Normalisation Process Theory Framework Research Articles

Perspectives of people experiencing homelessness with recent non-fatal street drug overdose on the Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx) intervention.

In Scotland, a third of all deaths of people experiencing homelessness (PExH) are street-drug-related, and less than half of their multiple physical- and mental health conditions are treated. New, holistic interventions are required to address these health inequalities. PHOENIx (Pharmacist Homeless Outreach Engagement and Non-medical Independent prescribing Rx) is delivered on outreach by National Health Service (NHS) pharmacist independent prescribers in partnership with third sector homelessness charity workers. We describe participant's perspectives of PHOENIx. This study aims to understand experiences of the PHOENIx intervention by participants recruited into the active arm of a pilot randomised controlled trial (RCT). Semi-structured in-person interviews explored participants' evaluation of the intervention. In this study, the four components (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalisation Process Theory (NPT) framework underpinned data collection and analyses. We identified four themes that were interpreted within the NPT framework that describe participant evaluation of the PHOENIx intervention: differentiating the intervention from usual care (coherence), embedding connection and consistency in practice (cognitive participation), implementation of practical and emotional operational work (collective action), and lack of power and a commitment to long-term support (reflexive monitoring). Participants successfully engaged with the intervention. Facilitators for participant motivation included the relationship-based work created by the PHOENIx team. This included operational work to fulfil both the practical and emotional needs of participants. Barriers included concern regarding power imbalances within the sector, a lack of long-term support and the impact of the intervention concluding. Findings identify and describe participants' evaluations of the PHOENIx intervention. NPT is a theoretical framework facilitating understanding of experiences, highlighting both facilitators and barriers to sustained engagement and investment. Our findings inform future developments regarding a subsequent definitive RCT of PHOENIx, despite challenges brought about by challenging micro and macro-economic and political landscapes.

What are the barriers and facilitators to the implementation of pharmacogenomics in mental health settings? A theory-based systematic review

Abstract Introduction Prescribing of psychotropic medicines is largely led by a trial-and-error approach. Treatment inefficacy, side effects and poor adherence are common challenges.[1] Pharmacogenomics (PGx) studies how genetic variability influences medication response. PGx Testing (PGxT) can identify relevant gene variants and help tailor prescribing of medicines to individuals. Conducting PGxT has been demonstrated to improve treatment outcomes, including medication efficacy and tolerability. Yet, access to and adoption of PGxT in mental health settings is limited to date.[2] Aim To explore factors influencing PGx implementation in mental health settings, using Normalisation Process Theory (NPT) as a theoretical framework. NPT seeks to understand factors influencing the success of intervention implementation. This enabled us to: -Identify barriers hindering the uptake of PGx. -Determine facilitators helping the adoption of PGx prescribing practices. -Map key barriers and facilitators to constructs of the NPT framework Methods The review was registered with PROSPERO (ID: CRD42023399926). Four literature databases were searched using synonyms for three terms (‘pharmacogenomics’, ‘mental health’ and ‘perspectives’), providing a total of 17499 records. Using pre-specified eligibility criteria, records were screened by four independent reviewers in three consecutive stages: title, abstract and full-text screening. Records were included if they contained data about relevant stakeholders (healthcare professional or patient) perspectives towards PGx implementation in mental health settings. Exclusion criteria included studies from non-mental health settings, review articles and clinical PGx studies. Data extraction and quality assessment were completed independently by a minimum of two reviewers. The QuADS tool was applied to enable quality assessment. Using an abductive approach, one reviewer utilised thematic analysis to map barriers and facilitators to the NPT framework, and then develop themes within and across NPT constructs. Results A total of 27 records with qualitative and/or quantitative data relating to PGx implementation in mental health were included. Major barrier themes included a PGx knowledge gap, in part due to a lack of education and training; a lack of top-down policy about PGx implementation; and uncertainty about the use of PGx. Major facilitator themes included interest in PGx as a new and improved approach to prescribing, a perception that PGx integration into electronic health records helps implementation, and a belief that PGx should be multidisciplinary. Conclusion PGx has the potential to improve prescribing in psychiatry, but integration of PGxT and realisation of its potential benefits has not been maximised. For the first time, by extracting data from a range of sources, barriers and facilitators to implementing PGx in mental health settings have been systematically reviewed, using a novel approach by adopting NPT as a theoretical framework. A limitation of the review was that some included studies had already implemented PGxT, so were potentially biased towards reporting positive perceptions about the uptake of PGxT. The review findings are useful to patients, policymakers, service providers and clinician stakeholders in designing pathways for PGx implementation, and health researchers to inform future research in the field of PGx implementation science. Future policy and research should aim to address identified barriers and use facilitators as leverage to enhance implementation.

Implementation of Remote Activity Sensing to Support a Rehabilitation Aftercare Program: Observational Mixed Methods Study With Patients and Health Care Professionals.

Physical activity is central to maintaining the quality of life for patients with complex chronic conditions and is thus at the core of neurorehabilitation. However, maintaining activity improvements in daily life is challenging. The novel Stay With It program aims to promote physical activity after neurorehabilitation by cultivating self-monitoring skills and habits. We examined the implementation of the Stay With It program at the Valens Rehabilitation Centre in Switzerland using the normalization process theory framework, focusing on 3 research aims. We aimed to examine the challenges and facilitators of program implementation from the perspectives of patients and health care professionals. We aimed to evaluate the potential of activity sensors to support program implementation and patient acceptance. Finally, we aimed to evaluate patients' engagement in physical activity after rehabilitation, patients' self-reported achievement of home activity goals, and factors influencing physical activity. Patients were enrolled if they had a disease that was either chronic or at risk for chronicity and participated in the Stay With It program. Patients were assessed at baseline, the end of rehabilitation, and a 3-month follow-up. The health care professionals designated to deliver the program were surveyed before and after program implementation. We used a mixed methods approach combining standardized questionnaires, activity-sensing data (patients only), and free-text questions. This study included 23 patients and 13 health care professionals. The diverse needs of patients and organizational hurdles were major challenges to program implementation. Patients' intrinsic motivation and health care professionals' commitment to refining the program emerged as key facilitators. Both groups recognized the value of activity sensors in supporting program implementation and sustainability. Although patients appreciated the sensor's ability to monitor, motivate, and quantify activity, health care professionals saw the sensor as a motivational tool but expressed concerns about technical difficulties and potential inaccuracies. Physical activity levels after patients returned home varied considerably, both within and between individuals. The self-reported achievement of activity goals at home also varied, in part because of vague definitions. Common barriers to maintaining activity at home were declining health and fatigue often resulting from heat and pain. At the 3-month follow-up, 35% (8/23) of the patients withdrew from the study, with most citing deteriorating physical health as the reason and that monitoring and discussing their low activity would negatively affect their mental health. Integrating aftercare programs like Stay With It into routine care is vital for maintaining physical activity postrehabilitation. Although activity trackers show promise in promoting motivation through monitoring, they may lead to frustration during health declines. Their acceptability may also be influenced by an individual's health status, habits, and technical skills. Our study highlights the importance of considering health care professionals' perspectives when integrating new interventions into routine care.

Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals.

Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability. This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration. We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems. Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration. Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation.

Rapid Implementation of Teletherapy for Voice Disorders: Challenges and Opportunities for Speech-Language Pathologists

The COVID-19 pandemic necessitated a rapid restructuring of the clinical management of voice and upper airway disorders by speech-language pathologists (SLPs). As in-person therapy sessions were suspended, voice-specialized SLPs across healthcare settings shifted to online teletherapy. In this survey study, we queried voice therapists on their experiences with and opinions regarding the adoption of teletherapy into routine clinical practice. Voice-specialized SLPs were recruited nationwide to complete an online survey which included questions about the usability of software and hardware, patient management, the effectiveness of therapy, overall satisfaction, and suggestions for improvement. 48 participants completed the survey. The majority of respondents reported frequent technical difficulties and poor access to or understanding of appropriate equipment. Overall, participants endorsed better patient access, attendance, and compliance, as well as increased scheduling flexibility. While 95% of the respondents stated they would recommend teletherapy to another SLP, only 20% supported a shift to exclusively virtual sessions. Forty percent of respondents endorsed a hybrid model consisting of initial in-person sessions followed by virtual ones. Incorporating teletherapy into clinical voice practice has, for the most part, followed Carl May's normalization process theory framework, in that clinicians have invested understanding, training, time and effort, and appraisal into its implementation. However, the unusually rapid pace of change necessitated by the pandemic has presented its own set of challenges. Given the inherent conveniences of virtual therapy, the online modality is likely here to stay. It is critical that we understand the facilitators and barriers to its successful adoption.

Institutional logics and the adoption and implementation of remote patient monitoring

ABSTRACT Remote patient monitoring (RPM) of chronic diseases represents a care modality with great potential to substantially improve outcomes and reduce hospital admission and costs to society. Empirical research has examined the processes of RPM adoption and implementation; however, implementation of RPM – a complex technological and health service innovation – remains challenging. Various analytical frameworks have tried to understand the conditions for successful adoption and implementation of RPM and other complex healthcare innovations. This conceptual study argues that incorporation of lessons from literature on institutional logics could enrich these frameworks. Healthcare is a domain influenced by multiple competing, collaborating or co-existing institutional logics such as professional, state, market, corporate and increasingly a community logic, expressed in patient-centred care principles. We outline the concept of patient-centred care as an emerging institutional logic and explore how to incorporate it into two widely used analytical frameworks, NASSS (‘non-adoption, abandonment, scale-up, spread, and sustainability’) and normalisation process theory (NPT). The main benefit of adding an institutional logics approach to the NPT framework is primarily to increase awareness of how institutional logics at meso-and macro-levels may affect the scope of implementation at a micro-level. In the case of the NASSS framework institutional logics provides a rationale for achieving cross-level alignment between domains.

Implementing the Social Care Workforce Race Equality Standard in England: Early Observations

AbstractThe implementation in England of a Social Care Workforce Race Equality Standard (SCWRES), initially confined to social work, started with a first set of eighteen volunteer local authorities (LAs) in 2021. This article discusses a rapid evaluation of the SCWRES during its first year. We used Normalization Process Theory (NPT) to better understand the implementation process of this initiative. Thirty-one interviews were undertaken in 2021. Transcripts were analysed using the constant comparative approach and emerging themes were then mapped onto the NPT framework and its four main constructs. Using these we found some lack of clarity over the aims and data demands of the SCWRES (coherence), but generally substantial personal and employer investment in the intervention (cognitive participation); implementation was assisted by personal support to the LAs from senior managers at national level (collective action); and there was general constructive reflection and positive feedback about the SCWRES (reflexive monitoring). Barriers to implementation of new initiatives might be expected during a global pandemic. However, support for the SCWRES was generally high and participants considered they had learned much in its first six months despite pandemic pressures. This article highlights aspects of implementation to be addressed in any further SCWRES rollout.

Automated Decision Support For Community Mental Health Services Using National Electronic Health Records: Qualitative Implementation Case Study

BackgroundA high proportion of patients with severe mental illness relapse due to nonadherence to psychotropic medication. In this paper, we use the normalization process theory (NPT) to describe the implementation of a web-based clinical decision support system (CDSS) for Community Mental Health Services (CMHS) called Actionable Intime Insights or AI2. AI2 has two distinct functions: (1) it provides an overview of medication and treatment history to assist in reviewing patient adherence and (2) gives alerts indicating nonadherence to support early intervention.ObjectiveOur objective is to evaluate the pilot implementation of the AI2 application to better understand the challenges of implementing a web-based CDSS to support medication adherence and early intervention in CMHS.MethodsThe NPT and participatory action framework were used to both explore and support implementation. Qualitative data were collected over the course of the 14-month implementation, in which researchers were active participants. Data were analyzed and coded using the NPT framework. Qualitative data included discussions, meetings, and work products, including emails and documents.ResultsThis study explores the barriers and enablers of implementing a CDSS to support early intervention within CMHS using Medicare data from Australia’s national electronic record system, My Health Record (MyHR). The implementation was a series of ongoing negotiations, which resulted in a staged implementation with compromises on both sides. Clinicians were initially hesitant about using a CDSS based on MyHR data and expressed concerns about the changes to their work practice required to support early intervention. Substantial workarounds were required to move the implementation forward. This pilot implementation allowed us to better understand the challenges of implementation and the resources and support required to implement and sustain a model of care based on automated alerts to support early intervention.ConclusionsThe use of decision support based on electronic health records is growing, and while implementation is challenging, the potential benefits of early intervention to prevent relapse and hospitalization and ensure increased efficiency of the health care system are worth pursuing.

Implementing primary care diabetes prevention for women with previous gestational diabetes: a mixed-methods study.

The implementation of diabetes prevention for women with previous gestational diabetes (GDM) has been stymied by many barriers that are located within routine general practice (GP). We aimed to unpack the GP factors and understand the mechanisms that explain why a diabetes prevention intervention for this population succeeds or fails. We performed a mixed-methods study with a Normalization Process Theory framework that included clinical audits, semistructured interviews, and focus groups within mixed urban and rural primary care practices in Victoria, Australia. Staff of primary care practices and external support staff who provide services to women with previous GDM participated in a 12-month quality improvement collaborative intervention. We compared diabetes screening and prevention activity planning with the strategies and factors identified through a process evaluation of full-, moderate-, and low-active participating practices. The intervention doubled screening rates (26%-61%) and 1-in-10 women received a diabetes prevention planning consultation. Critical improvement factors were: mothers being seen as participants in the quality improvement work; staff collectively building care strategies; staff taking a long-term care of a community perspective rather than episodic service delivery; and feedback processes being provided and acted on across the practice. The observable factors from the external perspective were: leadership by identified practice staff, reminder systems in action and practice staff driving the process collectively. Successful engagement in diabetes prevention for women with previous GDM requires proactive building of the critical improvement factors and audit feedback into routine GP.

Normalisation process theory and the implementation of a new glaucoma clinical pathway in hospital eye services: Perspectives of doctors, nurses and optometrists

Normalisation process theory reports the importance of contextual integration in successfully embedding novel interventions, with recent propositions detailing the role that 'plasticity' of intervention components and 'elasticity' of an intended setting contribute. We report on the introduction of a clinical pathway assessing patient non-responsiveness to treatment for glaucoma and ocular hypertension. The aim of this study was to assess the feasibility of implementing the Cardiff Model of Glaucoma Care into hospital eye services, identifying any issues of acceptability for staff through the filter of normalisation process theory. A prospective observational study was undertaken in four hospital eye services. This incorporated detailed qualitative semi-structured interviews with staff (n = 8) to gather their perceptions on the intervention's usefulness and practicality. In addition, observational field notes of patient and staff consultations (n = 88) were collected, as well as broader organisational observations from within the research sites (n = 52). Data collection and analysis was informed by the normalisation process theory framework. Staff reported the pathway led to beneficial knowledge on managing patient treatment, but the model was sometimes perceived as overly prescriptive. This perception varied significantly based on the composition of clinics in relation to staff experience, staff availability and pre-existing clinical structures. The most commonly recounted barrier came in contextually integrating into sites where wider administrative systems were inflexible to intervention components. Flexibility will be the key determinant of whether the clinical pathway can progress to wider implementation. Addressing the complexity and variation associated with practice between clinics required a remodelling of the pathway to maintain its central benefits but enhance its plasticity. Our study therefore helps to confirm propositions developed in relation to normalisation process theory, contextual integration, intervention plasticity, and setting elasticity. This enables the transferability of findings to healthcare settings other than ophthalmology, where any novel intervention is implemented.

Identifying relevant factors for successful implementation into routine practice: expert interviews to inform a heart failure self-care intervention (ACHIEVE study)

BackgroundAdherence to heart failure (HF) self-care behaviours has been found to be effective for alleviating illness symptoms, increasing quality of life and reducing hospital re-admissions and mortality. However, many patients fail to implement on-going self-care into their daily lives. It is therefore crucial to improve the behaviour of HF patients to increase self-care adherence. The aim of this study is to identify relevant factors to successfully implement a complex, theory-based HF self-care intervention into routine practice.MethodsWe conducted semi-structured interviews to obtain key stakeholders’ opinions on previously developed behaviour change techniques for enhancing HF patients’ self-care behaviours, in order to optimise implementation of these techniques in an intervention. The interview topic guide was developed based on the Normalisation Process Theory (NPT), a tool that takes into account the feasibility of implementation and the acceptability to stakeholders. Interviews were analysed using thematic analysis and supported by MAXQDA 2020, a software for qualitative research.ResultsInterview participants included 18 key stakeholders consisting of three crucial groups: clinical experts (n = 7), patients (n = 3) and high calibre policy makers/potential funders (n = 8). The interviews revealed numerous factors to consider for successful implementation of an intervention into routine practice. The findings are presented according to two major categories: (1) themes within the NPT framework and (2) themes beyond the NPT framework. Themes within the NPT component ‘Coherence’ include three sub-themes: ‘understandability’, ‘value beyond existing interventions’ and ‘perceived benefits’. The NPT component ‘Cognitive participation’ revealed two sub-themes: ‘time resources’ and ‘financial sustainability’. Finally, the NPT component ‘Collective action’ uncovered three sub-themes: ‘need for training’, ‘compatibility with existing practice’ and ‘influence on roles’. A further two themes were identified beyond the NPT framework, namely: ‘structural challenges’ and (2) ‘role of carers’.ConclusionsFactors identified previously by NPT were validated, but stakeholders further identified relevant aspects beyond NPT. Based on these findings, we suggest the existing NPT framework could be expanded to include a fifth component: questions considering specific environmental factors (contextual considerations). Sensitising researchers to these issues at an early stage when designing an intervention can facilitate its later success.

Health Care Professional Association Agency in Preparing for Artificial Intelligence: Protocol for a Multi-Case Study.

BackgroundThe emergence of artificial intelligence (AI) in health care has impacted health care systems, including employment, training, education, and professional regulation. It is incumbent on health professional associations to assist their membership in defining and preparing for AI-related change. Health professional associations, or the national groups convened to represent the interests of the members of a profession, play a unique role in establishing the sociocultural, normative, and regulative elements of health care professions.ObjectiveThe aim of this paper is to present a protocol for a proposed study of how, when faced with AI as a disruptive technology, health professional associations engage in sensemaking and legitimization of change to support their membership in preparing for future practice.MethodsAn exploratory multi-case study approach will be used. This study will be informed by the normalization process theory (NPT), which suggests behavioral constructs required for complex change, providing a novel lens through which to consider the agency of macrolevel actors in practice change. A total of 4 health professional associations will be studied, each representing an instrumental case and related fields selected for their early consideration of AI technologies. Data collection will consist of key informant interviews, observation of relevant meetings, and document review. Individual and collective sensemaking activities and action toward change will be identified using stakeholder network mapping. A hybrid inductive and deductive model will be used for a concurrent thematic analysis, mapping emergent themes against the NPT framework to assess fit and identify areas of discordance.ResultsAs of January 2021, we have conducted 17 interviews, with representation across the 4 health professional associations. Of these 17 interviews, 15 (88%) have been transcribed. Document review is underway and complete for one health professional association and nearly complete for another. Observation opportunities have been challenged by competing priorities during COVID-19 and may require revisiting. A linear cross-case analytic approach will be taken to present the data, highlighting both guidance for the implementation of AI and implications for the application of NPT at the macro level. The ability to inform consideration of AI will depend on the degree to which the engaged health professional associations have considered this topic at the time of the study and, hence, what priority it has been assigned within the health professional association and what actions have been taken to consider or prepare for it. The fact that this may differ between health professional associations and practice environments will require consideration throughout the analysis.ConclusionsUltimately, this protocol outlines a case study approach to understand how, when faced with AI as a disruptive technology, health professional associations engage in sensemaking and legitimization of change to support their membership in preparing for future practice.International Registered Report Identifier (IRRID)DERR1-10.2196/27340

Co-construction of the family-focused support conversation: a participatory learning and action research study to implement support for family members whose relatives are being discharged for end-of-life care at home or in a nursing home

BackgroundMany people move in and out of hospital in the last few weeks of life. These care transitions can be distressing for family members because they signify the deterioration and impending death of their ill relative and forthcoming family bereavement. Whilst there is evidence about psychosocial support for family members providing end-of-life care at home, there is limited evidence about how this can be provided in acute hospitals during care transitions. Consequently, family members report a lack of support from hospital-based healthcare professionals.MethodsThe aim of the study was to implement research evidence for family support at the end-of-life in acute hospital care. Informed by Participatory Learning and Action Research and Normalization Process Theory (NPT) we co-designed a context-specific intervention, the Family-Focused Support Conversation, from a detailed review of research evidence. We undertook a pilot implementation in three acute hospital Trusts in England to assess the potential for the intervention to be used in clinical practice. Pilot implementation was undertaken during a three-month period by seven clinical co-researchers - nurses and occupational therapists in hospital specialist palliative care services. Implementation was evaluated through data comprised of reflective records of intervention delivery (n = 22), in-depth records of telephone implementation support meetings between research team members and co-researchers (n = 3), and in-depth evaluation meetings (n = 2). Data were qualitatively analysed using an NPT framework designed for intervention evaluation.ResultsClinical co-researchers readily incorporated the Family-Focused Support Conversation into their everyday work. The intervention changed family support from being solely patient-focused, providing information about patient needs, to family-focused, identifying family concerns about the significance and implications of discharge and facilitating family-focused care. Co-researchers reported an increase in family members’ involvement in discharge decisions and end-of-life care planning.ConclusionThe Family-Focused Support Conversation is a novel, evidenced-based and context specific intervention. Pilot implementation demonstrated the potential for the intervention to be used in acute hospitals to support family members during end-of-life care transitions. This subsequently informed a larger scale implementation study.Trial registrationn/a.

Normalizing inconvenience to promote childhood vaccination: a qualitative implementation evaluation of a novel Michigan program

BackgroundIn 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations. This study utilizes Normalization Process Theory (NPT) to assess program implementation, identifying potential threats to fidelity and sustainability.MethodsWe conducted 32 semi-structured interviews with individuals involved in these education programs across 16 LHDs. Participating LHDs were selected from a stratified, representative sample. One interviewer conducted all interviews using a semi-structured interview guide; two authors coded and analyzed the interview transcripts according to the NPT framework (i.e, sense-making, engagement, collective action, and reflexive monitoring).ResultsThere was a lack of consensus about who the stakeholders of this new rule and its resulting program were (sense-making). Perhaps as a result, most LHDs did not solicit advice from key stakeholder groups (i.e., schools, health care providers, community stakeholders) in their planning (engagement). While most interviewees identified providing education and information as the goal, some identified the more challenging goal of persuading vaccine hesitant parents to immunize their children. There was also some variation in perception of who held health educators accountable for meeting the goals of the waiver education program (collective action). Formal program evaluation by LHDs was rare, although some held informal staff debriefings. Additionally, sessions that went particularly well or poorly were top-of-mind (reflexive monitoring).ConclusionsThe immunization waiver education program may be at risk of not becoming fully embedded into routine LHD practice, potentially compromising its long-term effectiveness and sustainability. Managers at the local and state level should maintain oversight to ensure that the program is delivered with fidelity. As the program relies on sustaining inconvenience to encourage parents to immunize their children, any shortcuts taken will undermine its success.

Acute kidney injury electronic alerts: mixed methods Normalisation Process Theory evaluation of their implementation into secondary care in England

ObjectiveAround one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across...

"Primary care is primary care": Use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario.

BackgroundIn Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario.MethodsA qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered.ResultsUsing the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners’ roles, and the need for more training and education in transgender care for practitioners.ConclusionsPrimary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals.

Exploring the implementation of cognitive behaviour therapy for psychosis using the Normalization Process Theory framework.

Evidence suggests that only a minority of service users experiencing psychosis have access to Cognitive Behavioural Therapy for psychosis (CBTp). Normalization Process Theory (NPT) is a theoretical framework which focuses on processes by which interventions are implemented and normalized in clinical practice. This study explored the views and experiences of mental health professionals regarding the implementation of CBTp. Barriers and facilitators to implementation were explored using the NPT framework. A qualitative methodology was adopted involving semi-structured focus groups and individual interviews. A total of 14 members of staff working in the community and crisis mental health teams were recruited. Thematic analysis was used to generate initial themes. The framework approach was utilized to map initial themes to the NPT framework. Inductive coding generated five overarching themes consisting of 15 individual subthemes which captured the perceived barriers to engagement; contextual barriers to implementation; optimization of implementation; positive attitudes towards implementation; and expectations of implementing CBTp. All but two subthemes mapped on to the NPT framework. The deductive analysis suggested that difficulties in making sense of CBTp among professionals were reflected as service level barriers which impeded wider implementation. The results of this study suggested a mixture of barriers and facilitators to CBTp implementation. Interpreting our findings within an NPT framework indicates the importance of strong clinical leadership to address difficulties in sense-making and service investment in CBTp. Findings indicate a mixture of barriers and facilitators to CBTp implementation. NPT analysis indicates difficulties in coherence among stakeholders regarding the purpose and value of CBTp. Difficulties making sense of CBTp translates into service level barriers and impede the collective action of stakeholders. The role of clinical leadership is crucial in increasing coherence and collective action in services.

Cognitive stimulation therapy in dementia care: exploring the views and experiences of service providers on the barriers and facilitators to implementation in practice using Normalization Process Theory.

Cognitive stimulation therapy (CST) is an evidence-based, cost-effective psychosocial intervention for people with dementia but is currently not a standard part of post-diagnostic care. This qualitative study explored the views and experiences of dementia care providers on the barriers and facilitators to its implementation in usual care. Thirty four semi-structured interviews (24 participants) were conducted across four dementia care sites in the North of England; ten were follow-up interviews. Data were analyzed using thematic analysis and then mapped to the Normalization Process Theory framework. Participants considered CST a "good fit" with their "preferred" ways of working and goals of dementia care namely the provision of person-centered services. For facilitators delivering the intervention, compared to other behavioral interventions, CST was seen to offer benefits to their work and was easy to understand as an intervention. Training in CST and seeing benefits for clients were important motivators. Time and resources were crucial for the successful implementation of CST. Participants were keen to objectively measure benefits to participants but unsure how to do this. CST is a cost-effective psychosocial intervention for people with dementia, recommended by national guidance. Despite our findings which show that, using the NPT framework, there are more facilitators than barriers to the implementation of CST, it is still not a standard part of post-diagnostic dementia care. Further research is needed to explore the reasons for this implementation gap in ensuring evidence-based care in translated into practice.

Developing, delivering and evaluating primary mental health care: the co-production of a new complex intervention.

BackgroundHealth services face the challenges created by complex problems, and so need complex intervention solutions. However they also experience ongoing difficulties in translating findings from research in this area in to quality improvement changes on the ground. BounceBack was a service development innovation project which sought to examine this issue through the implementation and evaluation in a primary care setting of a novel complex intervention.MethodsThe project was a collaboration between a local mental health charity, an academic unit, and GP practices. The aim was to translate the charity’s model of care into practice-based evidence describing delivery and impact. Normalisation Process Theory (NPT) was used to support the implementation of the new model of primary mental health care into six GP practices. An integrated process evaluation evaluated the process and impact of care.ResultsImplementation quickly stalled as we identified problems with the described model of care when applied in a changing and variable primary care context. The team therefore switched to using the NPT framework to support the systematic identification and modification of the components of the complex intervention: including the core components that made it distinct (the consultation approach) and the variable components (organisational issues) that made it work in practice. The extra work significantly reduced the time available for outcome evaluation. However findings demonstrated moderately successful implementation of the model and a suggestion of hypothesised changes in outcomes.ConclusionsThe BounceBack project demonstrates the development of a complex intervention from practice. It highlights the use of Normalisation Process Theory to support development, and not just implementation, of a complex intervention; and describes the use of the research process in the generation of practice-based evidence. Implications for future translational complex intervention research supporting practice change through scholarship are discussed.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1726-6) contains supplementary material, which is available to authorized users.

Tools to overcome potential barriers to chlamydia screening in general practice: Qualitative evaluation of the implementation of a complex intervention.

BackgroundChlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice.MethodsWe used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention).ResultsOur results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening.Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn’t engage with the screening intervention.Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices.Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity.ConclusionsA complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices.