Normalization Process Theory (NPT) provides an explanation for how new practices and technologies become routinely embedded into social contexts. It focuses on the work that individuals and groups do to implement, embed, and integrate new practices. NPT proposes that this work occurs through four generative mechanisms: coherence, cognitive participation, collective action, and reflexive monitoring. It explains embedding as an ongoing process that requires continuous investment from participants. NPT can be used as a research tool to understand how and why practices become routinely implemented in various organizational and social contexts.

1. Introduction to Normalization Process Theory: rationale, structure, and function Carl May & Tracy Finch www.normalizationprocess.org © The authors 2010/ contact [email_address]

2. rationale

3. why normalization process theory? robust social science theories already explain individual differences in attitudes to new technologies and practices (e.g. Theory of Planned Behavior) the flow of innovations through social networks (e.g. Diffusion of Innovations Theory) reciprocal interactions between people and artifacts (e.g. Actor Network Theory) NPT offers an explanation of the work of implementation, embedding, and integration – focusing on the agentic contribution of individuals and groups. NPT explains phenomena not well covered by existing theories.

4. definition definition of normalization: the routine embedding of a classification, artefact, technique or organizational practice in everyday life research question: how can those factors that promote or inhibit normalization be identified, conceptualized, and evaluated?

5. normalization process theory: aim to explain how practices are routinely embedded in their organizational and professional contexts to explain the routine embedding of practices by reference to the role of four generative mechanisms (coherence; cognitive participation; collective action; reflexive monitoring). to explain how the work, (individually and collective), of implementing practices requires continuous investment by participants in ensembles of action that carry forward in time and space.

6. normalization process theory: general propositions to understand the embedding of a practice we must look at what people actually do and how they work . practices become routinely embedded in social contexts as the result of people working, individually and collectively, to implement them. the work of implementation is operationalized through four generative mechanisms (coherence; cognitive participation; collective action; reflexive monitoring). the production and reproduction of a practice requires continuous investment by agents in ensembles of action that carry forward in time and space.

7. structure

8. the structure of NPT/ defining constructs and constraints NPT assumes four constructs representing generative mechanisms driven by investments of human agency. These are the means by which social goals are achieved and, in turn, are foci of contests and conflicts NPT assumes that individual and collective contributions are interdependent NPT mechanisms are constrained (and released) by the operation of norms (notions of how beliefs, behaviours, and actions should be accomplished); and conventions (how beliefs, behaviours, and actions are practically accomplished)

9. 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

10. phenomena represented by NPT constructs appear simultaneously in relation to each other, not sequentially all NPT constructs are not necessary to explain all phenomena phenomena represented by NPT constructs are constrained by norms and convention

11. the structure of NPT/ defining processes ‘ process’ refers to patterns of organized, dynamic, and contingent interaction between: agents (the individuals or groups that interact in encounters around a practice); o bjects (the classifications, artifacts, practices and procedures employed by agents) ; and contexts (the technical and organizational structures in which agents and objects are implicated).

12. NPT does not assume … a normative expectation that a practice ought to be implemented and voluntarism on the part of agents that a practice (or any of its components) is superior in performance to its alternatives or competitors that normalization is a necessary or automatic outcome of an implementation-embedding-integration process That normalization is a permanent state of affairs

13. the structure of NPT/ constructs, components, and constraints CONSTRUCT A CONSTRUCT B CONSTRUCT C CONSTRUCT D IMMEDIATE COMPONENTS C 3 & C 4 ORGANIZING COMPONENTS C 1 & C 2 CONSTRAINT: STRUCTURES & NORMS CONSTRAINT: PROCESSES & CONVENTIONS

14. construct/ coherence coherence: defines and organizes the components of a practice what is the work? Differentiation, communal and individual specification, and internalization

15. coherence/ components differentiation defines a practice and organizes its relationships with other practices and contexts; communal specification or co-ordination forms and organizes shared beliefs and knowledge about the purpose of the practice individual specification forms and organizes personal beliefs and knowledge about the demands of the practice internalization defines the value of the practice to its users.

16. coherence/ analytic model COLLECTIVE ACTION REFLEXIVE MONITORING COHERENCE COGNITIVE PARTICIPATION IMMEDIATE COMPONENTS (Individual Specification & Internalization) ORGANIZING COMPONENTS (Differentiation & Communal Specification) NORMATIVE CONSTRAINTS PROCESSUAL CONSTRAINTS

17. coherence/ general propositions embedding of a practice is dependent on work that defines and organizes it as a cognitive and behavioral ensemble. embedding work is shaped by factors that promote or inhibit actors’ apprehension of a practice as meaningful. the production and reproduction of a practice that actors collectively invest meaning in it.

18. construct/ cognitive participation cognitive participation: Work that defines and organizes the people implicated in a practice what is the work? Initation, legitimation, enrolment and activation

19. cognitive participation/ components initiation brings a practice into practice legitimation forms and organizes shared beliefs about the legitimacy of participating in a practice enrolment forms and organizes the ways that participants join in a practice activation forms and organizes the ways that participants continue to support a practice

20. cognitive participation/ analytic model REFLEXIVE MONITORING COHERENCE COGNITIVE PARTICIPATION COLLECTIVE ACTION IMMEDIATE COMPONENTS (initiation and legitimation) ORGANIZING COMPONENTS (enrolment and activation) NORMATIVE CONSTRAINTS PROCESSUAL CONSTRAINTS

21. cognitive participation/ general propositions embedding of a practice is dependent on work that defines and organizes its participants. embedding work is shaped by factors that promote or inhibit participants’ involvement. the production and reproduction of a practice requires that actors collectively invest commitment in it.

22. collective action/ construct collective action: Work that defines and organizes the enacting of a complex intervention what is the work? Interaction work, relational integration, skill-set work, contextual integration

23. collective action/ components skill-set work of allocation and performance of the tasks related to a practice relational integration in which confidence and accountability about a practice are formed and organised; interactional work in which the practice 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 a practice

24. collective action/ analytic model COHERENCE COGNITIVE PARTICIPATION COLLECTIVE ACTION REFLEXIVE MONITORING IMMEDIATE COMPONENTS (Interaction work & Relational Integration) ORGANIZING COMPONENTS (Skill set work & Contextual Integration) NORMATIVE CONSTRAINTS PROCESSUAL CONSTRAINTS

25. collective action/ general propositions embedding of a practice is dependent on work to operationalize it. embedding work is shaped by factors that promote or inhibit actors’ enacting it. the production and reproduction of a practice requires that actors collectively invest effort in it.

26. reflexive monitoring/ construct reflexive monitoring: defines and organizes assessment of the outcomes of a practice what is the work? Systematization, communal and individual Appraisal, and reconfiguration

27. reflexive monitoring/ components systematizing forms and organises knowledge about the effects of a practice communal appraisal people work together to assess whether the effects of a practice are worthwhile for others individual appraisal people assess whether the effects of a practice are worthwhile for themselves reconfiguration organizes changes in the ways that a practice is enacted

28. reflexive monitoring/ analytic model COGNITIVE PARTICIPATION COLLECTIVE ACTION REFLEXIVE MONITORING COHERENCE IMMEDIATE COMPONENTS (Individual Appraisal & Reconfiguration) ORGANIZING COMPONENTS (Systemization & Communal Appraisal) NORMATIVE CONSTRAINTS PROCESSUAL CONSTRAINTS

29. reflexive monitoring/ general propositions embedding of a practice is dependent on work that defines and organizes the everyday understanding of its effects. embedding work is shaped by factors that promote or inhibit individual and collective appraisal of the practice. the production and reproduction of a practice requires that actors collectively invest in its understanding .

30. normalization process theory can be used as a research and development tool to inform comparative investigations and case studies using qualitative methods provide a conceptual framework for explanatory systematic reviews suggest hypotheses for prospective quantitative studies understand the outcomes of service evaluations

31. this presentation summarizes four articles May, C., and T. Finch. 2009. Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology 43: 535-54. May, C., F.S. Mair, T. Finch, A. et al. 2009. Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science 4. May, C., T. Finch, F. Mair, et al. 2007. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Services Research 7. May, C. 2006. A rational model for assessing and evaluating complex interventions in health care. BMC Health Services Research 6: 1-11.

32. normalization process theory This work was supported by the Economic and Social Research Council Grants RES 000270084 and 189250003 .