Background
What is NPT and what does it do?
The purpose of this review
Methods
Systematic citation searches
Inclusion and exclusion criteria
Screening
Data extraction
Data analysis
Public registration of the review
Results
Search results
Types of studies
First author/first paper | Country of origin | Theory frame | Research problem | Evidence base cited to support intervention | Use of NPT specified in protocol | NPT study type | Data collected | Application of NPT to data | Factors leading to intervention success or failure | Differences between categories of participants | Differences between settings |
---|---|---|---|---|---|---|---|---|---|---|---|
1. Ballinger et al. [19] | UK | NPT | Stroke rehabilitation | Systematic review [149] | – | Process evaluation | Qualitative | Retrospective | Yes | No | No |
2. Bamford et al. [20] | UK | NPT | New professional roles in dementia care | Systematic review [150] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | No |
3. Blakeman et al. [21] | UK | NPT | Chronic kidney disease management (telephone support) | NICE guideline [151] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | No |
4. Blickem et al. [22] | UK | NPT | Self-management support for long-term conditions (telephone support) | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | No | |
5. Brooks et al. [23] | UK | NPT | Care planning (mental health) | Systematic review [152] | Yes | Intervention design | Qualitative | Prospective | Yes | Yes | Yes |
6. Buckingham et al. [24] | UK | NPT | COPD management in primary care | Systematic review [153] | – | Feasibility study | Mixed | Prospective | Yes | Yes | N/A |
UK | NPT | Stroke rehabilitation | Systematic review [154] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes | |
8. Coupe et al. [27] | UK | NPT | Collaborative care for depression | Yes | Process evaluation | Qualitative | Retrospective | Yes | Yes | Yes | |
9. Finch et al. [28] | UK | NPT | Cognitive behavioural therapy | Systematic review [156] | Yes | Feasibility study | Qualitative | Prospective | Yes | Yes | N/A |
Australia | NPT | Diabetes management in primary care | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | No | ||
11. Gabbay et al. [32] | UK | NPT | Debt counselling for depression in primary care | NICE guideline [178] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes |
12. Gask et al. [33] | UK | NPM | Collaborative care for depression | Systematic review [155] | Yes | Process evaluation | Qualitative | Retrospective | Yes | Yes | No |
UK | NPT | Primary care prescribing | NICE guideline [157] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | No | |
14. Godfrey et al. [36] | UK | NPT | Delirium prevention in hospital | Systematic review [158] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes |
15. Hind et al. [37] | UK | NPT | Aquatic therapy for children with Duchenne muscular Dystrophy | Yes | Feasibility Study | Qualitative | Prospective | Yes | No | No | |
Australia | NPT | Identifying women at risk of intimate partner violence | Yes | Process evaluation | Mixed | Prospective | Yes | Yes | Yes | ||
UK | NPT | Social network support in long-term conditions | Systematic review [159] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes | |
18. Khowaja et al. [47] | India, Mozambique, Nigeria, Pakistan | NPT | Maternal health in low-income countries | WHO guideline [160] | – | Feasibility study | Mixed | Prospective | Yes | Yes | Yes |
19. Leon et al. [48] | South Africa | NPM | Testing and counselling for HIV in South Africa | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | No | |
20. Mair et al. [49] | UK | NPM | Telemedicine for COPD | Systematic review [164] | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | N/A |
UK | NPT | Osteoarthritis guidelines in primary care | NICE guideline [165] | – | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes | |
22. Ricketts [53] | UK | NPT | Chlamydia screening in primary care | – | Process evaluation | Qualitative | Retrospective | Yes | No | No | |
23. Speed et al. [54] | UK | NPM | Management of constipation in primary care | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | No | |
24. Sturgiss et al. [55] | Australia | NPT | Weight management programme in primary care | Yes | Feasibility study | Quantitative (survey) | Prospective | Yes | No | No | |
UK | NPT | Stroke rehabilitation (incontinence) | RCP-ICSWP guideline [166] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes | |
26. Willis [58] | Australia | NPT | Community support for women with postnatal depression | Yes | Historical review of documents | Textual analysis | Retrospective | Yes | N/A | N/A |
Study | Country of origin | Theory frame | Implementation problem | Evidence base cited to support intervention | Use of NPT specified in protocol | NPT study type | Data collected | Application of NPT to data | Factors leading to intervention success or failure | Differences between categories of participants | Differences between settings |
---|---|---|---|---|---|---|---|---|---|---|---|
27. Aarts et al. [59] | Netherlands | NPM | Infertility support (online) | Systematic review [167] | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | N/A |
UK | NPT | Telecare/digital health in the community | Systematic review [168] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes | |
29. Alharbi et al. [63] | Sweden | NPT | Person-centred care | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | N/A | |
30. Ahmed et al. [64] | UK | NPT | Screening questionnaire (genetic conditions in primary care) | Systematic review [169] | – | Feasibility study | Qualitative | Retrospective | Yes | No | No |
31. Alverbratt et al. [65] | Sweden | NPT | Patient assessment tool in psychiatry | – | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes | |
32. Ariens et al. [66] | Netherlands | NPT | Teledermatology | Yes | Process evaluation | Quantitative (survey using eHit Toolkit [226]) | Prospective | Yes | No | No | |
33. Atkins et al. [67] | South Africa | NPM | Supporting treatment adherence in tuberculosis | Systematic review [170] | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | No |
34. Bamford et al. [68] | UK | NPT | Nutrition guidelines | FSA guideline [171] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | No |
35. Basu et al. [69] | UK | NPT | Improving motor outcome in infants after perinatal stroke | Feasibility study | Qualitative | Prospective | Yes | No | N/A | ||
36. Bayliss et al. [70] | UK | NPT | Training for chronic fatigue management | NICE guideline [172] | Feasibility study | Qualitative | Prospective | Yes | Yes | No | |
37. Bee et al. [71] | UK | NPT | Cognitive behavioural therapy by phone | Feasibility study | Qualitative | Prospective | Yes | No | No | ||
38. Bocum et al. [72] | Burkina Faso | NPM | Antenatal syphilis screening | Feasibility study | Qualitative | Retrospective | Yes | No | Yes | ||
39. Bouamrane and Mair [73] | UK | NPT | Surgical assessment (online) | Systematic review [168] | Yes | Process evaluation | Qualitative | Prospective | Yes | No | N/A |
40. Bouamrane and Mair [74] | UK | NPT | Electronic referrals (online) | Systematic review [168] | Yes | Process evaluation | Qualitative | Prospective | Yes | No | N/A |
41. Bouamrane and Mair [75] | UK | NPT | Surgical assessment (online) | Systematic review [173] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | N/A |
42. Bridges et al. [76] | UK | NPT | Compassionate nursing care | Yes | Process evaluation | Qualitative | Prospective | Yes | No | Yes | |
43. Chiang et al. [77] | Australia | NPT | Risk assessment tools | Systematic review [174] | – | Feasibility study | Qualitative | Prospective | Yes | No | No |
44. Conn et al. [78] | Canada | NPT | Improving recovery after colorectal surgery | Meta-analysis [175] | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | No |
45. Desveaux et al. [79] | Canada | NPT | Hospital accreditation | Systematic review [230] | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | yes |
46. Dickinson et al. [80] | UK | NPT | Cognitive stimulation for people with dementia | Process evaluation | Qualitative | Retrospective | Yes | Yes | Yes | ||
47. Dikomiitis et al. [81] | UK | NPT | Decision support tool for cancer | – | Feasibility study | Qualitative | Prospective | Yes | No | No | |
48. Drew et al. [82] | UK | ENPT | Fracture prevention clinics | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | No | |
49. Dugdale et al. [83] | UK | NPT | Substance misuse management (online) | – | Process evaluation | Qualitative | Prospective | Yes | Yes | No | |
50. Ehrlich [84] | Australia | NPT | Care coordination in long-term conditions | Yes | Field study | Qualitative | Prospective | N/A | N/A | N/A | |
51. Finch [85] | UK | NPM | Telecare/telemedicine | – | Field study | Qualitative | Prospective | Yes | No | No | |
52. Franx et al. [86] | Netherlands | NPT | Collaborative care for depression | NICE guideline [178] | Yes | Process evaluation | Qualitative | Retrospective | Yes | Yes | No |
UK | NPT | Stroke management using telecare | Systematic review [179] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | No | |
54. Foss et al. [89] | Norway | NPT | Social network mapping for chronic disease management | Systematic review [231] | Yes | Process evaluation | Qualitative | Prospective | Yes | No | No |
55. Foster et al. [90] | Australia | NPT | Diabetes management | Systematic review [180] | – | Feasibility study | Qualitative | Prospective | Yes | Yes | No |
56. Gould et al. [91] | UK | NPT | Infection prevention and control | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | No | |
57. Green et al. [147] | UK | NPT | Cancer risk assessment tool | NICE guideline [181] | – | Feasibility study | Qualitative | Retrospective | Yes | N/A | N/A |
58. Gunn et al. [92] | Australia | NPT | Reorganisation of primary care mental health services | Systematic review [155] | – | Process evaluation | Qualitative | Retrospective | Yes | No | Yes |
59. Hall et al. [93] | UK | NPT | Monitoring technologies in care homes for people with dementia | Systematic review [232] | Process evaluation | Qualitative | Retrospective | Yes | Yes | Yes | |
60. Hall et al. [94] | UK | NPT | Supporting staff working with people with autism | Yes | Process evaluation | Qualitative | Prospective | Yes | No | No | |
61. Hazell et al. [95] | UK | NPT | Guided self-help cognitive therapy | NICE guideline [233] | Yes | Process evaluation | Quantitative (survey) | Prospective | Yes | Yes | N/A |
62. Henderson et al. [96] | UK | NPT | Diagnostic decision support in primary care | – | Process evaluation | Mixed | Prospective | Yes | No | N/A | |
63. Herbert et al. [97] | UK | NPT | Enhanced recovery after surgery | Process evaluation | Qualitative | Prospective | Yes | Yes | N/A | ||
64. Hoberg et al. [98] | USA | NPM | Group therapy model | APA guideline [234] | – | Feasibility study | Qualitative | Prospective | Yes | No | No |
65. Holtrop et al. [99] | USA | NPT (collective action constructs) | Care management for chronic disease in primary care | Yes | Process evaluation | Qualitative | Prospective | Yes | No | Yes | |
66. Kanagasundaram et al. [100] | UK | NPT | Diagnostic decision support (acute kidney injury) | NICE guideline [183] | – | Feasibility study | Mixed | Retrospective | Yes | Yes | N/A |
67. Kulnik et al. [101] | UK | NPT | Inter-professional self-management support | Systematic review [184] | – | Process evaluation | Mixed | Prospective | Yes | Yes | Yes |
68. Johnson et al. [102] | UK | NPT | Guideline implementation | Overview of systematic reviews [235] | Yes | Process evaluation | Quantitative (prospective cohort intervention) | Prospective | Yes | Yes | N/A |
69. Jones, C. et al. [103] | UK | NPT | Diagnostic point of care testing | – | Ethnographic case study | Qualitative | Prospective | Yes | Yes | N/A | |
70. Jones, F. et al. [104] | UK | NPT | Self-care training programme for stroke practitioners | – | Process evaluation | Qualitative | Retrospective | Yes | No | No | |
71. Leggat et al. [105] | Australia | NPT | Quality improvement in hospitals | Systematic review [236] | No | Process evaluation | Qualitative | Retrospective | Yes | Yes | Yes |
72. Lhussier et al. [106] | UK | NPT | Care planning in primary care | No | Field study | Qualitative | Retrospective | Yes | Yes | N/A | |
73. Ling et al. [107] | UK | NPT | Integrated care policy | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | Yes | |
UK | NPT | Shared decision-making tools | Systematic review [185] | Yes | Feasibility study | Qualitative | Retrospective | Yes | Yes | Yes | |
75. Lowrie et al. [110] | UK | NPT | Chronic heart failure management in the community | NICE guideline [186] | – | Feasibility study | Qualitative | Retrospective | Yes | Yes | N/A |
76. Martindale et al. [111] | UK | NPT | Management of acute kidney injury in the community | NICE guideline [183] | – | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes |
77. May et al. [112] | UK | NPT | Telecare for chronic disease management in the community | Systematic review [164] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes |
78. Morton and Wigley [113] | UK | NPT | Nursing assessment tool for maternal/child health in the community | Yes | Process evaluation | Qualitative | Prospective | Yes | No | N/A | |
79. Murray et al. [114] | UK | NPT | E-health systems | Systematic review [187] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes |
80. Newton [115] | Australia | NPT | Caseload midwifery models | Systematic review [188] | Yes | Process evaluation | Mixed | Prospective | Yes | No | N/A |
81. Nordmark et al. [116] | Norway | NPT | Discharge planning | Systematic review [189] | – | Feasibility study | Qualitative | Prospective | Yes | Yes | Yes |
82. O’Connell and Kaner [117] | UK | NPT | Alcohol brief interventions in primary care | – | Field study | Qualitative | Retrospective | Yes | No | N/A | |
83. Owens and Charles [118] | UK | NPT | Text messaging in child and adolescent mental health services | Systematic review [190] | Yes | Feasibility study | Qualitative | Prospective | Yes | No | N/A |
84. Polus et al. [119] | Australia | NPM | Chiropractic services for indigenous Australians | – | Feasibility study | Qualitative | Prospective | Yes | Yes | N/A | |
UK | NPT | Decision support tools for emergency services | Yes | Process evaluation | Qualitative | Retrospective | Yes | Yes | Yes | ||
86. Røsstad et al. [122] | Norway | NPT | Care pathways for older patients | Systematic review [191] | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | No |
87. Sanders et al. [123] | UK | NPT | Back pain management in primary care | Yes | Process evaluation | Qualitative | Retrospective | Yes | No | N/A | |
88. Scalia [124] | USA | NPT | Option Grid decision support tools | Yes | Field study | Qualitative | Prospective | Yes | No | Yes | |
89. Scantlebury [125] | UK | NPT | Maternity unit electronic health record | Systematic review [192] | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | N/A |
90. Segrott et al. [126] | UK | ENPT | Adolescent substance misuse programmes | Systematic review [193] | Yes | Process evaluation | Mixed | Prospective | Yes | Yes | Yes |
91. Shemeili [127] | Abu Dhabi | NPT | Medicines management in hospital care of older people | Yes | Process evaluation | Qualitative | Prospective | Yes | No | N/A | |
92. Shulver et al. [128] | Australia | NPT | Telecare for older people | Yes | Field study | Qualitative | Prospective | Yes | Yes | Yes | |
93. Spangaro et al. [129] | Australia | NPM | Screening for intimate partner violence | Systematic review [238] | – | Process evaluation | Qualitative | Retrospective | Yes | No | N/A |
94. Stevenson [130] | UK | NPT | UK Clinical Practice Research datalink | Yes | Process evaluation | Qualitative | Prospective | Yes | No | No | |
95. Tarzia et al. [131] | Australia | NPT | Decision-making for older adults with dementia | – | Field study | Qualitative | Retrospective | Yes | Yes | N/A | |
96. Tazzyman et al. [148] | UK | NPT | Revalidation of medical practitioners | Yes | Process evaluation | Qualitative | Prospective (structured through the NoMAD Questionnaire) | Yes | Yes | N/A | |
97. Temple-Smith et al. [132] | Australia | NPT | Chlamydia testing in general practice | Yes | Process evaluation | Mixed | Prospective | Yes | No | No | |
Austria, England, Ireland, Greece, Netherlands | NPT | Migrant health | Yes | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes | ||
99. Thomas et al. [137] | Sweden | ENPT | Healthy lifestyle promotion in primary care | – | Process evaluation | Mixed | Retrospective | Yes | Yes | Yes | |
100. Tierney et al. [138] | Ireland | NPT | Interdisciplinary teams in primary care | Yes | Process evaluation | Quantitative | Prospective | Yes | Yes | No | |
101. Toye et al. [139] | Canada | NPT | Assessment instrument for homecare | Yes | Feasibility study | Qualitative | Prospective | Yes | Yes | Yes | |
102. Trietsch et al. [140] | Netherlands | NPT | Quality improvement collaboratives | Systematic review [197] | – | Process evaluation | Qualitative | Retrospective | Yes | Yes | Yes |
103. Vest et al. [141] | US | NPT | Clinical guideline implementation in chronic kidney disease | ACP guideline [198] | – | Process evaluation | Qualitative | Retrospective | Yes | N/A | N/A |
104. Volker et al. [142] | Australia | NPT | Cardiovascular disease prevention | – | Process evaluation | Qualitative | Prospective | Yes | Yes | Yes | |
105. Webster et al. [143] | UK | NPT | Delivery of a psychosocial intervention for people with depression and long-term conditions | Yes | Process evaluation | Qualitative | Prospective | Yes | No | No | |
106. Walker et al. [144] | Australia | NPT | Colorectal cancer risk prediction | NICE guideline [199] | – | Feasibility study | Qualitative | Retrospective | Yes | No | No |
107. Wilhelmsen et al. [145] | Norway | NPT | Web-based cognitive behavioural therapy | – | Feasibility study | Qualitative | Retrospective | Yes | No | No | |
108. Wilkes et al. [146] | UK | NPM | Open access infertility clinics | – | Feasibility study | Qualitative | Retrospective | Yes | Yes | No |
What was being implemented?
Was what was being implemented evidence-based?
How did researchers justify the use of NPT?
‘Normalisation Process Theory (NPT) has been used to consider complex interventions prior to the development of a randomised control trial to test their effectiveness (…). It has also been used in the context of mental health to explore the impact of new forms of collaborative care on the way in which professionals carry out their routines of work in primary care (…). The four constructs (coherence, cognitive participation, collective action and reflexive monitoring) permit a means of appraising factors that might ‘promote and inhibit the routine incorporation of complex interventions into everyday life’ (…). It focuses on the work that people need to do to ensure interventions become ‘normalised’. As a heuristic framework it can support the optimisation of a trial intervention at three points:
supporting intervention design describing the context of a trial supporting the interpretation of a trial’s results’ [23].
Did NPT explain implementation outcomes?
suggests that patient decision aids that are specifically designed for use in clinical encounters can be embedded in clinical settings, provided there is agreement about the need to use them, that the team members are willing to work together to make sure that such tools can be integrated in existing work patterns, and understood as making a positive overall contribution to the work that has to be performed. These considerations match the mechanisms of the NPT, which provides an explanatory framework for understanding the sustained use of these tools by the two systems examined. The motivation for the use of the Option Grid at CapitalCare was their wish to achieve success in an external quality improvement initiative. At HealthPartners, implementation efforts were motivated by a ‘champion’ physician. The nursing staff also played a pivotal role by systematically identifying eligible patients and providing those patients with the relevant encounter tool. These organizations, in different ways and to different degrees, exhibited coherence, collective action and cognitive participation that supported the sustained use of the tools. The organizational appraisal, in other words, their reflexive monitoring, was positive overall, despite concerns about readability and time pressures.(Part omitted)
Implementing patient decision aids into clinical settings is a difficult process (…) In the UK, an implementation program known as MAking Good Decisions In Collaboration (MAGIC) highlighted the need for an organizational coherence, i.e. a widely held and agreed understanding of SDM principles in order to facilitate the implementation of patient decision aids (…). Commitment at multiple organizational levels has been recognized as an important precondition for implementation (…). This lack of commitment was noticeable at the CapitalCare sites that did not use patient encounter tools [124].
‘This paper briefly considers implementation theories in respect of complex interventions and provides an overview of process evaluations to set the context for the study. We draw on Normalisation Process Theory (NPT) (…) as a conceptual lens through which to explore those features of the implementation process that were intended to secure practice change and to engage caregivers in the program. We also consider the interaction between influential macro and micro contextual factors that affected delivery by multi-disciplinary stroke unit staff and suggest that prior focus on generative mechanisms identified within NPT can be used to inform implementation processes within complex healthcare settings’ [26].
How did researchers apply the theory’s constructs?
‘We found that effective care management normalization required relationship development between practice providers and staff and the care manager. Since identification and referral of patients needing care management was key to care management happening at all, the practice personnel understanding and appreciating the care manager role through a relationship with the care manager was critical. This was captured well through the NPT collective action component of relational integration. We interpreted relational integration to be the professional relationship development that occurred when care manager, providers and practice staff work together and understand and appreciate each other’s roles and contribution to patient care. Although it is its own component in NPT, we found it to be more of an outcome that occurred when the other components worked well (contextual integration, skill set workability and interactional workability). (…) We found that when any of the other components were not in place, there was also a lack of development of trust around shared patient care. Since care management is a relationship rich endeavor, the lack of this relationship is a key factor in care management’s disuse’ [99].
non-linear and interact dynamically to provide a comprehensive explanation of the implementation processes. NPT was designed to be applied flexibly, can be used at one or more points in a qualitative study, has been successfully used beyond its original field and provides a robust theoretical framework to understand the dynamics of implementation [148].
has been to extend the use of NPT to explore the implementation of a broad and complex policy, with wide ranging implications for an entire profession, and the wider healthcare system. Much previous work using NPT in healthcare has addressed the implementation of micro level interventions. This expanded application of NPT has highlighted a number of factors which seem to have affected the implementation of revalidation. The four dimensions of the framework (see Table 3) had an intuitive relevance and provided a useful explanatory framework for understanding the implementation of revalidation. There is scope to apply NPT more widely to complex social interventions and policy initiatives at the organisational and system level in future [148].
Coherence ‘The significant qualities DLDA) | Cognitive participation ‘Enrolment and engagement of individuals and groups’ | Collective action ‘Interaction with already existing practices’ | Reflexive monitoring ‘How a practice is understood and assessed by actors implicated in it’ |
---|---|---|---|
Differentiation. Understanding the difference between DLDA and ‘the old fashioned way’ of working in a psychiatric nursing context. | Initiation. The participants’ motivation in trying to incorporate the DLDA Tool. | Interactional workability. Operating DLDA. | Systematisation. The participants’ judgement of DLDA regarding usefulness and effectiveness. |
Communal specification. The process through which users through teamwork share and create an understanding of this new practice. | Enrolment. The work participants do to organise themselves and their co-workers in the practice of DLDA. | Relational integration. Participants understandings of DLDA not only being aware of how and when to use DLDA, but also understanding the expressions of other staff members. | Communal appraisal. Communal appraisal regarding the outcomes and values of DLDA. |
Individual specification. The process in which users create an understanding of the new practice. | Legitimation. The belief that DLDA is right for the context in terms of being a needed complement to existing tools and approaches. | Skill-set workability. Refers to how DLDA is conducted and distributed. This will influence how the work is defined and divided between participants. | Individual appraisal. Individual appraisal regarding the outcomes and value of DLDA. |
Internalised meaning. The coherence of DLDA was based on the meaning users collectively invest in it. | Activation of DLDA. What the participants could do together to improve conditions for DLDA to be sustained and become part of daily practice. | Contextual integration. The incorporation of DLDA into a social context of the current wards. | Reconfiguration. Suggestions from participants that aim to modify and enhance the utility of the DLDA Tool. |
How did researchers integrate NPT into their research methods?
A coding framework was developed using the four domains and sub-domains of NPT by using an adapted version of the NoMAD instrument (part omitted), which was developed to assess implementation processes (Normalization Measure Development is an instrument designed for assessing the implementation of complex interventions). The adapted NoMaD instrument was applied to the transcripts by coding evidence of the sub-domains in Dedoose [206]. Following coding, two members of the research team (AT and JF) analysed the data across the three interview stages, using the constant comparative method, in order to understand changes and continuities over time. The inductive method of constant comparison analysis involved searching within individual transcripts, making comparison between transcripts within the same cohort, and comparing transcripts from different cohorts for conceptual similarities and differences. This method was combined with the deductive approach of using the four domains on NPT as a framework for the analysis.
Municipalities | ||||||
---|---|---|---|---|---|---|
A | B | C | D | E | F | |
PaTH in use in full scalea | Elements of PaTH in usea | PaTH not in usea | ||||
Makes sense (coherenceb) | ||||||
Expecting PaTH to be useful | Yes | Yes | Yes | Yes | Yes | Yes |
Regular staff understood how to use PaTH | Mixed | Mixed | Mixed | Mixed | Mixed | Mixed |
Commitment and engagement (cognitive participationb) | ||||||
Sustained leadership | Yes | Yes | No | No | No | No |
Practice in using checklists | Intensive | Intensive | Minimal | Minimal | Minimal | Minimal |
General attention to PaTH at workplace | Yes | Yes | No | Nurses only | No | No |
Facilitating use of PaTH (collective actionb) | ||||||
Extra personnel resources | Yes | Yes | No | Yes | No | No |
Major competing priorities | No | No | No | No | Yes | Yes |
Usability in electronic health record | Good | Fair | Poor | Poor | Poor | Poor |
Working schedule facilitated for PaTH | Yes | Yes | No | No | No | No |
Checklists incorporated in daily routines | Yes | Yes | No | No | No | No |
Value of PaTH (reflexive monitoringb) | ||||||
Impact on collaboration with the hospital | Mixed | Mixed | No | No | No | No |
Impact on collaboration with GPs | Yes | Yes | No | Yes | No | No |
Impact on service quality | Yes | Yes | No | Yes | No | Yes |
Value for individual nurse/nursing assistant | Yes | Yes | No | No | No | No |
Valued as a management tool | Yes | Yes | No | Yes | No | No |
Coherence | Cognitive participation | Collective action | Reflexive monitoring | |
---|---|---|---|---|
What is the process? | Who performs the process? | How does the process get performed? | How is the process understood? | |
How RNs, DNs and HCOs perceived the DPP and whether they experienced the DPP as valuable to them and agreed about its usefulness and purpose | Whether RNs, DNs and HCOs saw the DPP as a legitimate part of their work and whether they supported it over time | How the DPP was provided within the existing context, how the embedding and integration work had proceeded due to knowledge and resources | How RNs, DNs and HCOs individually and collectively evaluated the DPP and its supportive tools | |
Factors that promote or inhibit the routine embedding of DPP. | Factors that promote or inhibit participation in DPP | Factors that promote or inhibit enacting DPP | Factors that promote or inhibit appraisal of DPP | |
Data source | No. of text units | |||
Survey | 0 | 1 | 12 | 0 |
Interview RNs | 0 | 119 | 225 | 78 |
Interview DNs, HCOs | 0 | 122 | 80 | 59 |
Adverse events/information system failures | 0 | 3 | 2 | 0 |
Workshops | 12 | 8 | 37 | 6 |
Mapping of overarching themes and subthemes to NPT framework | ||
---|---|---|
NPT construct | Theme | Subthemes |
Coherence | Making sense of the case manager intervention | Perceived value of the concept of case management. Clarity over the case manager role. |
Cognitive participation | Investment in case management | Practice investment in case management. Investment by case managers. Fit of case management with existing skill sets. |
Collective action | Implementing case management in practice | Time available for case management. Implementation in research vs clinical practice. Support and supervision of case managers. |
Reflexive monitoring | Appraising and embedding of case management | Assessing the impacts of case management. The ‘right’ intervention but at the wrong time. Embedding case management in practice. |
How did users’ criticise NPT
‘While May et al (…) acknowledge that the NPT generative mechanisms are in dynamic interaction with local contexts and external drivers, the framework primarily addresses the mechanisms. Indeed, the theory tends to place undue emphasis on individual and collective agency without explicitly locating this within, and as shaped by, the organisational and relational context in which implementation occurs’ [26].
‘ENPT places considerable emphasis on the notion of implementation as an expression of agency. However, the agents in question appear to be mainly conceptualised as professional practitioners (e.g. nurses), rather than the participants who receive interventions. There is scope to consider further how the key constructs of ENPT can be applied to understand how participant (and non-participant) agency may shape whether interventions become integrated and embedded within delivery systems’ [126]