Background
Normalisation Process Theory
Coherence | Cognitive Participation | Collective Action | Reflexive Monitoring | |
---|---|---|---|---|
Construct | The process and work of sense making and understanding that individuals and organisations undertake that promote or inhibit the routine embedding of a practice | The process and work that individuals undertake to promote engagement with the new practice | The work done by individuals and organisations to enact the new practice. | The work inherent to formal and informal appraisal of new practice, to enable assessment of advantages and disadvantages, developing users comprehension of the effects of a practice |
Sub-constructs | Differentiation Do stakeholders see this as a new way working? | Enrolment Do the stakeholders believe they are the correct people to drive forward the implementation? | Interactional workability Does the intervention make it easier or harder to complete tasks? | Systemisation Will stakeholders be able to judge the effectiveness of the intervention? |
Individual specification Do individuals understand what tasks the intervention requires of them? | Initiation Are they willing and able to engage others in the implementation? | Skill set workability Do those implementing the intervention have the correct skills and training for the job? | Individual appraisal How will individuals judge the effectiveness of the intervention? | |
Communal specification Do all those involved agree about the purpose of the intervention? | Activation Can stakeholders identify what tasks and activities are required to sustain the intervention? | Relational integration Do those involved in the implementation have confidence in the new way of working? | Communal appraisal How will stakeholders collectively judge the effectiveness of the intervention? | |
Internalisation Do all the stakeholders grasp the potential benefits and value of the intervention? | Legitimation Do they believe it is appropriate for them to be involved in the intervention? | Contextual integration Do local and national resources and policies support the implementation? | Reconfiguration Will stakeholders be able to modify the intervention based on evaluation and experience? |
Normalisation Process Theory’s use in implementing health service interventions
Rationale for this review
Complexity of the UK primary health care system
Purpose of the review
Methods
Search and screening strategy
Search terms | |
1. Setting “primary care” OR “family practice” OR “general practice” | |
2. Study type “intervent*” OR “programme” OR “improv*” OR “evaluation” | |
3. Intervention activity “Normalisation Process Theory” OR “NPT” | |
4. Location “United Kingdom” OR “UK” OR “Great Britain” OR “Brit*” OR “Engl*” OR “Northern Ir*” OR “Scot*” OR “Wales” OR “Welsh” | |
Search Combinations 1 AND 2 AND 3 AND 4 |
Inclusion criteria | |
• Method: Must use NPT • Setting: Primary care • Geography: United Kingdom • Time: 1 Jan 2012–1 Apr 2018 • Language: English • Document type: Empirical research • Availability: Full-text available |
Data extraction
Risk of bias assessment
Data analysis
Results
Search results
Risk of bias assessment
Article characteristics
Author and Date | Location | Design | Method | Setting | Sample | Topic | Implementation Stage |
---|---|---|---|---|---|---|---|
England | Mixed Methods | Semi-structured interviews; focus groups; synthesis of qualitative literature; quantitative systematic review | Primary care | Patients (n = 50); Patient interviewees (n = 16); HCP interviewees (n = 16) | Blood pressure | Development | |
England | Qualitative | Semi-structured interviews | Primary care | Patients (n = 11); GP (n = 8) | ME/CFS | Evaluation | |
England | Qualitative | Ethnographic | Primary care | Patients (n = 20); Telephone Support Workers (n = 3) | Chronic kidney disease | Trial | |
Scotland | Qualitative | Semi-structured interviews and focus groups | Primary care | GP (n = 25) | Electronic referral system | Evaluation | |
Scotland | Qualitative | Semi-structured interviews and focus groups | Primary care | GP (n = 25) | Electronic referral system | Evaluation | |
Scotland | Qualitative | Semi-structured interviews and focus groups | Primary care Secondary care | Patients (n = 30); Carers (n = 20); Community Care Professionals (n = 39); Heart Failure Specialists (n = 22); Palliative Care Professionals (n = 4) | Chronic heart failure | Development | |
Scotland | Qualitative | Semi-structured interviews and group interviews | Primary care Community health | Patients (n = 32); Carers (n = 3); HCP (n = 28) | COPD | Trial | |
England | Qualitative | Semi-structured interviews and focus groups | Primary care | GP (n = 13); PN (n = 9); Practice Managers (n = 5); Practice Administrators (n = 23) | Patient feedback | Evaluation | |
England | Qualitative | Semi-structured interviews | Primary care | Case managers (n = 6); Supervisors (n = 5); GP (n = 15) | Collaborative care: Depression | Evaluation | |
Europe (Austria, England, Greece, Ireland, Netherlands, Scotland) | Documentary review | Mapping | Primary care | Cross-cultural communication | Development | ||
England | Mixed-methods | Semi-structured interviews; patient survey; e-consultation data | Primary care | Primary care practice stakeholders [GP (n = 10); Nurse Practitioner (n = 1); Practice Managers(n = 6); Practice Administrators (n = 6)]; Patients (n = 75) | e-consultation | Evaluation | |
England | Qualitative | In-depth interview | Primary care | GP (n = 17); Practice Managers/Administrators (n = 9); Practice Pharmacists (n = 3) | Prescribing | Evaluation | |
Scotland | Mixed-methods | Patient data, semi-structured interviews (practice nurses and patients) | Primary care | PN (n = 10); patients (n = 14) | Asthma management | Trial | |
England | Mixed-methods | Semi-structured interviews and survey data | Primary care | Patients (n = 24) and Stakeholders from 31 practices including GP; Nurses, Practice manager and Administrators | Long-term conditions | Evaluation | |
England | Qualitative | Semi-structured interviews | Primary care | PN (n = 11); Assistant Practitioners (n = 1) | Long-term conditions | Evaluation | |
England | Qualitative | Semi-structured interviews | Primary care | Psychological Well-being Practitioners (n = 6); PN (n = 17) | Collaborative care: Mental health co-morbidity | Evaluation | |
England | Qualitative | Case-study; semi-structured interviews; observations; semi-structured questionnaire, and documentary analysis | Primary care Secondary care Community health | Staff stakeholders (n = 213) | Integrated care | Evaluation | |
Europe (Austria, England, Greece, Republic of Ireland, Netherlands) | Qualitative | Stakeholder (JT PLA Style Focus Group) | Primary care | Total: n = 304 governmental and non-governmental agencies England n = 9. Total: Stakeholders (n = 78): England: Migrant Community stakeholders (n = 7); GP (n = 1), Interpreter (n = 1), Policy Maker (n = 1) | Guidelines and training initiatives (G/TIs) are available to support communication in cross-cultural consultations | Development | |
England | Qualitative | Semi-structured interviews | Primary care | GP (n = 7); PN (n = 5); Community Pharmacist (n = 5); Practice Pharmacist (n = 4); Practice Administrator (n = 2); HCA (n = 1); Patients (n = 5) | Prevention of acute kidney injury | Evaluation | |
England | Qualitative | Ethnographic | Primary care | GP (n = 9); PN (n = 4) | Osteoarthritis | Evaluation | |
England | Qualitative | Semi-structured interviews | Primary care | GP (n = 12); PN (n = 8); Pharmacists (n = 12); Patients (n = 10) | Acute kidney injury | Evaluation | |
England | Qualitative | In-depth, semi-structured interviews | Primary care | GP (n = 14) | Brief alcohol interventions | Evaluation | |
England | Qualitative | Ethnographic | Primary care | GP (n = 10); PN (n = 5) | Osteoarthritis | Evaluation | |
Wales | Qualitative | Semi-structured interviews and focus groups | Primary care | GP (n = 31); PN (n = 2); Practice Manager (n = 10) | Emergency admission prediction | Evaluation | |
England | Qualitative | Ethnographic | Primary care | HCP; Commissioners, and Patients. (n = unspecified) | Mental health | Evaluation | |
England | Quantitative | Survey | Primary care | Nurse Prescriber (n = 234); GP (n = 97); Pharmacist (n = 88) | Polypharmacy prescribing | Development | |
England | Qualitative | Semi-structured interviews | Primary care | GP (n = 9); PN (n = 13); Reception Staff (n = 7). | Sexual health | Evaluation | |
England | Qualitative | Semi-structured interviews | Primary care Secondary care | Primary Care Pharmacists (n = 2); Hospital Pharmacists (n = 9); Hospital Nurse (n = 3); Clinical Auditor (n = 1) | Prescribing safety | Evaluation | |
England | Qualitative | Semi-structured interviews and focus groups | Primary care | Patients (n = 50); Practice Staff (n = 7); Stakeholders (n = 11) | CPRD implementation | Evaluation | |
Europe (Austria, England, Greece, Republic of Ireland, Netherlands) | Qualitative | Ethnography | Primary care | 66 Stakeholders [GP (n = 14); PN (n = 8); Policy Makers (n = 12); Administrators (n = 6); Trainers (n = 4); Interpreters (n = 4); Migrants/Migrant Representatives (n = 18)] | Cross-cultural communication | Evaluation | |
England | Qualitative | Semi-structured interview | Primary care | Patients (n = 4); GP (n = 5); PN (n = 3); HCA (n = 1); mental health gateway worker (n = 1) | Collaborative care | Evaluation |
Date of publication and geography
Study design and methods
Study setting and sample
Operationalising normalisation process theory in UK primary care
Implementation stage
Primary care topics under investigation
Author rationale for NPT use
To aid design of instruments and procedures
To aid analysis
To aid implementation planning
Selection and application of NPT constructs
Frequency of construct occurrence
Alignment with NPT constructs and definitions
Application of NPT sub-constructs
Use and adaptation of NPT
Authors’ reflections on NPT use
Author reflection | Example quotation |
---|---|
“NPT helped to illuminate the context and localised systems approach that may need to be adopted to work with local stakeholders to implement sick day guidance” [49]. | |
“It is essential to understand the dynamic process of adaptation as an integral part of implementation and routinization, and to assess its contribution to eventual longer term outcomes (positive and negative)” [48]. | |
Perception that NPT facilitated appreciation of “beliefs and opinions of people with different sociocultural status and educational background” [60]. | |
Provides a uniform interpretation scheme for the different views and beliefs of a diverse group of stakeholders [60]. | |
“We have highlighted the use of Normalisation Process Theory to support development, and not just implementation, of a complex intervention” [48]. | |
In adopting this approach, the intervention was grounded “in an in-depth understanding of the barriers and facilitators most relevant to this specific intervention and user population” [31]. | |
“Whilst NPT is presented as a temporal process, analysis showed that many participants experience the constructs of NPT simultaneously” [28]. | |
Requires prior awareness of stakeholders and context in order to sensitise to the constructs [59]. | “We acknowledge that research teams found it difficult to answer some of the 16 sensitizing questions without knowing which stakeholders or sites were going to be involved with the implementation work” [53]. |
“There is a need for greater consideration in implementation theory of the importance of the patient role and the implementation work they need to do” [43]. | |
Places insufficient emphasis on those who receive complex interventions [43]. | |
Risk of artificially imposing (“shoehorning”) constructs onto data collection and analysis [48]. | “One tension in utilising such an approach is that it can influence the focus of the data collected, subsequent analysis, and the findings. But as detailed in the methods section we took steps to ensure themes, issues and topics which sat outside of the scope of NPT could be explored and accounted for” [48]. |
“…understanding of the obstacles and drivers associated with embedding real-time feedback in general practices has been enhanced by organising qualitative data according to NPT constructs. … it is important to note that all four NPT constructs operated and were experienced concurrently” [38]. |