth’ of perspectives 
rather than depth – i...
Using NPT in Trials 
• An intervention can be demonstrated as ‘effective’ in a trial 
context, but problematic to ‘impleme...
Using NPT – bear in mind! 
• NPT is not about an individual’s intentions and perceptions it is 
focused on helping you to ...
Task Three: Group work 
WHEN and HOW might I use NPT? 
• In small groups, discuss (20 mins) & feed back on 
these question...
What is NPT? 
A way of thinking about implementation problems that focuses on: 
How interventions can become part of ever...
Keep up to date with developments: 
• Sign up for the e- bulletin at the registration desk (if you haven’t 
already) 
Reso...
Thank you
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory
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Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory

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Master Class Presentation slides for 'Getting ideas into Practice: normalising the implementation of complex interventions across the healthcare system', Collaborating for Better Care Partnership Master Class with Dr Tracy Finch, Professor Carl May, Dr Tim Rapley.

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Master Class 'Getting New Ideas in to Practice' presentation, Normalisation Process Theory

  1. 1. Master Class ‘Getting new ideas into practice: normalising the implementation of complex interventions across the healthcare system’ 23rd October 2014 @AHSN_NENC #NPTmaster
  2. 2. Programme 09:30 Welcome, Ian Renwick, Chair of the ‘Collaborating for Better Care Partnership’ 09.35 Introduction, Dr Tracy Finch & Dr Tim Rapley 09.45 Task One: WHAT is NPT? 09:55 Workshop One - Using NPT to think through implementation scenarios 10:15 Group feedback 10:30 Introducing NPT; Carl May, Professor of Healthcare Innovation University of Southampton 11.00 Refreshment Break 11.15 Task Two: WHO should use NPT? 11.25 Workshop Two – Understanding different user perspectives 11.45 Group feedback 12.00 Lunch 12.45 Using NPT within different methodological approaches, Dr Tracy Finch 13.05 Task Three: WHEN and HOW might I use NPT? 13.15 Workshop Three – Understanding application of NPT for different ‘problems’ 13.35 Group feedback 14:00 NPT: Key Messages, Dr Tim Rapley & Dr Tracy Finch 14.20 Questions & Answers 15.00 Close @AHSN_NENC #NPTmaster
  3. 3. Welcome Ian Renwick Chair, Collaborating for Better Care Partnership (Chief Executive, Gateshead Health NHS Foundation Trust)
  4. 4. Wi-fi access @AHSN_NENC #NPTmaster Network: NUFC guest Password: newcastle Takes you to loading page- enter following log in details: User name: guest1 Password: premier100
  5. 5. Introduction Dr Tracy Finch Senior Lecturer in Psychology of Healthcare, Newcastle University Dr Tim Rapley Lecturer in Medical Sociology, Newcastle University
  6. 6. Today • Introduction to Normalization Process Theory as one approach within Implementation Science • Very interactive – we get to ‘play’ with the theory! • Stimulate thinking and, through discussion, generate some ideas about how you might use NPT in your own work
  7. 7. Pre-MasterclassSurvey Response rate: between 29-38 of 60 (48% -63%) across the survey. 0 2 4 6 8 10 12 Healthcareprofessional Clinicalacademic Researcher/ non-clinacademic Managerial/ servicedevelopment Other Total responses: 29
  8. 8. Familiar with NPT? 0 2 4 6 8 10 12 14 16 Never heard of before Heard of it but don't know about it Heard presentations or read papers Used theory or toolkit before Total responses: 29
  9. 9. Hoping to take away from the day? • Practical knowledge to apply in practice (11/23) • Develop implementation strategy (3/23) • Improve knowledge & understanding of implementation process/NPT (5/23) • Learn about new innovations (3/23) • Time to think about own evaluation (1/23)
  10. 10. Interventions appraised using the survey 45% (17/38) used ‘own example’: • Electronic monitoring systems • self-care initiatives • NHS health checks • multi-disciplinary care teams/pathways • hospital at home • brief alcohol intervention (pharmacy) • evidence-based commissioning, • decision-support • staff training packages….. Feedback on results to come after the event…
  11. 11. A brief background on ‘Implementation’ • Problem of getting ‘proven’ interventions and therapies into practice – ‘implementation science’ • Calls for implementation strategies and evaluations to be more theory-based • But theories differ in focus - individual, organisational, or the intervention?
  12. 12. Why is ‘implementation’ so difficult? Complex interventions: “Conventionally defined as interventions with several interacting components, they present a number of special problems for evaluators, in addition to the practical and methodological difficulties that any successful evaluation must overcome. Many of the extra problems relate to the difficulty of standardising the design and delivery of the interventions, their sensitivity to features of the local context, the organisational and logistical difficulty of applying experimental methods to service or policy change, and the length and complexity of the causal chains linking intervention with outcome.” From www.mrc.ac.uk/complexinterventionsguidance
  13. 13. Normalization Process Theory • Theory of how new technologies and practices become ‘normalised’ • Focuses on how implementing a new intervention or practice involves people working together • Considers: – Attitudes and practices of different groups of people involved in implementing a new intervention – The context where it is being implemented – The intervention/practice itself May & Finch (2009). Implementing, integrating and embedding practices: an outline of normalization process theory. Sociology, 43 (3): 535-54.
  14. 14. The key theory papers….
  15. 15. What is NPT? A way of thinking about implementation problems that focuses on: How interventions can become part of everyday practice How different groups of people need to work together to achieve it How do I use it? Thinking of your intervention, use the four sets of questions on the right to identify possible barriers to successful implementation, and suggest solutions to improve the process.
  16. 16. What is NPT useful for? We suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. Growing body of studies that have used NPT in diverse contexts…..
  17. 17. Summary of NPT literature • Qualitative review of 29 studies that used NPT, between 2006 & 2012 • Mixed methods, but mostly qualitative – focus on understanding implementation process
  18. 18. Decision Support Technologies Telecare services Mental Health COPD Infertility Depression Chronic Constipation TB Midwifery Chronic Heart Failure Speech & Language therapy Language interpretation services E-Health initiatives (ICT) Back Pain Information systems Development (ISD) Chronic Kidney Disease 2012 Summary of NPT literature
  19. 19. NPT Projects & Collaborators ESRC ‘Toolkit’ Grant 189-25-0003: ‘Normalizing new health technologies - building a web-enabled toolkit for implementation practitioners. NoMAD study: ESRC Grant RES-062-23-3274: ‘Improving the normalisation of complex interventions: Developing quantitative measures for users based on Normalization Process Theory’. Service and Delivery Organisation (SDO): Research grant 08/1602/135. Understanding the implementation & Integration of e-health.
  20. 20. Task One: WHAT is NPT? Dr Tim Rapley
  21. 21. • Think with NPT via practical examples … • Not a sacred object - use, adapt, tailor …
  22. 22. NPT launch
  23. 23. • Participants distinguish the intervention from current ways of working • Whether the intervention is easy to describe to participants and whether they can appreciate how it differs or is clearly distinct from current ways of working.
  24. 24. • Who are the participants? – Technology of LIFELAX intervention • Trial team - intervention deliverers • General Practitioners • Practice Managers • Practice Nurses • Patients
  25. 25. • Participants distinguish the intervention from current ways of working – Technology of LIFELAX intervention • Trial team - intervention deliverers • General Practitioners • Practice Managers • Practice Nurses NOT AT ALL • Patients
  26. 26. Task One: Group Work • 5 minutes … – Read scenario; – Focus on one group of participants; – Discuss potential implementation problems. • 15 minutes … – Go through the 16 NPT tool questions – one by one; – Use the questions to structure your discussion of the potential implementation problems.
  27. 27. What is NPT? A way of thinking about implementation problems that focuses on: How interventions can become part of everyday practice How different groups of people need to work together to achieve it How do I use it? Thinking of your intervention, use the four sets of questions on the right to identify possible barriers to successful implementation, and suggest solutions to improve the process.
  28. 28. Introducing NPT Carl May Professor of Healthcare Innovation, University of Southampton
  29. 29. Individual behaviour, practice implementation, and organizational integration: introducing Normalization Process Theory Carl May PhD
  30. 30. Acknowledgements: Frances Mair, Tracy Finch, Catherine Pope, Anne MacFarlane, Shaun Treweek, Tim Rapley, BieNioOng, Mark Johnson, Anne Rogers, Nilay Shah, Catherine O’Donnell, Elizabeth Murray, Peter Griffiths, Jane Gunn, Victor Montori •Grant RES 000-27-0084 •Grant RES 189-25-0003 •Grant RES 062-23-3274
  31. 31. There is nothing so practical as a good theory Kurt Lewin 43
  32. 32. It’s all about the work •What is the work? (How is a practice made coherent by its users?) •Who does the work? (How do people and groups come toparticipateinto a complex intervention?) •How does the work get done? (How is a complex intervention enactedin practice?) •Why did the work happen like that? (How is a complex intervention monitoredby its users?)
  33. 33. TRANSLATIONAL GAPS MATTER IN HEALTHCARE 45
  34. 34. T1research seeks to move a basic discovery into a candidate health application; T2research assesses the value of T1application for health practice (leading to the development of evidence-based guidelines); T3research attempts to move (evidence-based guidelines) into health practice, through delivery, dissemination, and diffusion research; T4research seeks to evaluate the “real world” health outcomes of a T1application in practice. Used by kind permission: Pienta, K. http://kenpienta.com/lab/translational- research/(accessed 12 September 2013)
  35. 35. 47 Picture: courtesy of Prof KJ Pienta
  36. 36. 1. CROSSING THE GAPS AT T3AND T4 48
  37. 37. What is implementation? •Implementation includes anydeliberately 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. •Participants may seek to modify the ways that people think, act and organize themselves or others, they may seek to initiate a process with the intention of creating a new outcome.
  38. 38. What is implemented? Interventions –may be intended to change behaviour and its intended outcomes (e.g. strategies for making ‘expert patients’; or using telemedicine systems) –may be intended to change expertise and actions (e.g. devices; or decision-making tools and clinical guidelines) –may be intended to change the procedures enactedto achieve goals. (e.g. electronic health records, ordering systems)
  39. 39. A technology is nota ‘thing’ •It is an ensemble of beliefs, techniques, artefacts, behaviours, interactions, and relationships. •People work to give ‘it’ coherence, organize participation, collectively enact‘it’ and monitorits effects
  40. 40. 2. THEORY IS A PRACTICAL TOOL FOR THINKING ACROSS GAPS 52
  41. 41. Theories are the basic building blocks of Science •Theories are structured rational explanations of structures, relationships, identities and processes •Theories are conceptual toolkits: they help us differentiate, characterize, and understand natural and social phenomena
  42. 42. Processes are changes in state over time •Implementation is the process that takes place after a decision to adopt a new way of conceptualizing, enacting and organizing practice –“the way we are going to do things here” •Normalization is the process by which activities and their consequences become routinely incorporated in everyday work –“the way we do things here, it’s just natural”
  43. 43. More than 60 theories, models, and frameworks relevant to implementation are available to practitioners and researchers* 55 Focus on attributes of organizations and policy environments (inner and outer contexts), reflects influence of diffusionmodels. Heavy emphasis on individual differences (attitudes and intentions), reflects influence of psychological individualism. Much less interest in implementation processes * TabakRG, KhoongEC, Chambers DA, BrownsonRC: Bridging Research and Practice: Models for Dissemination and Implementation Research. Am J PrevMed 2012, 43(3):337-350.
  44. 44. •Why is it so difficult to implement new technologies in practice? •Need to understand how new ways of thinking, acting and organizing become embedded in healthcare systems. •Need a conceptual map for the process evaluation of complex interventions and for the organization of implementation processes.
  45. 45. Capability: How users interact with interventions*May C: A rational model for assessing and evaluating complex interventions in health care. BMC Health ServRes 2006, 6(86 ) Interactional workability: how a complex intervention is practically operationalized by the people using it Skill-set workability: the distribution and conduct of work associated with a complex intervention in a division of labour Relational integration: how knowledge and work about a complex intervention is mediated and understood within networks. Contextual integration: the realization of resources of a complex intervention within an organizational domain.
  46. 46. Screening for intimate partner violence in NSW •Interactional workability: Intervention impacts on interactions between health worker and women. Direct and scripted brief intervention, favourableresponse from women. •Relational integration: intervention improves trust between professionals and women in interactions. Adds to confidence about mechanisms for referral and care pathways. •Skill-set workability: Intervention fits with existing role definitions. Questions prescribed, universal, embedded in brief intervention. •Contextual integration: Institutional processes support intervention. Clear support for implemention. Annual monitoring of outcomes. *SpangaroJ, et al: Pandora Doesn't Live Here Anymore: Normalization of Screening for Intimate Partner Violence in Australian Antenatal, Mental Health, and Substance Abuse Services. Violence and Victims 2011, 26(1):130-144. 60
  47. 47. Hoberg, A. et al., Feasibility evaluation of Interpersonal and Social Rhythm GroupTherapyDelivery Model Archives of Psychiatry In Press Supporting implementation design
  48. 48. Contribution: the work that people do to implement complex interventions Coherence:defines and organizes the components of a complex intervention Collective Action:defines and organizes the enacting of a complex intervention Cognitive Participation: defines and organizes the people implicated in a complex intervention Reflexive Monitoring: defines and organizes assessment of the outcomes of a complex intervention *May C, Finch T: Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology 2009, 43(3):535-554.
  49. 49. Quality improvement collaborative for depression (13 primary care MDTs, Netherlands) •Coherence: The stepped-care model offered clinicians a technique for shared understanding on depression (who is severely and non severely depressed). •Cognitive participation: The new low intensity stepped-care treatment options fitted well into the primary care perspective. •Collective action: The possibility to tailor the stepped-care model to the local setting, and to train staff to apply the stepped-care interventions was important, but poor organizational infrastructures and lack of funding of the new low intensive interventions. •Reflexive monitoring: Improved motivation because outcome measurement can structure and advance care for individual patients. But absence of supportive systems (ICT, reminder systems) or staff. FranxG, et al,. Implementing a stepped care approach in primary care Implement Sci2012, 7(8) 63
  50. 50. Collective Action: What do I need to do to use the decision aid? Coherence Does it make sense to use a decision aid to do my job? Reflexive Monitoring: How well was I able to use the decision aid? Do I understand the decision aid? Patients –yes Bedside nurse –yes Nurse Practitioner -yes Patients –yes Cardiologist -no Bedside nurse -yes Study coordinator -no Nurse Practitioner -yes Are there resources? Do we have the skills? Cognitive Participation: Are the tasks feasible? Can we work together on this? Patients –yes Nurse Practitioner -yes Patients –yes Bedside nurse –no Nurse Practitioner -yes Mullan RJ, et al., Will this decision aid be implemented? The AMI Choice Decision Aid Trial. 5thInternational Shared Decision-Making Conference, Boston, October 2009 (Slide courtesy of Rebecca Mullan).u
  51. 51. Relationships between capability, contribution and context* 65 (Context 1) Capacity: social structural resources (norms, roles) available to agents Contribution: agency expressed through coherence; participation; action; monitoring (Context 2) Potential: social cognitive resources (intentions, commitments) available to agents Capability: workability and integration of the implementation object ay . . Implement ci 13 (1).
  52. 52. key papers May C, Finch T. Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology2009; 43:535-54. Available here May C, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science2009; 4. Available here. May C, Towards a general theory of implementation. Implementation Science 2013, 8:18 Available here 67
  53. 53. 68 Thank you!
  54. 54. Normalisation for whom? • Back to complexity – different roles, different perspectives: – Front end clinical staff ‘ v ’ interventions – Team leaders/supervisors – multiple hats? – Others in the referral process (eg. primary/secondary care interface; different departments) – Admin/technical/support staff – can sometimes be the key people – Evaluators/researchers – different agendas to service delivery? – Senior managers/planners/quality assurance
  55. 55. Example: Teledermatology Specialist Dermatology Nurses Consultant Dermatologists Patient Advocacy Coherence ‘Yes’ as skill development; ‘No’ as autonomy limited ‘No’ as didn’t seem to save patients travelling Initially, yes as a tool for reducing waits Initially, yes as protecting professional territory In practice found didn’t save time or waiting Lack of fit with problems of skin Emphasised need for seeing/touching /talking with the patient Cognitive Participation Engaged. Close partnership with consultant. Engaged but sceptical Saw that many patients would want F2F consult Collective Action Logistical problems re primary care placements Constrained by electronic proforma Data transfer did not happen Lacked relational integration -found high need to see patients anyway. [Not involved] Reflexive Monitoring Some access to data, but felt lack of worth effort Data on processes & outcomes disappointing & never published. Unsure of evidence Finch TL, MairFS, May CR. Teledermatologyin the U.K.: Lessons in service innovation. British Journal of Dermatology 2007, 156(3), 521-527.
  56. 56. Task Two: Group work • Focusing on your ‘ ase study’ and within small groups: – Agree at least 2 or 3 roles whose perspectives should be represented and decide who is wearing which ‘hat’ (5 mins) – Work through the tool, u c ‘ ’ representative feeds into answering the items (15 mins) – Completing the whole tool is unlikely – skip ahead to different items if you wish
  57. 57. Task Two: Group Feedback • Discussion: – What were the challenges of taking different perspectives? – Any roles that were more/less difficult to accommodate in working through? – Any suggestions for ensuring relevant perspectives get captured?
  58. 58. Using NPT within different methodological approaches Different purposes, different methods Dr Tracy Finch
  59. 59. Applying NPT Two ways of thinking about this: 1) What is the objective you want to achieve? – Designing an intervention? – Planning Implementation? – Designing and conducting an evaluation? 2) If research, what methodological approach is most useful? – i.e. qualitative; survey; trials; systematic reviews…
  60. 60. NPT: Developing, evaluating, implementing….. • NPT has a role in developing, evaluating and implementing complex interventions • Need to distinguish between: 1. The intervention – would continue after 2. The evaluation – wouldn’t continue after • Consider long term impact: – Effectiveness in the ‘real world’ – How widely it can be implemented
  61. 61. Developing an intervention E.g. ImPACT – support of low back pain management in Primary Care using physiotherapists • Define the ‘context’ – possible changes? – Staff groups affected – Other initiatives going on that might compete? • Define the ‘intervention’ • Undertake NPT analysis of the intervention – NPT as a framework for ‘thinking it through’ • May need literature review, primary data collection, workshop discussions etc PROCEDE TO EVALUATION OR ABANDON??? Outcome: Low coherence to GPs identified & addressed – led to better participation & fit with existing practices
  62. 62. NPT: Optimising evaluation of a complex intervention • Example: WISE (Whole System Informing Self-management Engagement) 1. Define context • factors that might affect engagement with the study? • Timing of data collection against clinical activity? 2. Define the trial parameters - consider all the different patient and professional groups likely to be affected 3. NPT analysis of trials • How will the study procedures affect the work of people it depends upon? Outcome: NPT used to optimise training content by anticipating and overcoming ‘participation’ issues NPT AS A ‘TRIAL KILLER’??
  63. 63. NPT: Planning implementation E.g. Robotic Urological Surgery – NPT used by commissioning agency to plan implementation across Emilia-Romagna (Italy). 1. Consider context – If previously developed and evaluated, what is different about the new context? – Might the intervention need reconfiguration? 2. Define the intervention – Easier said than done! (eg. technology, new practice, or some combination of both?) 3. NPT analysis – Use NPT to maximise approach to implementation
  64. 64. Regional Implementation of Robotic Surgery
  65. 65. NPT Users’ Manual: Methodological Guidance ‘Advice’ Sections on: • Reviews • Surveys • Qualitative research • Trials Key points: • Guidance only – actual approach you take must be tailored to needs of specific study context • Suggests ‘considerations’ based on experience of using NPT with respect to these varied methodological approaches
  66. 66. Using NPT in Systematic Reviews 1) Determine research questions and overall design of a systematic review; 2) Serve as a framework for data analysis within a systematic review; OR…. 3) Support the interpretation of a systematic review's results.
  67. 67. Example: NPT based review of e-Health • Systematic ‘review of reviews’ to understand barriers and facilitators to e-Health Implementation • Statements of results/findings coded against constructs of the NPT • Emphasis on Contextual Integration (Collective Action) issues in literature • Less on interactions with patients, inter-professional relationships, and fit with existing staff skills and roles • Policymakers are getting a misleading impression from the literature Mair F, May C, O'Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health systems: An explanatory systematic review. Bulletin World Health Organisation 2012, 90 (5), 357-64
  68. 68. Using NPT in Qualitative Research • Majority of NPT studies have used qualitative approaches • Useful for identifying, describing and understanding implementation process • Can be used to guide: – Research focus and questions – Research design – Sampling – Data collection – Coding and analysis of data
  69. 69. Using NPT in Qualitative Research Consider: • NPT is not a methodology or a method, and should be used in a flexible and dynamic way • NPT is ‘ ’ – may be used alongside other theories/approaches • Using NPT in qualitative research requires translating the constructs for use in your own context/study
  70. 70. Example: NPT & implementing interpreters Context: Uptake of language interpreter services within primary care, Ireland. Data: Interviews and focus groups (GPs, managers, interpreters, service users) Approach: Themes coded against part of NPT Added value: Enabled them to bring together disparate themes to clearly identify key ‘barriers and levers’ to uptake See: acFarlane A O’Reilly-de BrúnM. Using a Theory-Driven Conceptual Framework in Qualitative Health Research. Qualitative Health Research, 2012;22(5):607-18.
  71. 71. NPT & Qual
  72. 72. Using NPT in Surveys • The ‘How much?’ question: – Structured surveys have the potential to collect data efficiently, and on a large scale • The ‘what is likely to happen?’ question: – Surveys, used prospectively, may have some predictive utility with respect to outcomes • Potentially useful in comparative research • Surveys are appealing to practitioners and researchers - facilitate take-up of the Theory!
  73. 73. NPT in Survey research: Examples • Development of NPT based instrument (TARS) for normalisation of e-health. • NoMAD study: Aims to develop and test NPT based measures of implementation process and outcome. Project website: http://www.esrc.ac.uk/my-esrc/ grants/RES-062-23-3274/read
  74. 74. NPT in Survey research: Some considerations • Usually useful for giving ‘breadth’ of perspectives rather than depth – ie numbers of staff • Recognize limits in using survey data – ‘measurement’ vs ‘planning’ vs ‘appraisal’ (both?) • Some survey tools now available – but still need to ‘customise’ and ‘localise’ how you use them
  75. 75. Using NPT in Trials • An intervention can be demonstrated as ‘effective’ in a trial context, but problematic to ‘implement’ in the real world. Consider: Who are the people I expect to use the results of my trial and what can I do to make sure that these people will not be forced to dismiss my trial as irrelevant to them, their patients, or their healthcare systems? Another example: Forster et al (2011) – team vs caseload models in midwifery services (Melbourne).
  76. 76. Using NPT – bear in mind! • NPT is not about an individual’s intentions and perceptions it is focused on helping you to making sense of collective, distributed, patterns of work. • NPT will encourage you to focus on the range of people, situations, times and places that are involved in all aspects of enacting implementation • BUT – the context is all important, and NPT needs to be adapted/translated to the context of use • NPT is NOT a theory of everything – and we are depending on users/testers/sceptics to test its limits!
  77. 77. Task Three: Group work WHEN and HOW might I use NPT? • In small groups, discuss (20 mins) & feed back on these questions: 1. Would you use NPT/the toolkit? 2. When might you want to use it? 3. How would you use it? 4. What data would you collect? Note: General discussion in relation to your use, rather than case study from previous tasks.
  78. 78. What is NPT? A way of thinking about implementation problems that focuses on: How interventions can become part of everyday practice How different groups of people need to work together to achieve it How do I use it? Thinking of your intervention, use the four sets of questions on the right to identify possible barriers to successful implementation, and suggest solutions to improve the process.
  79. 79. Keep up to date with developments: • Sign up for the e- bulletin at the registration desk (if you haven’t already) Resources will be available on: You Tube - video will be uploaded (a link included in next e- bulletin) Slide Share - slide deck will be uploaded (link included in next e-bulletin) AHSN web site www.ahsn-nenc.org.uk NEQOS web site www.neqos.nhs.uk/ Twitter - @AHSN_NENC
  80. 80. Thank you

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