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Normalization Process Theory

Melissa Knowlton

Athabasca University

Carl May

Carl May is a professor at the University of Southampton. He is a medical sociologist with interests in implementation science and health services.

His research is based from two questions:

  • “How do professionals and patients interact, and how are these interactions shaped by clinical knowledge, technique and technology in practice?”
  • “How are new knowledge, techniques and technologies made workable and implemented in health care organizations?”

In the beginning, his studies focused on professional-patient interaction, knowledge and practice.

Carl May has developed several theories, in conjunction with other researchers

  • Normalization Process Theory (with Dr. Tracy Finch)
  • Minimally Disruptive Medicine (with Prof Victor Montori and Prof France Mair)
  • Burden of Treatment Theory

Professor Carl May (2018)

About The Theorist

What is Normalization Process Theory (NPT)?

The Normalization Process Theory provides a framework for the implementation of new practices (May & Finch, 2009)

What is it?

It is used in a variety of contexts to inform the implementation process of new practices or to evaluate and critique a current implementation process (Drew et al., 2015).

Core Concepts

  • Practices become embedded in routine activities as a result of the work of people, either independently or as a group,

  • Implementation occurs through four mechanisms that represent the involvement and role of the participants (coherence, cognitive participation, collective action, reflexive monitoring),

  • In order for embedded practice to be produced and reproduced, it requires the continuous effort and work of the participants (May & Finch, 2009).

Coherence

Coherence

"The sense-making work that people do individually or collectively" (May et al., 2015, Coherence).

Coherence involves understanding the differences between the new and current practices, the objectives and benefits of the practice, recognising the new roles and responsibilities, and appreciating the value of the new practice (May et al., 2015)

Cognitive Participation

Cognitive Participation

“Cognitive Participation is the relational work that people do to build and sustain a community of practice around a new technology or complex intervention” (May et al., 2015, Cognitive Participation).

Cognitive participation involves initiation to drive the work forward, enrolment strategies to become and remain engaged in the practice, reassurance that other participants believe it is right for them and can contribute genuinely, and a collective definition of the work they need to do in order to sustain the practice and remain involved (May et al., 2015).

Collective Action

Collective Action

“Collective Action is the operational work that people do to enact a set of practices” (May et al., 2015, Collective Action).

Collective Action involves the work that people have to do together, or with other objects in the practice, it involves the different skill-sets and knowledge needed to build confidence, the division of work and management of the practice (May et al., 2015).

Reflexive Monitoring

Reflexive Monitoring

“Reflexive Monitoring is the appraisal work that people do to assess and understand the ways that a new set of practices affect them and others around them” (May et al., 2015, Reflexive Monitoring)

Reflexive monitoring involves evaluating the usefulness and efficiency of the practice, it is evaluated by the users individually and as a group to determine the effect on their work, and finally they modify the practice as needed (May et al., 2015).

Application in Practice

The NPT is used as a tool to analyse the implementation process of different practices, the following practices are evaluated using this theory:

  • Enhanced Recovery After Surgery program (ERAS)
  • Clinical Practice Guidelines

ERAS

Able to recognize the importance of coherence for successful implementation process

ERAS

Barriers were found in the process in translating beliefs into action, many of the participants believed the practice made sense but the issues arose with facilitating it into action. (Sutton et al., 2018)

It demonstrated the importance of considering the implementation process across all four core concepts when discussing barriers. (Sutton et al., 2018)

NPT was helpful in identifying factors that inhibit and promote implementation however did not provide sufficient information regarding factors effecting the process of implementation and delivery. (Sutton et al., 2018)

Demonstrated the importance of the core constructs being strongly unified and the complexity of integrating complex health care interventions. (Sutton et al., 2018)

Recommended the use of other tools to use in conjunction with the NPT in order to gain a more rounded analysis

Clinical Practice Guidelines

The goal was to evaluate the implementation processes used for new clinical practice guidelines in nursing. (May, Sibley & Hunt, 2014)

Clinical Practice Guidelines

Discussed five key factors that dispose an intervention to normalization:

• If they are associated with practices that people can use in their work, and integrate it into their workload. (May et al., 2014)

• When they are differentiated from current clinical practices and whether that differentiation is legitimate according to the people using the new practice.(May et al., 2014)

• When they are associated with an emergent community of practice and all members of that community are able to contribute in group processes and define their engagement. (May et al., 2014)

• When they reflect improvements in the users’ knowledge and when that knowledge can be applied and integrated into their workflow. (May et al., 2014)

• When there is minimal disruption to the norms and professional roles, as well as appropriate structural and cognitive resources in order to share responsibilities across professional boundaries. (May et al., 2014)

The Extended Normalization Process Theory

New Developments of the Theory

Extended NPT is an advanced version of NPT that Carl May has developed using existing concepts linked with relevant concepts from sociological and psychological theories (May, 2013).

This theory focuses on agency contribution and capability, and the potential for organizing resources. Agency is described as “the ability to make things happen through their own actions” (May, 2013, p. 1).

Extended NPT is a combination of existing theories that identifies and describes the essential components of the implementation process (May, 2013).

The Constructs

The Constructs

  • This theory has four constructs: capacity, capability, and potential that all tie together into the fourth construct, contribution (May, 2013)

  • The NPT concepts, as described earlier, support the contribution construct in this theory. Contribution describes what agents do to implement complex interventions (May, 2013)

  • Capacity is described as the “social-structural resources available to agents”, capability is defined by the “possibilities presented by a complex intervention”, and potential is the “social-cognitive resources available to agents” (May, 2013, p. 4 fig. 3)

Implementation of Secondary Fracture Preventions Services After Hip Fracture

The study was successful in demonstrating the use of Extended Normalization Process Theory to explore the implementation of this complex intervention in health care (Drew et al., 2015).

How is it used?

The purpose of the study was to determine how secondary fracture prevention services can be implemented successfully, using extended NPT (Drew et al., 2015).

The four constructs were used to realize the experiences and views of the health care professionals involved in the implementation of services (Drew et al., 2015).

Capacity to organize and coordinate action, and capability to use the services were influenced strongly by fracture prevention coordinators (Drew et al., 2015).

Potential to utilize the fracture prevention services was high in general, influenced by commitment from the interdisciplinary team and the coordinators, commitment from the general practitioners created the largest challenge in the potential construct (Drew et al., 2015).

References

References

Drew, S., Judge, A., May, C., Farmer, A., Cooper, C., Kassim Javaid, M., & Gooberman-Hill, R. (2015). Implementation of secondary fracture prevention services after hip fracture: a qualitative study using extended Normalization Process Theory. Implementation Science, 10(1), 1-8. doi:10.1186/s13012-015-0243-z

May, C. (2013). Towards a general theory of implementation. Implementation Science, 8(1), 1-14. doi:10.1186/1748-5908-8-18

May, C., & Finch, T. (2009). Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory. Sociology, (3), 535.

May, C., Rapley, T., Mair, F.S., Treweek, S., Murray, E., Ballini, L., Macfarlane, A. Girling, M. and Finch, T.L. (2015) Normalization Process Theory On-line Users’ Manual, Toolkit and NoMAD instrument. Available from http://www.normalizationprocess.org

May, C., Sibley, A., & Hunt, K. (2014). The nursing work of hospital-based clinical practice guideline implementation: An explanatory systematic review using Normalisation Process Theory. International Journal Of Nursing Studies, 51(2), 289-299. doi:10.1016/j.ijnurstu.2013.06.019

Professor Carl May PhD BScEcon. (n.d.). Retrieved June, 27, 2018 from https://www.southampton.ac.uk/healthsciences/research/staff/Carl_May.page

Sutton, E., Herbert, G., Burden, S., Lewis, S., Thomas, S., Ness, A., & Atkinson, C. (2018). Using the Normalization Process Theory to qualitatively explore sense-making in implementation of the Enhanced Recovery After Surgery programme: "It's not rocket science". Plos ONE, 13(4), 1-14. doi:10.1371/journal.pone.0195890

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