Normalisation Process Theory Constructs Research Articles

Implementing PERFECT-ER with Plan-Do-Study-Act on acute orthopaedic hospital wards: Building knowledge from an implementation study using Normalization Process Theory.

Delivering care to growing numbers of patients with increasingly 'complex' needs is currently compromised by a system designed to treat patients within organizational clinical specialties, making this difficult to reconfigure to fit care to needs. Problematic experiences of people with cognitive impairment(s) admitted to hospitals with a hip fracture, exemplify the complex challenges that result if their care is not tailored. This study explored whether a flexible, multicomponent intervention, adapting services to the needs of this patient group, could be implemented in acute hospital settings. We used action research with case study design to introduce the intervention using a Plan-Do-Study-Act (PDSA) model to three different hospital sites (cases) across England. The qualitative data for this paper was researcher-generated (notes from observations and teleconference meetings) and change agent-generated (action plans and weekly reflective reports of change agents' activities). Normalization Process Theory (NPT) was used to analyze and explain the work of interacting actors in implementing and then normalizing (embedding) the intervention across contexts and times. Data analysis was abductive, generating inductive codes then identified with NPT constructs. Across the three cases, change agents had to work through numerous implementation challenges: needing to make sense of the intervention package, the PDSA model as implementation method, and their own role as change agents and to orientate these within their action context (coherence). They had to work to encourage colleagues to invest in these changes (cognitive participation) and find ways to implement the intervention by mobilising changes (collective action). Finally, they created strategies for clinical routines to continue to self-review, reconfiguring actions and future plans to enable the intervention to be sustained (reflexive monitoring). Successful implementation of the (PERFECT-ER) intervention requires change agents to recognize and engage with local values, and then to enable its fit with practice and wider contextual goals. A context of constant change fragments normalization. Thus, sustaining practice change over time is fragile and requires change agents to continue a recursive two-way sense-making process. This enables implementation and normalization to re-energize and overcome barriers to change.

Exploring readiness for implementing goal-oriented care in primary care using normalization process theory.

To use normalization process theory (NPT) to build a strategy for the implementation of goal-oriented care (GOC) in primary care in Flanders, Belgium. GOC is a possible approach to more coordinated and integrated care and tailors care to patients' personal life goals. The concept has gained interest among policy makers and researchers, but the main drivers for successful implementation are the primary healthcare professionals (PHCPs) who need to see added value of GOC in order to embed it into their daily practice. NPT, developed to understand the processes of implementing new ways of organizing care, offers a useful lens to understand adoption of GOC in primary care practice. PHCPs (n = 131) who participated in a 2-hour community meeting on GOC were asked to complete the Normalization MeAsure Development survey. This 23-item survey is based on NPT and describes participants' views about how an intervention would impact their work, their expectations about it, and whether it could become a routine part of their work. The NPT constructs coherence (sense-making work) and cognitive participation (relational work) showed positive tendency toward implementation of GOC. The participants had an initial understanding on GOC and there was much interest in supporting and start working with this approach. The other constructs collective action (operational work) and reflexive monitoring (appraisal work) will need further efforts to trigger implementation. A common ground is needed to integrate GOC as a common practice which can be achieved by intensive interprofessional collaboration.

One size does not fit all: Participants’ experiences of the selfBACK app to support self-management of low back pain—a qualitative interview study

BackgroundLow back pain (LBP) is one of the most common reasons for disability globally. Digital interventions are a promising means of supporting people to self-manage LBP, but implementation of digital interventions has been suboptimal. An artificial intelligence-driven app, selfBACK, was developed to support self-management of LBP as an adjunct to usual care. To better understand the process of implementation from a participant perspective, we qualitatively explored factors influencing embedding, integrating, and sustaining engagement with the selfBACK app, and the self-perceived effects, acceptability, and satisfaction with the selfBACK app.MethodsUsing a qualitative interview study and an analytic framework approach underpinned by Normalization Process Theory (NPT), we investigated the experiences of patients who participated in the selfBACK randomized controlled trial (RCT). Interviews focused on the motivation to participate in the RCT, experiences of using the selfBACK app, and views about future intended use and potential of using digital health interventions for self-management of LBP. Participants were purposively sampled to represent diversity in age, sex, and implementation reflected by a proxy measure of number of app-generated self-management plans during the first three months of RCT participation.ResultsTwenty-six participants aged 21–78, eleven females and fifteen men, with two to fourteen self-management plans, were interviewed between August 2019 and April 2020. A broad range of factors influencing implementation of selfBACK within all constructs of NPT were identified. Key facilitating factors were preferences and beliefs favoring self-management, a friendly, motivational, and reassuring supporter, tailoring and personalization, convenience and ease of use, trustworthiness, perceiving benefits, and tracking achievements. Key impeding factors were preferences and beliefs not favoring self-management, functionality issues, suboptimal tailoring and personalization, insufficient time or conflicting life circumstances, not perceiving benefits, and insufficient involvement of health care practitioners. Self-perceived effects on pain and health, behavior/attitude, and gaining useful knowledge varied by participant.ConclusionsThe high prevalence of LBP globally coupled with the advantages of providing help through an app offers opportunities to help countless people. A range of factors should be considered to facilitate implementation of self-management of LBP or similar pain conditions using digital health tools.

Strategies for supporting the implementation of a task-shared psychological intervention in South Africa’s chronic disease services: qualitative insights from health managers’ experiences of project MIND

ABSTRACT Background Although evidence indicates that task-shared psychological interventions can reduce mental health treatment gaps in resource-constrained settings, systemic barriers have limited their widespread implementation. Evidence on how to sustain and scale such approaches is scant. This study responds to this gap by examining the experiences of South African health managers involved in the implementation of a task-shared counselling service for Project MIND. Objectives To qualitatively describe managers’ experiences of implementing the MIND programme and their insights into potential strategies for supporting sustained implementation. Methods Two focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted with managers of urban and rural primary care facilities in the Western Cape province. All managers were female and 30–50 years old. FGDs and IDIs used an identical semi-structured topic guide to explore the experiences of the MIND programme and perceived barriers to sustained implementation. Normalisation process theory (NPT) guided the thematic analysis. Results Four themes emerged that mapped onto the NPT constructs. First, managers noted that their relational work with staff to promote support for the intervention and reduce resistance was key to facilitating implementation. Second, managers emphasised the need for staff reorientation and upskilling to foster openness to mental health practice and for adequate time for quality counselling. Third, managers underscored the importance of strengthening linkages between the health and social service sectors to facilitate delivery of comprehensive mental health services. Finally, managers recommended ongoing monitoring of the service and communication about its impacts as strategies for supporting integration into routine practice. Conclusions Findings contribute to the emerging literature on strategies to support implementation of task-shared interventions in low- and middle-income countries. The findings highlight the leadership role of managers in identifying and actioning these strategies. Investing in managers’ capacity to support implementation of psychological interventions is critical for scale-up of these mental health innovations.

Using Normalisation Process Theory (NPT) to develop an intervention to improve referral and uptake rates for self-management education for patients with type 2 diabetes in UK primary care

BackgroundReferral and uptake rates of structured self-management education (SSME) for Type 2 diabetes (T2DM) in the UK are variable and relatively low. Research has documented contributing factors at patient, practitioner and organisational levels. We report a project to develop an intervention to improve referral to and uptake of SSME, involving an integrative synthesis of existing datasets and stakeholder consultation and using Normalisation Process Theory (NPT) as a flexible framework to inform the development process.MethodsA three-phase mixed-methods development process involved: (1) synthesis of existing evidence; (2) stakeholder consultation; and (3) intervention design. The first phase included a secondary analysis of data from existing studies of T2DM SSME programmes and a systematic review of the literature on application of NPT in primary care. Influences on referral and uptake of diabetes SSME were identified, along with insights into implementation processes, using NPT constructs to inform analysis. This gave rise to desirable attributes for an intervention to improve uptake of SSME. The second phase involved engaging with stakeholders to prioritise and then rank these attributes, and develop a list of associated resources needed for delivery. The third phase addressed intervention design. It involved translating the ranked attributes into essential components of a complex intervention, and then further refinement of components and associated resources.ResultsIn phase 1, synthesised analysis of 64 transcripts and 23 articles generated a longlist of 46 attributes of an embedded SSME, mapped into four overarching domains: valued, integrated, permeable and effectively delivered. Stakeholder engagement in phase 2 progressed this to a priority ranked list of 11. In phase 3, four essential components attending to the prioritised attributes and forming the basis of the intervention were identified: 1) a clear marketing strategy for SSME; 2) a user friendly and effective referral pathway; 3) new/amended professional roles; and 4) a toolkit of resources.ConclusionsNPT provides a flexible framework for synthesising evidence for the purpose of developing a complex intervention designed to increase and reduce variation in uptake to SSME programmes in primary care settings.

The attitudes of hospital directors towards normalising accreditation standards: A qualitative descriptive study for Saudi Arabia.

BackgroundAccreditation is an important performance management tool. The engagement of stakeholders in pursuing accreditation plays a critical role in integrating standards into routine practice.ObjectiveThis study explores the attitude of hospital directors towards accreditation and investigates the mechanisms of normalising standards in Saudi Arabian hospitals.MethodsFifteen hospital directors across Saudi Arabia participated in semi-structured qualitative interviews. The interviews were conducted virtually, audiotaped, transcribed verbatim, and then analysed thematically using the NVivo-12 software package. The normalisation process theory (i.e. coherence, participation, actions and monitoring) was adopted to frame the study and describe the findings on normalising accreditation standards heuristically.ResultsOverall, the hospital directors perceived accreditation favourably, particularly by those with more experience or previous exposure to accreditation. This attitude was a factor in normalising standards into daily operations. The clarity of standards, availability of full-time quality professionals and alignment of accreditation standards with hospital strategies assisted hospital directors in making sense of accreditation (coherence) and moving towards engaging hospital teams in the process (cognitive participation). This motivation-driven engagement catalysed the initiation of purposeful operational activities to integrate standards in operations (collective actions). The integration included distributing standard sets to relevant owners, conducting gap analysis, constructing a corrective plan and prioritising tasks within timeframes. Despite the financial and structural constraints experienced, the integration resulted in enhanced organisational safety culture, team spirit, communication, public trust, reporting of safety concerns and standardising of procedures. Following the integration, the objective appraisal of accreditation benefits (reflexive monitoring) was critical in addressing what went wrong, what worked well, and subsequently in sustaining performance gains.ConclusionThe effectiveness of integrating accreditation standards heavily relies on making sense of accreditation and understanding the mechanisms through which standards are routinised into operations. This study, using normalisation process theory constructs, indicates that standards integration phases are sequential, interlinked and influenced by culture, teamwork and leadership engagement. The findings helped in clarifying the accreditation operating process which may provide advantages to policymakers and stakeholders in making informed decisions on the implementation of accreditation.

Sustainable and effective methods to increase long‐acting reversible contraception uptake from the ACCORd general practice trial

ObjectiveMost Australian women access contraception through general practitioners (GPs) but choose oral methods rather than long‐acting reversible contraceptives (LARCS). The Australian Contraceptive ChOice pRoject (ACCORd) successfully tested a complex intervention for LARC uptake. We aimed to explore the critical elements of this intervention to increase LARC uptake. DesignACCORd was a cluster randomised control trial conducted in 57 GP clinics in Melbourne, Australia. To explore intervention impact, fidelity checks (n=21 GPs) and interviews with 37 GPs and 40 patients were undertaken 12 months after initial consultations. Data were inductively coded, thematically analysed and mapped to Normalization Process Theory constructs. ResultsDoctors understood the importance of effectiveness‐based contraceptive counselling (EBCC). GPs demonstrated cognitive engagement in the promotion of LARC and some appreciated the rapid referral pathways. GPs and women valued the effectiveness approach. GPs held varying views about having a rapid referral pathway, with many already having established pathways in place. Some GPs viewed intrauterine device insertion costs or insertion training as barriers to ongoing practice. Most GPs and women saw the ACCORD model as effective and sustainable. ConclusionsGP training in EBCC and the use of rapid referral pathways were critical features of an effective sustainable model for successful uptake of LARCs in primary care. Implications for public healthImproving Australian women's access to and use of LARCs is sustainable with EBCC training and support for general practitioners.

Factors influencing the implementation of person-centred care in nursing homes by practice development champions: a qualitative process evaluation of a cluster-randomised controlled trial (EPCentCare) using Normalization Process Theory

BackgroundPerson-centred care (PCC) has been suggested as the preferred model of dementia care in all settings. The EPCentCare study showed that an adapted PCC approach was difficult to implement and had no effect on prescription of antipsychotics in nursing home residents in Germany.This paper reports the qualitative process evaluation to identify facilitators and barriers of the implementation of PCC in German nursing homes from the perspective of participating practice development champions.MethodsFive individual and 14 group interviews were conducted with 66 participants (staff and managers) from 18 nursing homes. The analysis was based on inductive coding to identify factors influencing the PCC implementation process. Identified factors were systematised and structured by mapping them to the four constructs (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalization Process Theory (NPT) as a framework that explains implementation processes.ResultsFacilitating implementation factors included among others broadening of the care perspective (coherence), tolerance development within the care team regarding challenging behaviour (cognitive participation), testing new approaches to solutions as a multi-professional team (collective action), and perception of effects of PCC measures (reflexive monitoring). Among the facilitating factors reported in all the NPT constructs, thus affecting the entire implementation process, were the involvement of relatives, multi-professional teamwork and effective collaboration with physicians.Barriers implied uncertainties about the implementation and expectation of a higher workload (coherence), concerns about the feasibility of PCC implementation in terms of human resources (cognitive participation), lack of a person-centred attitude by colleagues or the institution (collective action), and doubts about the effects of PCC (reflexive monitoring). Barriers influencing the entire implementation process comprised insufficient time resources, lack of support, lack of involvement of the multi-professional team, and difficulties regarding communication with the attending physicians.ConclusionsThe findings provide a comprehensive and detailed overview of facilitators and barriers structured along the implementation process. Thus, our findings may assist both researchers and clinicians to develop and reflect more efficiently on PCC implementation processes in nursing homes.Trial registrationClinicalTrials.gov identifier: NCT02295462; November 20, 2014.

Embedding and Integrating a Digital Patient Management Platform Into Everyday Primary Care Routines: Qualitative Case Study.

BackgroundTraditional primary care is characterized by patient consultations via phone and physical visits. However, the current development in Swedish primary care is to blend digital solutions with traditional solutions. This paper addresses this development by examining the normalization of embedding and integrating a digital health care platform into everyday care routines in a primary care clinic. The digital health care platform enables both synchronous (video calls) and asynchronous (chat) communication, as well as self-registration of patient data using automated questions and forms requiring the patient’s input.ObjectiveThis study aims to explore the work that health care professionals (HCPs) have to undertake to implement and sustain a digital health care platform as part of their everyday work practice.MethodsHCPs were observed and interviewed to assess their individual and collective engagement and the mechanisms involved in the implementation of the digital platform and its effects on everyday work routines. The normalization process theory (NPT) was used to frame the data analysis.ResultsThe analysis identified several themes related to the four NPT constructs: coherence, cognitive participation, collective action, and reflexive monitoring. The use of these constructs enabled the analysis to identify ways of supporting implementation. For example, it showed the benefits of having implementation champions and scheduling work hours for HCPs to use the platform. The analysis also revealed a theme of materiality that deviated from the NPT constructs, as NPT gives ontological priority to human actors and social structures.ConclusionsDigital health care platform implementation is a complex process. Our findings provide insights into how individual and collective actions can be supported to embed and integrate a digital platform into everyday care routines. Primary health care organizations need to involve HCPs throughout the implementation process by reorganizing work and providing frequent feedback loops. HCPs are more likely to engage with and commit to changing practices if they perceive the digital platform to be beneficial compared with the current practice. However, they also need resources (eg, time, training, and continuous support) to put the platform into practice. Patient engagement and appraisal are important elements in implementation. Unless patients are willing to use the platform, there is no motivation for HCPs to embed the digital platform into everyday care practice.

Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development

BackgroundNormalisation Process Theory (NPT) is frequently used to inform qualitative research that aims to explain and evaluate processes that shape late-stage translation of innovations in the organisation and delivery of healthcare. A coding manual for qualitative researchers using NPT will facilitate transparent data analysis processes and will also reduce the cognitive and practical burden on researchers.Objectives(a) To simplify the theory for the user. (b) To describe the purposes, methods of development, and potential application of a coding manual that translates normalisation process theory (NPT) into an easily usable framework for qualitative analysis. (c) To present an NPT coding manual that is ready for use.MethodQualitative content analysis of papers and chapters that developed normalisation process theory, selection and structuring of theory constructs, and testing constructs against interview data and published empirical studies using NPT.ResultsA coding manual for NPT was developed. It consists of 12 primary NPT constructs and conforms to the Context-Mechanism-Outcome configuration of realist evaluation studies. Contexts are defined as settings in which implementation work is done, in which strategic intentions, adaptive execution, negotiating capability, and reframing organisational logics are enacted. Mechanisms are defined as the work that people do when they participate in implementation processes and include coherence-building, cognitive participation, collective action, and reflexive monitoring. Outcomes are defined as effects that make visible how things change as implementation processes proceed and include intervention mobilisation, normative restructuring, relational restructuring, and sustainment.ConclusionThe coding manual is ready to use and performs three important tasks. It consolidates several iterations of theory development, makes the application of NPT simpler for the user, and links NPT constructs to realist evaluation methods. The coding manual forms the core of a translational framework for implementation research and evaluation.

Understanding implementation context and social processes through integrating Normalization Process Theory (NPT) and the Consolidated Framework for Implementation Research (CFIR)

BackgroundFor successful implementation of an innovation within a complex adaptive system, we need to understand the ways that implementation processes and their contexts shape each other. To do this, we need to explore the work people do to make sense of an innovation and integrate it into their workflow and the contextual elements that impact implementation. Combining Normalization Process Theory (NPT) with the Consolidated Framework for Implementation Research (CFIR) offers an approach to achieve this. NPT is an implementation process theory that explains how changes in the way people think about and use an innovation occurs, while CFIR is a framework that categorizes and describes contextual determinants across five domains that influence implementation. We demonstrate through a case example from our prior research how we integrated NPT and CFIR to inform the development of the interview guide, coding manual, and analysis of the findings.MethodsIn collaboration with our stakeholders, we selected NPT and CFIR to study the implementation process and co-developed an interview guide to elicit responses that would illuminate concepts from both. We conducted, audio-recorded, and transcribed 28 interviews with various professionals involved with the implementation. Based on independent coding of select transcripts and team discussion comparing, clarifying, and crystallizing codes, we developed a coding manual integrating CFIR and NPT constructs. We applied the integrated codes to all interview transcripts.ResultsOur findings highlight how integrating CFIR domains with NPT mechanisms adds explanatory strength to the analysis of implementation processes, with particular implications for practical strategies to facilitate implementation. Multiple coding across both theoretical frames captured the entanglement of process and context. Integrating NPT and CFIR enriched understandings of how interactions between implementation processes and contextual determinants shaped each other during implementation.ConclusionThe integration of NPT and CFIR provides guidance to identify and explore complex entangled interactions between agents, processes, and contextual conditions within and beyond organizations to embed innovations into routine practices. Nuanced understandings gained through this approach moves understandings beyond descriptions of determinants to explain how change occurs or not during implementation. Mechanism-based explanations illuminate concrete practical strategies to support implementation.

Implementation of a Hearing Loss Screening Intervention in Primary Care.

Hearing loss (HL) is underdiagnosed and often unaddressed. A recent study of screening for HL using an electronic prompt showed efficacy in increasing appropriate referrals for subsequent testing. We build on the results of this study using a qualitative lens to explore implementation processes through the perspectives of family medicine clinicians. We collected clinic observations and semistructured interviews of family medicine clinicians and residents who interacted with the HL prompt. All data were analyzed using thematic, framework, and mixed methods integration strategies. We interviewed 27 clinicians and conducted 10 observations. Thematic analysis resulted in 6 themes: (1) the prompt was overwhelmingly viewed as easy, simple to use, accurate; (2) clinicians considered prompt as an effective way to increase awareness and conversations with patients about HL; (3) clinician and staff buy-in played a vital role in implementation; (4) clinicians prioritized prompt during annual visits; (5) medical assistant involvement in prompt workflow varied by health system, clinic, and clinician; (6) prompt resulted in more conversations about HL, but uncertain impact on patient outcomes. Themes are presented alongside constructs of normalization process theory and intervention outcomes. Integration of a HL screening prompt into clinical practice varied by clinician buy-in and beliefs about the impact on patient outcomes, involvement of medical assistants, and prioritization during clinical visits. Further research is needed to understand how to leverage clinician and staff buy-in and whether implementation of a new clinical prompt has sustained impact on HL screening and patient outcomes.

An integrated pre-pregnancy care programme framework theoretically modelled from the perspectives of women with Type 2 diabetes and healthcare professionals

BackgroundPregnancies in women with diabetes are associated with significant additional risks for the fetus, infant and mother such as, higher risk of stillbirths or congenital anomalies. Pre-pregnancy care can attenuate these risks. However, while women with Type 2 diabetes account for half of pregnancies in women with pre-existing diabetes, they are much less likely to receive pre-pregnancy care than women with Type 1 diabetes. This discrepancy may be related to the fact that most pre-pregnancy care is located in specialist diabetes centres where women with Type 1 diabetes are managed; whereas women with Type 2 diabetes are managed in primary care and reproductive care is not a routine element of diabetes care. Therefore, to improve pre-pregnancy care among women with Type 2 diabetes strategies need to be tailored to the specific needs of this group and the context of their diabetes care. ObjectivesThis paper seeks to inform the development of an integrated pre-pregnancy care programme by presenting strategies identified by women with Type 2 diabetes and healthcare professionals that address some of the barriers they experience in relation to pre-pregnancy care. MethodsA qualitative study using semi-structured in-depth interviews with women of reproductive age with Type 2 diabetes (n=30) and diabetes healthcare professionals (n=22) from both primary and secondary care. Data were transcribed verbatim and analysed thematically using Framework Analysis. The identified themes were then mapped to create a theoretical intervention framework using Normalisation Process Theory and the Capabilities, Opportunity, and Motivation to perform a Behaviour model. ResultsSix themes were identified expressing the need for a multimodal approach for improving the uptake of pre-pregnancy care in women with Type 2 diabetes. These themes were then mapped onto the constructs of Normalisation Process Theory as follows: coherence (enhancing understanding of reproductive needs among women and healthcare professionals); cognitive participation (constructing a positive narrative for pregnancy and Type 2 diabetes); collective action (increasing the visibly of the reproductive needs of women, integrating healthcare systems and utilising supportive technologies); and reflexive monitoring (using multi-modal approaches to support systemised care). The data were also modelled to identify target behaviours for intervention detailing what needs to be done by whom, when and where. ConclusionWomen with Type 2 diabetes account for half of pregnancies in those with pre‐existing diabetes; however, they are less likely to receive pre‐pregnancy care than women with Type 1 diabetes. Pre-pregnancy care can reduce the maternal and fetal risks associated with Type 2 diabetes. This study presents strategies to improve the current low uptake of pre-pregnancy care for women with Type 2 diabetes. These strategies have been tailored to the specific needs of women and healthcare professionals and support integration within the woman's routine diabetes management.

Participatory co-design and normalisation process theory with staff and patients to implement digital ways of working into routine care: the example of electronic patient-reported outcomes in UK renal services

BackgroundSuccessful implementation of digital health systems requires contextually sensitive solutions. Working directly with system users and drawing on implementation science frameworks are both recommended. We sought to combine Normalisation Process Theory (NPT) with participatory co-design methods, to work with healthcare stakeholders to generate implementation support recommendations for a new electronic patient reported outcome measure (ePRO) in renal services. ePROs collect data on patient-reported symptom burden and illness experience overtime, requiring sustained engagement and integration into existing systems.MethodsWe identified co-design methods that could be mapped to NPT constructs to generate relevant qualitative data. Patients and staff from three renal units in England participated in empathy and process mapping activities to understand ‘coherence’ (why the ePRO should be completed) and ‘cognitive participation’ (who would be involved in collecting the ePRO). Observation of routine unit activity was completed to understand ‘collective action’ (how the collection of ePRO could integrate with service routines).ResultsThe mapping activities and observation enabled the research team to become more aware of the key needs of both staff and patients. Working within sites enabled us to consider local resources and barriers. This produced ‘core and custom’ recommendations specifying core needs that could be met with customised local solutions. We identified two over-arching themes which need to be considered when introducing new digital systems (1) That data collection is physical (electronic systems need to fit into physical spaces and routines), and (2) That data collection is intentional (system users must be convinced of the value of collecting the data).ConclusionsWe demonstrate that NPT constructs can be operationalised through participatory co-design to work with stakeholders and within settings to collaboratively produce implementation support recommendations. This enables production of contextually sensitive implementation recommendations, informed by qualitative evidence, theory, and stakeholder input. Further longitudinal evaluation is necessary to determine how successful the recommendations are in practice.

Implementing social prescribing in primary care in areas of high socioeconomic deprivation: process evaluation of the 'Deep End' community Links Worker Programme.

BackgroundSocial prescribing involving primary care-based ‘link workers’ is a key UK health policy that aims to reduce health inequalities. However, the process of implementation of the link worker approach has received little attention despite this being central to the desired impact and outcomes.AimTo explore the implementation process of such an approach in practice.Design and settingQualitative process evaluation of the ‘Deep End’ Links Worker Programme (LWP) over a 2-year period, in seven general practices in deprived areas of Glasgow.MethodThe study used thematic analysis to identify the extent of LWP integration in each practice and the key factors associated with implementation. Analysis was informed by normalisation process theory (NPT).ResultsOnly three of the seven practices fully integrated the LWP into routine practice within 2 years, based on the NPT constructs of coherence, cognitive participation, and collective action. Compared with ‘partially integrated practices’, ‘fully integrated practices’ had better shared understanding of the programme among staff, higher staff engagement with the LWP, and were implementing all aspects of the LWP at patient, practice, and community levels of intervention. Successful implementation was associated with GP buy-in, collaborative leadership, good team dynamics, link worker support, and the absence of competing innovations.ConclusionEven in a well-resourced government-funded programme, the majority of practices involved had not fully integrated the LWP within the first 2 years. Implementing social prescribing and link workers within primary care at scale is unlikely to be a ‘quick fix’ for mitigating health inequalities in deprived areas.

General practice responses to opioid prescribing feedback: a qualitative process evaluation.

BackgroundThe rise in opioid prescribing in primary care represents a significant public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. An evidence-based bimonthly feedback intervention to reduce opioid prescribing was developed and implemented, targeting 316 general practices in West Yorkshire over 1 year.AimTo understand how general practice staff received and responded to the feedback intervention.Design and settingQualitative process evaluation involving semi-structured interviews, guided by Normalisation Process Theory (NPT), of primary care healthcare professionals targeted by feedback.MethodParticipants were purposively recruited according to baseline opioid prescribing levels and degree of change following feedback. Interview data were coded to NPT constructs, and thematically analysed.ResultsInterviews were conducted with 21 staff from 20 practices. Reducing opioid prescribing was recognised as a priority. While high achievers had clear structures for quality improvement, feedback encouraged some less structured practices to embed changes. The non-prescriptive nature of the feedback reports allowed practices to develop strategies consistent with their own ways of working and existing resources. Practice concerns were allayed by the credibility of the reports and positive experiences of reducing opioid prescribing. The scale, frequency, and duration of feedback may have ensured a good overall level of practice population reach.ConclusionThe intervention engaged general practice staff in change by targeting an issue of emerging concern, and allowing adaption to different ways of working. Practice efforts to reduce opioid prescribing were reinforced by regular feedback, credible comparative data showing progress, and shared experiences of patient benefit.

The implementation, use and sustainability of a clinical decision support system for medication optimisation in primary care: A qualitative evaluation.

The quality and safety of prescribing in general practice is important, Clinical decision support (CDS) systems can be used which present alerts to health professionals when prescribing in order to identify patients at risk of potentially hazardous prescribing. It is known that such computerised alerts may improve the safety of prescribing in hospitals but their implementation and sustainable use in general practice is less well understood. We aimed to understand the factors that influenced the successful implementation and sustained use in primary care of a CDS system. Participants were purposively recruited from Clinical Commissioning Groups (CCGs) and general practices in the North West and East Midlands regions of England and from the CDS developers. We conducted face-to-face and telephone-based semi-structured qualitative interviews with staff stakeholders. A selection of participants was interviewed longitudinally to explore the further sustainability 1-2 years after implementation of the CDS system. The analysis, informed by Normalisation Process Theory (NPT), was thematic, iterative and conducted alongside data collection. Thirty-nine interviews were conducted either individually or in groups, with 33 stakeholders, including 11 follow-up interviews. Eight themes were interpreted in alignment with the four NPT constructs: Coherence (The purpose of the CDS: Enhancing medication safety and improving cost effectiveness; Relationship of users to the technology; Engagement and communication between different stakeholders); Cognitive Participation (Management of the profile of alerts); Collective Action (Prescribing in general practice, patient and population characteristics and engagement with patients; Knowledge);and Reflexive Monitoring (Sustaining the use of the CDS through maintenance and customisation; Learning and behaviour change. Participants saw that the CDS could have a role in enhancing medication safety and in the quality of care. Engagement through communication and support for local primary care providers and management leaders was considered important for successful implementation. Management of prescribing alert profiles for general practices was a dynamic process evolving over time. At regional management levels, work was required to adapt, and modify the system to optimise its use in practice and fulfil local priorities. Contextual factors, including patient and population characteristics, could impact upon the decision-making processes of prescribers influencing the response to alerts. The CDS could operate as a knowledge base allowing prescribers access to evidence-based information that they otherwise would not have. This qualitative evaluation utilised NPT to understand the implementation, use and sustainability of a widely deployed CDS system offering prescribing alerts in general practice. The system was understood as having a role in medication safety in providing relevant patient specific information to prescribers in a timely manner. Engagement between stakeholders was considered important for the intervention in ensuring prescribers continued to utilise its functionality. Sustained implementation might be enhanced by careful profile management of the suite of alerts in the system. Our findings suggest that the use and sustainability of the CDS was related to prescribers' perceptions of the relevance of alerts. Shared understanding of the purpose of the CDS between CCGS and general practices particularly in balancing cost saving and safety messages could be beneficial.

Exploring implementation processes in general practice in a feedback intervention aiming to reduce potentially inappropriate prescribing: a qualitative study among general practitioners

BackgroundPotentially inappropriate prescribing (PIP) has been linked with adverse health outcomes and increased healthcare costs. Feedback interventions targeting PIP have shown promising results. However, translation from research to everyday practice remains a challenge. With the Normalisation Process Theory (NPT) as overarching framework, we aimed to explore the implementation processes performed by general practices in a real-life, quality improvement intervention using feedback on practice-level prescribing.MethodsAll 376 general practices in the Central Denmark Region received a prescribing feedback intervention targeting selected types of PIP. Six months later, they received an evaluation questionnaire, to which 45% responded. Among 102 practices reporting to have made changes in response to the intervention, we conducted individual, semi-structured interviews with ten GPs. Maximum variation was sought in terms of baseline prescribing status, implementation activities, practice type and geographical location. The interviews were analysed thematically using NPT.ResultsThe implementation processes in general practice reflected the four NPT constructs. Key motivators for implementation included the GPs’ professional values and interests, but pragmatic considerations were also of importance (coherence). A collective versus an individual approach to the engagement and planning of the implementation process (cognitive participation) was observed. Similarly, a distinction was evident between practice-level actions involving the entire practice team as opposed to individual-level actions performed by the individual GP (collective action). Several challenges to the implementation processes were identified, including patient influences and competing priorities at multiple levels (reflexive monitoring). Additionally, internal evaluation and normalisation of new practices occurred in varying degrees.ConclusionNPT provided a useful framework for understanding implementation processes in general practice. Our results emphasise that clear professional aims and feasible content of interventions are key for GP motivation. This may be ensured through cooperation with GPs’ professional organisation, which may strengthen intervention legitimacy and uptake. Two main implementation strategies were identified: practice-level and GP-level strategies. Intervention developers need to recognise both strategies to deliver intervention content and implementation support that promote sustainable improvements in prescribing practice. Competing demands and patient influences remain important challenges that need to be addressed in future studies to further facilitate the reduction of PIPs.

Perceptions and attitudes of parents and healthcare professionals about the option of using infant massage in neonatal intensive care units.

Infant moderate pressure massage is an effective evidence-based intervention that counters the consequences of prematurity and exposure to the Neonatal Intensive Care Unit (NICU) environment. This touch-based therapy reduces physiological stress and improves physical, cognitive and neurological development in stable preterm and low birth weight (LBW) infants. Currently, little is known about the barriers and facilitators that surround its implementation. This study explored the cultural, organisational and contextual factors perceived by parents and healthcare professionals (HCPs) about the option of implementing infant massage in the Lebanese context. A qualitative exploratory approach informed by normalisation process theory (NPT) was used; 22 parents and 38 HCPs were recruited from three university hospitals over 7-month period. COREQ guidelines were used to inform reporting and as a quality appraisal checklist. Framework approach was used for data analysis of the focus groups (seven with parents, six with HCPs) and non-participant observation. The four constructs of NPT guided data collection and analysis, interpretation of the findings and understanding of the implementation issues. Four themes emerged: understanding infant massage; perception of massage benefits and risks; perceived barriers for engaging in the practice of massage, and strategies to facilitate future implementation. Participants were accepting of the massage concept. However, HCPs were concerned that workload and lack of time would make implementation difficult and interfere with daily care. Both groups highlighted parental fear and anxiety, entry to NICU, and space availability as main contextual and organisational implementation barriers. Communication, gradual implementation, encouragement and support were potential facilitators perceived by parents while adequate preparation, commitment, and establishing protocol and guidelines were the identified facilitators for HCPs. Study findings provide important insights into the barriers and facilitators for the implementation of massage to assist in future evidence-based interventions within and beyond the Lebanese NICU context.

Implementation research on sustainable electrification of rural primary care facilities in Ghana and Uganda.

Access to energy is essential for resilient health systems; however, strengthening energy infrastructure in rural health facilities remains a challenge. In 2015–19, ‘Powering Healthcare’ deployed solar energy solutions to off-grid rural health facilities in Ghana and Uganda to improve the availability of maternal and child health services. To explore the links between health facility electrification and service availability and use, the World Health Organization (WHO), in partnership with Dodowa Health Research Centre and Makerere University School of Public Health, carried out an implementation research study. The objectives of this study were to (1) capture changes in service availability and readiness, (2) describe changes in community satisfaction and use and (3) examine the implementation factors of sustainable electrification that affect these changes. Data were collected through interviews with over 100 key informants, focus group discussions with over 800 community members and health facility assessment checklist adapted from the WHO’s Service Availability and Readiness Assessment tool. Implementation factors were organized using Normalization Process Theory constructs. The study found that access to energy is associated with increased availability of health services, access to communication technologies, appropriate storage of vaccines and medicines, enhanced health worker motivation and increased community satisfaction. Implementation factors associated with improved outcomes include stakeholder engagement activities to promote internalization, provision of materials and information to encourage participation, and establishment of relationships to support integration. Barriers to achieving outcomes are primarily health systems challenges—such as drug stockouts, lack of transportation and poor amenities—that continue to affect service availability, readiness and use, even where access to energy is available. However, through appropriate implementation and integration of sustainable electrification, strengthened energy infrastructure can be leveraged to catalyze investment in other components of functioning health systems. Improving access to energy in health facilities is, therefore, necessary but not sufficient for strengthening health systems.