Master Class Presentation slides for 'Getting ideas into Practice: normalising the implementation of complex interventions across the healthcare system', Collaborating for Better Care Partnership Master Class with Dr Tracy Finch, Professor Carl May, Dr Tim Rapley.

1. Master Class
‘Getting new ideas into practice:
normalising the implementation of
complex interventions across the
healthcare system’
23rd October 2014
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2. Programme
09:30 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
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3. Welcome
Ian Renwick
Chair, Collaborating for Better Care Partnership
(Chief Executive, Gateshead Health NHS
Foundation Trust)

4. Wi-fi access
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5. Introduction
Dr Tracy Finch
Senior Lecturer in Psychology of Healthcare,
Newcastle University
Dr Tim Rapley
Lecturer in Medical Sociology, Newcastle University

6. 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

7. Pre-MasterclassSurvey
Response rate: between 29-38 of 60 (48% -63%) across the survey.
0
2
4
6
8
10
12
Healthcareprofessional
Clinicalacademic
Researcher/ non-clinacademic
Managerial/ servicedevelopment
Other
Total responses: 29

8. Familiar with NPT?
0 2 4 6 8 10 12 14 16
Never heard of before
Heard of it but don't
know about it
Heard presentations or
read papers
Used theory or toolkit
before
Total responses: 29

9. 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)

10. Interventions appraised
using the survey
45% (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…

11. 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?

12. 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

13. 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.

14. The key theory papers….

15. 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.

16. 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…..

17. 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

18. Decision Support Technologies
Telecare services
Mental Health
COPD
Infertility
Depression
Chronic Constipation
TB
Midwifery
Chronic Heart Failure
Speech & Language therapy
Language interpretation services
E-Health initiatives (ICT)
Back Pain
Information systems Development (ISD)
Chronic Kidney Disease
2012
Summary of NPT literature

19. NPT Projects & Collaborators
ESRC ‘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.

20. Task One: WHAT is NPT?
Dr Tim Rapley

21. • Think with NPT via practical examples …
• Not a sacred object - use, adapt, tailor …

22. NPT launch

28. • 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.

29. • Who are the participants?
– Technology of LIFELAX intervention
• Trial team - intervention deliverers
• General Practitioners
• Practice Managers
• Practice Nurses
• Patients

30. • 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

38. 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.

39. 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.

40. Introducing NPT
Carl May
Professor of Healthcare Innovation,
University of Southampton

41. Individual behaviour, practice implementation, and organizational integration: introducing Normalization Process Theory
Carl May PhD

42. Acknowledgements: Frances Mair, Tracy Finch, Catherine Pope, Anne MacFarlane, Shaun Treweek, Tim Rapley, BieNioOng, 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

43. There is nothing so practical as a good theory
Kurt Lewin
43

44. 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 toparticipateinto a complex intervention?)
•How does the work get done? (How is a complex intervention enactedin practice?)
•Why did the work happen like that? (How is a complex intervention monitoredby its users?)

45. TRANSLATIONAL GAPS MATTER IN HEALTHCARE
45

46. T1research seeks to move a basic discovery into a candidate health application;
T2research assesses the value of T1application for health practice (leading to the development of evidence-based guidelines);
T3research attempts to move (evidence-based guidelines) into health practice, through delivery, dissemination, and diffusion research;
T4research seeks to evaluate the “real world” health outcomes of a T1application in practice.
Used by kind permission: Pienta, K. http://kenpienta.com/lab/translational- research/(accessed 12 September 2013)

47. 47
Picture: courtesy of Prof KJ Pienta

48. 1. CROSSING THE GAPS AT T3AND T4
48

49. What is implementation?
•Implementation includes anydeliberately 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.

50. 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 enactedto achieve goals. (e.g. electronic health records, ordering systems)

51. A technology is nota ‘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 monitorits effects

52. 2. THEORY IS A PRACTICAL TOOL FOR THINKING ACROSS GAPS
52

53. 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

54. 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”

55. 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 diffusionmodels.
Heavy emphasis on individual differences (attitudes and intentions), reflects influence of psychological individualism.
Much less interest in implementation processes
* TabakRG, KhoongEC, Chambers DA, BrownsonRC: Bridging Research and Practice: Models for Dissemination and Implementation Research. Am J PrevMed 2012, 43(3):337-350.

56. •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.

59. Capability: How users interact with interventions*May C: A rational model for assessing and evaluating complex interventions in health care. BMC Health ServRes 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.

60. Screening for intimate partner violence in NSW
•Interactional workability: Intervention impacts on interactions between health worker and women. Direct and scripted brief intervention, favourableresponse 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.
*SpangaroJ, 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

61. Hoberg, A. et al., Feasibility evaluation of Interpersonal and Social Rhythm GroupTherapyDelivery Model Archives of Psychiatry In Press
Supporting implementation design

62. 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.

63. 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.
FranxG, et al,. Implementing a stepped care approach in primary care Implement Sci2012, 7(8)
63

64. 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. 5thInternational Shared Decision-Making Conference, Boston, October 2009 (Slide courtesy of Rebecca Mullan).u

65. 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).

67. key papers
May C, Finch T. Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology2009; 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. 68
Thank you!

69. 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

70. Example: Teledermatology
Specialist 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, MairFS, May CR. Teledermatologyin the U.K.: Lessons in service innovation. British Journal of Dermatology 2007, 156(3), 521-527.

71. 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

72. 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?

73. Using NPT within different
methodological approaches
Different purposes,
different methods
Dr Tracy Finch

74. Applying NPT
Two 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…

76. 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

77. Developing an intervention
E.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

79. 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’??

82. NPT: Planning implementation
E.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

83. Regional Implementation of Robotic Surgery

84. 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

85. 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.

87. 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

88. 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

89. Using NPT in Qualitative
Research
Consider:
• 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

91. Example: NPT & implementing
interpreters
Context: 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 BrúnM. Using a Theory-Driven Conceptual Framework in Qualitative Health Research. Qualitative
Health Research, 2012;22(5):607-18.

92. NPT & Qual

93. 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!

94. 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

96. 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

97. 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).

98. 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!

99. 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.

100. 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.

101. 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

102. Thank you