Thinking through ‘implementation’ using normalization process theory to understand the dynamics of complex interventions in health services research

Carl May Ph.D

July 2010: Summer Institute on Health Services Research, University of Victoria, British Columbia

co-investigators

Luciana Ballini (Bologna)Tracy Finch (Newcastle)Anne Macfarlane (Galway)Elizabeth Murray (London)Frances Mair (Glasgow) Tim Rapley (Newcastle)Shaun Treweek (Dundee)

work described in this presentation is funded by the UK Economic and Social Research Council

health services research

“a field of inquiry that examines the impact of the organization, financing and management of health care services on the delivery, quality, cost, access to and outcomes of such services” (WHO 2007).

health services research

core problems: identifying and evaluating new and

modified ways of organizing and delivering healthcare

identifying and understanding the relationships between measurable inputs (investments) and outputs (effectiveness)

need for structured rigorous research in messy contexts

complex interventions

A complex intervention is any deliberately initiated attempt to introduce new, or modify existing, patterns of collective action in health care or some other formal organizational setting.

Deliberate initiation means that an intervention is: institutionally sanctioned; formally defined; consciously planned; and intended to lead to a changed outcome.

complex interventions

complex interventions directed at actors often seek to change behaviour and its intended outcomes (e.g. strategies for making ‘expert patients’; or new professional roles)

complex interventions aimed at objects often seek to change expertise and actions (e.g. novel therapeutic agents and medical devices; or decision-making tools and clinical guidelines)

complex interventions aimed at contexts often to seek to change the procedures enacted to achieve goals. (e.g. digital delivery, or organisational structures)

Most complex interventions engage with multiple actors, objects, and contexts simultaneously

normalization process theory

NPT is a middle range theory that can underpin process evaluations of complex interventions in health care

normalization process theory

• explains how material practices become routinely embedded in their contexts

• explains the routine embedding practices by reference to four generative mechanisms (coherence; cognitive participation; collective action; reflexive monitoring).

• explains how the work, (individually and collective), of implementing practices requires continuous investment in ensembles of action that carry forward in time and space.

normalization process theory focuses on the work that people do

generative processes of individual and communal sense making.

driven by investments in meaning. generative processes of cognitive

participation. driven by investments in commitment

generative processes of collective action. driven by investments in effort.

generative processes of individual and communal reflexive monitoring.

driven by investments in appraisal.

it’s all about the work

what is it? who does it? how does it get done? why did it happen like that?

NPT simplified

theories are abstract and need to be translated for everyday users

constructs and components of NPT can be translated them into simple statements for managers, clinicians, and researchers

heuristic devices to think through implementation problems not to measure them

example: falls prevention initiative (FPI) in hospital

definition: a fall is an unplanned descent to the floor

intervention: identify and monitor patients at risk of falling

falls prevention: coherence work

nurses distinguish the FPI from current ways of working

nurses collectively agree the purpose of the FPI

nurses individually understand what the FPI requires of them?

nurses construct potential value of the FPI for their work

falls prevention: participation work

key nurses drive forward the FPI nurses agree that the FPI should be part of

their work nurses buy in to delivering the FPI nurses continue to support the FPI

falls prevention: enacting work

nurses perform the tasks required by the FPI nurses maintain their trust in each others’ work

and expertise through the FPI the work of the FPI is appropriately allocated to

nurses the FPI is adequately supported by its host

organization

falls prevention: appraisal work

nurses access information about the effects of the FPI

nurses collectively assess the FPI as worthwhile work for patients

nurses individually assess the FPI as worthwhile work for themselves

nurses modify their work in response to their appraisal of the FPI

can 16 questions kill an intervention?

our work is aimed at more than theoretical understanding

we seek to develop modeling techniques that will help forecast emergent implementation problems and identify techniques to solve them

if 16 questions could kill an intervention, would that be a good thing?

key papers

May C, Finch T. Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology 2009; 43:535-54. Available here

May C, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science 2009; art4. Available here.

thank you