Master Class

‘Getting new ideas into practice: normalising the implementation of complex interventions across the

healthcare system’23rd October 2014

@AHSN_NENC#NPTmaster

Programme09:30 Welcome, Ian Renwick, Chair of the ‘Collaborating for Better Care Partnership’

09.35 Introduction, Dr Tracy Finch & Dr Tim Rapley

09.45 Task One: WHAT is NPT?

09:55 Workshop One - Using NPT to think through implementation scenarios

10:15 Group feedback

10:30 Introducing NPT; Carl May, Professor of Healthcare Innovation University of Southampton

11.00 Refreshment Break

11.15 Task Two: WHO should use NPT?

11.25 Workshop Two – Understanding different user perspectives

11.45 Group feedback

12.00 Lunch

12.45 Using NPT within different methodological approaches, Dr Tracy Finch

13.05 Task Three: WHEN and HOW might I use NPT?

13.15 Workshop Three – Understanding application of NPT for different ‘problems’

13.35 Group feedback

14:00 NPT: Key Messages, Dr Tim Rapley & Dr Tracy Finch

14.20 Questions & Answers

15.00 Close

@AHSN_NENC#NPTmaster

Welcome

Ian Renwick

Chair, Collaborating for Better Care Partnership

(Chief Executive, Gateshead Health NHS

Foundation Trust)

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@AHSN_NENC#NPTmaster

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Introduction

Dr Tracy Finch

Senior Lecturer in Psychology of Healthcare,

Newcastle University

Dr Tim Rapley

Lecturer in Medical Sociology, Newcastle University

Today

• Introduction to Normalization Process Theory as one approach within Implementation Science

• Very interactive – we get to ‘play’ with the theory!

• Stimulate thinking and, through discussion, generate some ideas about how you might use NPT in your own work

Pre-Masterclass Survey

Response rate: between 29-38 of 60 (48% - 63%) across the survey.

0

2

4

6

8

10

12

Healthcareprofessional

Clinicalacademic

Researcher/non-clin

academic

Managerial/service

development

Other

Total responses: 29

Familiar with NPT?

0 2 4 6 8 10 12 14 16

Never heard of before

Heard of it but don'tknow about it

Heard presentations orread papers

Used theory or toolkitbefore

Total responses: 29

Hoping to take away from the day?

• Practical knowledge to apply in practice (11/23)

• Develop implementation strategy (3/23)

• Improve knowledge & understanding of implementation process/NPT (5/23)

• Learn about new innovations (3/23)

• Time to think about own evaluation (1/23)

Interventions appraised

using the survey45% (17/38) used ‘own example’:

• Electronic monitoring

systems

• self-care initiatives

• NHS health checks

• multi-disciplinary care

teams/pathways

• hospital at home

• brief alcohol intervention

(pharmacy)

• evidence-based

commissioning,

• decision-support

• staff training packages…..

Feedback on results to come after the event…

A brief background on ‘Implementation’

• Problem of getting ‘proven’ interventions and therapies into practice – ‘implementation science’

• Calls for implementation strategies and evaluations to be more theory-based

• But theories differ in focus - individual, organisational, or the intervention?

Why is ‘implementation’ so difficult?Complex interventions:

“Conventionally defined as interventions with several interacting components,

they present a number of special problems for evaluators, in addition to the

practical and methodological difficulties that any successful evaluation must

overcome. Many of the extra problems relate to the difficulty of standardising

the design and delivery of the interventions, their sensitivity to features of the

local context, the organisational and logistical difficulty of applying

experimental methods to service or policy change, and the length and

complexity of the causal chains linking intervention with outcome.”

From www.mrc.ac.uk/complexinterventionsguidance

Normalization Process Theory

• Theory of how new technologies and practices become ‘normalised’

• Focuses on how implementing a new intervention or practice involves people working together

• Considers:

– Attitudes and practices of different groups of people involved in implementing a new intervention

– The context where it is being implemented

– The intervention/practice itself

May & Finch (2009). Implementing, integrating and embedding practices: an outline of normalization process theory. Sociology, 43 (3): 535-54.

The key theory papers….

What is NPT?

A way of thinking about implementation problems that focuses on:

How interventions can become part of everyday practice

How different groups of people need to work together to achieve it

How do I use it?

Thinking of your intervention, use the four sets of questions on the right to identify possible barriers to successful implementation, and suggest solutions to improve the process.

What is NPT useful for?

We suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation.

Growing body of studies that have used NPT in diverse contexts…..

Summary of NPT literature• Qualitative review of 29 studies that used NPT, between

2006 & 2012

• Mixed methods, but mostly qualitative – focus on understanding implementation process

Decision Support Technologies

Telecare services Mental Health COPD

InfertilityDepressionChronic

ConstipationTB

MidwiferyChronic Heart

FailureSpeech &

Language therapy

Language interpretation

services

E-Health initiatives (ICT)

Back Pain

Information systems

Development (ISD)

Chronic Kidney Disease

2012

Summary of NPT literature

NPT Projects & CollaboratorsESRC ‘Toolkit’ Grant 189-25-0003: ‘Normalizing new health

technologies - building a web-enabled toolkit for implementation

practitioners.

NoMAD study: ESRC Grant RES-062-23-3274: ‘Improving the

normalisation of complex interventions: Developing quantitative

measures for users based on Normalization Process Theory’.

Service and Delivery Organisation

(SDO): Research grant

08/1602/135. Understanding the

implementation & Integration of

e-health.

Task One: WHAT is NPT?

Dr Tim Rapley

• Think with NPT via practical examples …

• Not a sacred object - use, adapt, tailor …

NPT launch

• Participants distinguish the intervention from

current ways of working

• Whether the intervention is easy to describe to

participants and whether they can appreciate how it

differs or is clearly distinct from current ways of

working.

• Who are the participants?

– Technology of LIFELAX intervention• Trial team - intervention deliverers

• General Practitioners

• Practice Managers

• Practice Nurses

• Patients

• Participants distinguish the intervention from current ways of working

– Technology of LIFELAX intervention

• Trial team - intervention deliverers

• General Practitioners

• Practice Managers

• Practice Nurses NOT AT ALL

• Patients

Task One: Group Work

• 5 minutes …

– Read scenario;

– Focus on one group of participants;

– Discuss potential implementation problems.

• 15 minutes …

– Go through the 16 NPT tool questions – one by one;

– Use the questions to structure your discussion of the potential implementation problems.

What is NPT?

A way of thinking about implementation problems that focuses on:

How interventions can become part of everyday practice

How different groups of people need to work together to achieve it

How do I use it?

Thinking of your intervention, use the four sets of questions on the right to identify possible barriers to successful implementation, and suggest solutions to improve the process.

Introducing NPT

Carl May

Professor of Healthcare Innovation,

University of Southampton

Individual behaviour, practice implementation,

and organizational integration: introducing

Normalization Process Theory

Carl May PhD

Acknowledgements: Frances Mair, Tracy Finch, Catherine

Pope, Anne MacFarlane, Shaun Treweek, Tim Rapley, Bie

Nio Ong, Mark Johnson, Anne Rogers, Nilay Shah,

Catherine O’Donnell, Elizabeth Murray, Peter Griffiths,

Jane Gunn, Victor Montori

• Grant RES 000-27-0084

• Grant RES 189-25-0003

• Grant RES 062-23-3274

There is nothing so practical as a good theory

Kurt Lewin

43

It’s all about the work

• What is the work? (How is a practice made coherent

by its users?)

• Who does the work? (How do people and groups

come to participate into a complex intervention?)

• How does the work get done? (How is a complex

intervention enacted in practice?)

• Why did the work happen like that? (How is a complex

intervention monitored by its users?)

TRANSLATIONAL GAPS MATTER IN HEALTHCARE

45

T1 research seeks to move a basic

discovery into a candidate health

application;

T2 research assesses the value of T1

application for health practice (leading

to the development of evidence-based

guidelines);

T3 research attempts to move

(evidence-based guidelines) into health

practice, through delivery,

dissemination, and diffusion

research;

T4 research seeks to evaluate the “real

world” health outcomes of a T1

application in practice.

Used by kind permission: Pienta, K. http://kenpienta.com/lab/translational-

research/ (accessed 12 September 2013)

47

Picture: courtesy of Prof KJ Pienta

1. CROSSING THE GAPS AT T3 AND T4

48

What is implementation?

• Implementation includes any deliberately initiated attempt to introduce new, or modify existing, patterns of collective action in health care or some other formal organizational setting.

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

• Participants may seek to modify the ways that people think, act and organize themselves or others, they may seek to initiate a process with the intention of creating a new outcome.

What is implemented?

Interventions

– may be intended to change behaviour and its intended outcomes (e.g. strategies for making ‘expert patients’; or using telemedicine systems)

– may be intended to change expertise and actions (e.g. devices; or decision-making tools and clinical guidelines)

– may be intended to change the procedures enacted to achieve goals. (e.g. electronic health records, ordering systems)

A technology is not a ‘thing’

• It is an ensemble of beliefs,

techniques, artefacts,

behaviours, interactions, and

relationships.

• People work to give ‘it’

coherence, organize

participation, collectively

enact ‘it’ and monitor its

effects

2. THEORY IS A PRACTICAL TOOL FOR

THINKING ACROSS GAPS

52

Theories are the basic building blocks of

Science

• Theories are structured rational explanations of structures,

relationships, identities and processes

• Theories are conceptual toolkits: they help us differentiate,

characterize, and understand natural and social

phenomena

Processes are changes in state over time

• Implementation is the process that takes place after a decision to

adopt a new way of conceptualizing, enacting and organizing

practice

– “the way we are going to do things here”

• Normalization is the process by which activities and their

consequences become routinely incorporated in everyday work

– “the way we do things here, it’s just natural”

More than 60 theories, models, and frameworks

relevant to implementation are available to

practitioners and researchers*

55

Focus on attributes of organizations and policy

environments (inner and outer contexts), reflects influence

of diffusion models.

Heavy emphasis on individual differences (attitudes and

intentions), reflects influence of psychological

individualism.

Much less interest in implementation processes

* Tabak RG, Khoong EC, Chambers DA, Brownson RC: Bridging Research and Practice: Models for Dissemination and

Implementation Research. Am J Prev Med 2012, 43(3):337-350.

• Why is it so difficult to implement new technologies in practice?

• Need to understand how new ways of thinking, acting and organizing become embedded in healthcare systems.

• Need a conceptual map for the process evaluation of complex interventions and for the organization of implementation processes.

Capability: How users interact with interventions

*May C: A rational model for assessing and evaluating complex interventions in health care. BMC Health Serv Res

2006, 6(86 )

Interactional workability: how a

complex intervention is practically

operationalized by the people using

it

Skill-set workability: the distribution

and conduct of work associated with a

complex intervention in a division of

labour

Relational integration: how

knowledge and work about a

complex intervention is mediated

and understood within networks.

Contextual integration: the realization

of resources of a complex

intervention within an organizational

domain.

Screening for intimate partner violence in NSW

• Interactional workability: Intervention impacts on interactions between

health worker and women. Direct and scripted brief intervention,

favourable response from women.

• Relational integration: intervention improves trust between

professionals and women in interactions. Adds to confidence about

mechanisms for referral and care pathways.

• Skill-set workability: Intervention fits with existing role definitions.

Questions prescribed, universal, embedded in brief intervention.

• Contextual integration: Institutional processes support intervention.

Clear support for implemention. Annual monitoring of outcomes.

*Spangaro J, et al: Pandora Doesn't Live Here Anymore: Normalization of Screening for Intimate Partner Violence in Australian

Antenatal, Mental Health, and Substance Abuse Services. Violence and Victims 2011, 26(1):130-144.

60

Hoberg, A. et al., Feasibility evaluation of Interpersonal and Social Rhythm GroupTherapy Delivery Model Archives of Psychiatry In Press

Supporting implementation design

Contribution: the work that people do to implement complex

interventions

Coherence: defines and

organizes the components of a

complex intervention

Collective Action: defines

and organizes the enacting of a

complex intervention

Cognitive Participation:defines and organizes the

people implicated in a complex

intervention

Reflexive Monitoring:defines and organizes

assessment of the outcomes of

a complex intervention

*May C, Finch T: Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology 2009, 43(3):535-554.

Quality improvement collaborative for depression (13 primary care MDTs,

Netherlands)

• Coherence: The stepped-care model offered clinicians a technique for shared

understanding on depression (who is severely and non severely depressed).

• Cognitive participation: The new low intensity stepped-care treatment options

fitted well into the primary care perspective.

• Collective action: The possibility to tailor the stepped-care model to the local

setting, and to train staff to apply the stepped-care interventions was important,

but poor organizational infrastructures and lack of funding of the new low

intensive interventions.

• Reflexive monitoring: Improved motivation because outcome measurement can

structure and advance care for individual patients. But absence of supportive

systems (ICT, reminder systems) or staff.

Franx G, et al,. Implementing a stepped care approach in primary care Implement Sci 2012, 7(8)

63

Collective Action:

What do I need to

do to use the

decision aid?

Coherence

Does it make

sense to use a

decision aid to

do my job?

Reflexive

Monitoring: How

well was I able to

use the decision

aid?

Do I understand

the decision aid?

Patients – yes

Bedside nurse – yes

Nurse Practitioner - yes

Patients – yes

Cardiologist - no

Bedside nurse - yes

Study coordinator - no

Nurse Practitioner - yes Are there resources?

Do we have the skills?

Cognitive Participation:

Are the tasks feasible?

Can we work together on this?

Patients – yes

Nurse Practitioner - yes

Patients – yes

Bedside nurse – no

Nurse Practitioner - yes

Mullan RJ, et al., Will this decision aid be implemented? The AMI Choice Decision Aid Trial. 5th

International Shared

Decision-Making Conference, Boston, October 2009 (Slide courtesy of Rebecca Mullan).u

Relationships between capability, contribution and context*

65

(Context 1) Capacity: social

structural resources (norms,

roles) available to agents

Contribution: agency expressed

through coherence;

participation; action; monitoring

(Context 2) Potential: social

cognitive resources (intentions,

commitments) available to

agents

Capability: workability and

integration of the

implementation object

ay . . Implement ci 13 (1).

key papers

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

May C, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science2009; 4. Available here.

May C, Towards a general theory of implementation. Implementation Science 2013, 8:18 Available here

67

68

Thank you!

Normalisation for whom?• Back to complexity – different roles, different perspectives:

– Front end clinical staff ‘ v ’ interventions

– Team leaders/supervisors – multiple hats?

– Others in the referral process (eg. primary/secondary care interface; different departments)

– Admin/technical/support staff – can sometimes be the key people

– Evaluators/researchers – different agendas to service delivery?

– Senior managers/planners/quality assurance

Example: TeledermatologySpecialist Dermatology

Nurses

Consultant

Dermatologists

Patient Advocacy

Coherence ‘Yes’ as skill development;

‘No’ as autonomy limited

‘No’ as didn’t seem to save

patients travelling

Initially, yes as a tool for

reducing waits

Initially, yes as protecting

professional territory

In practice found didn’t save

time or waiting

Lack of fit with

problems of skin

Emphasised need for

seeing/touching

/talking with the

patient

Cognitive

Participation

Engaged. Close partnership

with consultant.

Engaged but sceptical Saw that many patients

would want F2F consult

Collective

Action

Logistical problems re

primary care placements

Constrained by electronic

proforma

Data transfer did not happen

Lacked relational integration

- found high need to see

patients anyway.

[Not involved]

Reflexive

Monitoring

Some access to data, but felt

lack of worth effort

Data on processes &

outcomes disappointing &

never published.

Unsure of evidence

Finch TL, Mair FS, May CR. Teledermatology in the U.K.: Lessons in service innovation. British Journal of Dermatology 2007, 156(3), 521-527.

Task Two: Group work

• Focusing on your ‘ ase study’ and within small groups:

– Agree at least 2 or 3 roles whose perspectives should be represented and decide who is wearing which ‘hat’ (5 mins)

– Work through the tool, u c ‘ ’ representative feeds into answering the items (15 mins)

– Completing the whole tool is unlikely – skip ahead to different items if you wish

Task Two: Group Feedback• Discussion:

– What were the challenges of taking different perspectives?

– Any roles that were more/less difficult to accommodate in working through?

– Any suggestions for ensuring relevant perspectives get captured?

Using NPT within different

methodological approaches

Different purposes, different methods

Dr Tracy Finch

Applying NPTTwo ways of thinking about this:

1) What is the objective you want to achieve?

– Designing an intervention?

– Planning Implementation?

– Designing and conducting an evaluation?

2) If research, what methodological approach is most useful?

– i.e. qualitative; survey; trials; systematic reviews…

NPT: Developing, evaluating,

implementing…..• NPT has a role in developing, evaluating and implementing

complex interventions

• Need to distinguish between:

1. The intervention – would continue after

2. The evaluation – wouldn’t continue after

• Consider long term impact:

– Effectiveness in the ‘real world’

– How widely it can be implemented

Developing an interventionE.g. ImPACT – support of low back pain management in Primary Care using physiotherapists

• Define the ‘context’ – possible changes?

– Staff groups affected

– Other initiatives going on that might compete?

• Define the ‘intervention’

• Undertake NPT analysis of the intervention

– NPT as a framework for ‘thinking it through’

• May need literature review, primary data collection, workshop discussions etc

PROCEDE TO EVALUATION OR ABANDON???Outcome: Low coherence to GPs identified & addressed – led to better participation & fit with existing practices

NPT: Optimising evaluation of a

complex intervention• Example: WISE (Whole System Informing Self-management

Engagement)

1. Define context • factors that might affect engagement with the study?• Timing of data collection against clinical activity?

2. Define the trial parameters - consider all the different patient and professional groups likely to be affected

3. NPT analysis of trials• How will the study procedures affect the work of people it depends upon?

Outcome: NPT used to optimise training content by anticipating and overcoming ‘participation’ issues

NPT AS A ‘TRIAL KILLER’??

NPT: Planning implementationE.g. Robotic Urological Surgery – NPT used by commissioning agency to plan implementation across Emilia-Romagna (Italy).

1. Consider context

– If previously developed and evaluated, what is different about the new context?

– Might the intervention need reconfiguration?

2. Define the intervention

– Easier said than done! (eg. technology, new practice, or some combination of both?)

3. NPT analysis

– Use NPT to maximise approach to implementation

Regional Implementation of Robotic Surgery

NPT Users’ Manual: Methodological

Guidance‘Advice’ Sections on:• Reviews• Surveys• Qualitative research• Trials

Key points:• Guidance only – actual approach you take must be tailored to needs of specific

study context

• Suggests ‘considerations’ based on experience of using NPT with respect to these varied methodological approaches

Using NPT in Systematic Reviews

1) Determine research questions and overall design of a systematic review;

2) Serve as a framework for data analysis within a systematic review;

OR….

3) Support the interpretation of a systematic review's results.

Example: NPT based review of e-Health • Systematic ‘review of reviews’ to understand barriers and

facilitators to e-Health Implementation

• Statements of results/findings coded against constructs of the NPT

• Emphasis on Contextual Integration (Collective Action) issues in literature

• Less on interactions with patients, inter-professional relationships, and fit with existing staff skills and roles

• Policymakers are getting a misleading impression from the literature

Mair F, May C, O'Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health systems: An explanatory systematic review. Bulletin World Health Organisation 2012, 90 (5), 357-64

Using NPT in Qualitative Research• Majority of NPT studies have used qualitative

approaches

• Useful for identifying, describing and understanding implementation process

• Can be used to guide:– Research focus and questions– Research design– Sampling– Data collection – Coding and analysis of data

Using NPT in Qualitative

ResearchConsider:

• NPT is not a methodology or a method, and should be used in a flexible and dynamic way

• NPT is ‘ ’ – may be used alongside other theories/approaches

• Using NPT in qualitative research requires translating the constructs for use in your own context/study

Example: NPT & implementing

interpretersContext: Uptake of language interpreter services within primary care, Ireland.

Data: Interviews and focus groups (GPs, managers, interpreters, service users)

Approach: Themes coded against part of NPT

Added value: Enabled them to bring together disparate themes to clearly identify key ‘barriers and levers’ to uptake

See: acFarlane A O’Reilly-de Brún M. Using a Theory-Driven Conceptual Framework in Qualitative Health Research. Qualitative Health Research, 2012;22(5):607-18.

NPT & Qual

Using NPT in Surveys

• The ‘How much?’ question:

– Structured surveys have the potential to collect data efficiently, and on a large scale

• The ‘what is likely to happen?’ question:

– Surveys, used prospectively, may have some predictive utility with respect to outcomes

• Potentially useful in comparative research

• Surveys are appealing to practitioners and researchers - facilitate take-up of the Theory!

NPT in Survey research:

Examples

• Development of NPT based instrument (TARS) for normalisation of e-health.

• NoMAD study: Aims to develop and test NPT based measures of implementation process and outcome. Project website: http://www.esrc.ac.uk/my-esrc/grants/RES-062-23-3274/read

NPT in Survey research: Some

considerations

• Usually useful for giving ‘breadth’ of perspectives rather than depth – ie numbers of staff

• Recognize limits in using survey data –‘measurement’ vs ‘planning’ vs ‘appraisal’ (both?)

• Some survey tools now available – but still need to ‘customise’ and ‘localise’ how you use them

Using NPT in Trials• An intervention can be demonstrated as ‘effective’ in a trial

context, but problematic to ‘implement’ in the real world.

Consider: Who are the people I expect to use the results of my trial and what can I do to make sure that these people will not be forced to dismiss my trial as irrelevant to them, their patients, or their healthcare systems?

Another example:

Forster et al (2011) – team vs caseload models in midwifery services (Melbourne).

Using NPT – bear in mind!• NPT is not about an individual’s intentions and perceptions it is

focused on helping you to making sense of collective, distributed, patterns of work.

• NPT will encourage you to focus on the range of people, situations, times and places that are involved in all aspects of enacting implementation

• BUT – the context is all important, and NPT needs to be adapted/translated to the context of use

• NPT is NOT a theory of everything – and we are depending on users/testers/sceptics to test its limits!

Task Three: Group work

WHEN and HOW might I use NPT?• In small groups, discuss (20 mins) & feed back on

these questions:

1. Would you use NPT/the toolkit?2. When might you want to use it?3. How would you use it?4. What data would you collect?

Note: General discussion in relation to your use, rather than case study from previous tasks.

What is NPT?

A way of thinking about implementation problems that focuses on:

How interventions can become part of everyday practice

How different groups of people need to work together to achieve it

How do I use it?

Thinking of your intervention, use the four sets of questions on the right to identify possible barriers to successful implementation, and suggest solutions to improve the process.

Keep up to date with developments:• Sign up for the e- bulletin at the registration desk (if you haven’t

already)

Resources will be available on:

You Tube - video will be uploaded (a link included in next e- bulletin)

Slide Share - slide deck will be uploaded (link included in next e-bulletin)

AHSN web site www.ahsn-nenc.org.uk

NEQOS web site www.neqos.nhs.uk/

Twitter - @AHSN_NENC

Thank you