Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review

BackgroundEffective implementation of technologies into clinical workflow is hampered by lack of integration into daily activities. Normalisation process theory (NPT) can be used to describe the kinds of ‘work’ necessary to implement and embed complex new practices. We determined the suitability of NPT to assess the facilitators, barriers and ‘work’ of implementation of two clinical decision support (CDS) tools across diverse care settings.MethodsWe conducted baseline and 6-month follow-up quantitative surveys of clinic leadership at two academic institutions’ primary care clinics randomised to the intervention arm of a larger study. The survey was adapted from the NPT toolkit, analysing four implementation domains: sense-making, participation, action, monitoring. Domains were summarised among completed responses (n=60) and examined by role, institution, and time.ResultsThe median score for each NPT domain was the same across roles and institutions at baseline, and decreased at 6 months. At 6 months, clinic managers’ participation domain (p=0.003), and all domains for medical directors (p<0.003) declined. At 6 months, the action domain decreased among Utah respondents (p=0.03), and all domains decreased among Wisconsin respondents (p≤0.008).ConclusionsThis study employed NPT to longitudinally assess the implementation barriers of new CDS. The consistency of results across participant roles suggests similarities in the work each role took on during implementation. The decline in engagement over time suggests the need for more frequent contact to maintain momentum. Using NPT to evaluate this implementation provides insight into domains which can be addressed with participants to improve success of new electronic health record technologies.Trial registration numberNCT02534987.

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Implementing online consultations in primary care: a mixed-method evaluation extending normalisation process theory through service co-production

BMJ Open ◽

10.1136/bmjopen-2017-019966 ◽

2018 ◽

Vol 8 (3) ◽

pp. e019966 ◽

Cited By ~ 20

Author(s):

Michelle Farr ◽

Jonathan Banks ◽

Hannah B Edwards ◽

Kate Northstone ◽

Elly Bernard ◽

...

Keyword(s):

Primary Care ◽

Mixed Method ◽

Process Theory ◽

Normalisation Process Theory ◽

Free Text ◽

Method Evaluation ◽

Current Form ◽

Financial Investment ◽

Face To Face ◽

Consultation System

ObjectivesTo examine patient and staff views, experiences and acceptability of a UK primary care online consultation system and ask how the system and its implementation may be improved.DesignMixed-method evaluation of a primary care e-consultation system.SettingPrimary care practices in South West England.MethodsQualitative interviews with 23 practice staff in six practices. Patient survey data for 756 e-consultations from 36 practices, with free-text survey comments from 512 patients, were analysed thematically. Anonymised patients’ records were abstracted for 485 e-consultations from eight practices, including consultation types and outcomes. Descriptive statistics were used to analyse quantitative data. Analysis of implementation and the usage of the e-consultation system were informed by: (1) normalisation process theory, (2) a framework that illustrates how e-consultations were co-produced and (3) patients’ and staff touchpoints.ResultsWe found different expectations between patients and staff on how to use e-consultations ‘appropriately’. While some patients used the system to try and save time for themselves and their general practitioners (GPs), some used e-consultations when they could not get a timely face-to-face appointment. Most e-consultations resulted in either follow-on phone (32%) or face-to-face appointments (38%) and GPs felt that this duplicated their workload. Patient satisfaction of the system was high, but a minority were dissatisfied with practice communication about their e-consultation.ConclusionsWhere both patients and staff interact with technology, it is in effect ‘co-implemented’. How patients used e-consultations impacted on practice staff’s experiences and appraisal of the system. Overall, the e-consultation system studied could improve access for some patients, but in its current form, it was not perceived by practices as creating sufficient efficiencies to warrant financial investment. We illustrate how this e-consultation system and its implementation can be improved, through mapping the co-production of e-consultations through touchpoints.

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Exploring the scope for Normalisation Process Theory to help evaluate and understand the processes involved when scaling up integrated models of care: a case study of the scaling up of the Gnosall memory service

Journal of Integrated Care ◽

10.1108/jica-11-2018-0072 ◽

2020 ◽

Vol ahead-of-print (ahead-of-print) ◽

Author(s):

Michael Clark ◽

David Jolley ◽

Susan Mary Benbow ◽

Nicola Greaves ◽

Ian Greaves

Keyword(s):

Primary Care ◽

Scale Up ◽

Scaling Up ◽

Process Theory ◽

Normalisation Process Theory ◽

Small Scale ◽

Content Type ◽

Service Models ◽

Integrated Service

PurposeThe scaling up of promising, innovative integration projects presents challenges to social and health care systems. Evidence that a new service provides (cost) effective care in a (pilot) locality can often leave us some way from understanding how the innovation worked and what was crucial about the context to achieve the goals evidenced when applied to other localities. Even unpacking the “black box” of the innovation can still leave gaps in understanding with regard to scaling it up. Theory-led approaches are increasingly proposed as a means of helping to address this knowledge gap in understanding implementation. Our particular interest here is exploring the potential use of theory to help with understanding scaling up integration models across sites. The theory under consideration is Normalisation Process Theory (NPT).Design/methodology/approachThe article draws on a natural experiment providing a range of data from two sites working to scale up a well-thought-of, innovative integrated, primary care-based dementia service to other primary care sites. This provided an opportunity to use NPT as a means of framing understanding to explore what the theory adds to considering issues contributing to the success or failure of such a scaling up project.FindingsNPT offers a framework to potentially develop greater consistency in understanding the roll out of models of integrated care. The knowledge gained here and through further application of NPT could be applied to inform evaluation and planning of scaling-up programmes in the future.Research limitations/implicationsThe research was limited in the data collected from the case study; nevertheless, in the context of an exploration of the use of the theory, the observations provided a practical context in which to begin to examine the usefulness of NPT prior to embarking on its use in more expensive, larger-scale studies.Practical implicationsNPT provides a promising framework to better understand the detail of integrated service models from the point of view of what may contribute to their successful scaling up.Social implicationsNPT potentially provides a helpful framework to understand and manage efforts to have new integrated service models more widely adopted in practice and to help ensure that models which are effective in the small scale develop effectively when scaled up.Originality/valueThis paper examines the use of NPT as a theory to guide understanding of scaling up promising innovative integration service models.

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Facilitating professional liaison in collaborative care for depression in UK primary care; a qualitative study utilising normalisation process theory

BMC Family Practice ◽

10.1186/1471-2296-15-78 ◽

2014 ◽

Vol 15 (1) ◽

Cited By ~ 40

Author(s):

Nia Coupe ◽

Emma Anderson ◽

Linda Gask ◽

Paul Sykes ◽

David A Richards ◽

...

Keyword(s):

Primary Care ◽

Qualitative Study ◽

Collaborative Care ◽

Process Theory ◽

Normalisation Process Theory

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Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review

BMC Family Practice ◽

10.1186/s12875-020-01107-y ◽

2020 ◽

Vol 21 (1) ◽

Cited By ~ 1

Author(s):

Lisa Huddlestone ◽

Jessica Turner ◽

Helen Eborall ◽

Nicky Hudson ◽

Melanie Davies ◽

...

Keyword(s):

Systematic Review ◽

Primary Care ◽

Process Theory ◽

Normalisation Process Theory ◽

Implementation Processes ◽

Primary Care Settings ◽

The Uk

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Co-designing organisational improvements and interventions to increase inpatient activity in four stroke units in England: a mixed-methods process evaluation using normalisation process theory

BMJ Open ◽

10.1136/bmjopen-2020-042723 ◽

2021 ◽

Vol 11 (1) ◽

pp. e042723

Author(s):

David Clarke ◽

Karolina Gombert-Waldron ◽

Stephanie Honey ◽

Geoffrey Cloud ◽

Ruth Harris ◽

...

Keyword(s):

Mixed Methods ◽

Process Evaluation ◽

Environmental Changes ◽

Family Members ◽

Process Theory ◽

Normalisation Process Theory ◽

Stroke Survivors ◽

Stroke Units ◽

Facilitators And Barriers ◽

Increased Activity

ObjectiveTo explore facilitators and barriers to using experience-based co-design (EBCD) and accelerated EBCD (AEBCD) in the development and implementation of interventions to increase activity opportunities for inpatient stroke survivors.DesignMixed-methods process evaluation underpinned by normalisation process theory (NPT).SettingFour post-acute rehabilitation stroke units in England.ParticipantsStroke survivors, family members, stroke unit staff, hospital managers, support staff and volunteers. Data informing our NPT analysis comprised: ethnographic observations, n=366 hours; semistructured interviews with 76 staff, 53 stroke survivors and 27 family members pre-EBCD/AEBCD implementation or post-EBCD/AEBCD implementation; and observation of 43 co-design meetings involving 23 stroke survivors, 21 family carers and 54 staff.ResultsFormer patients and families valued participation in EBCD/AEBCD perceiving they were equal partners in co-design. Staff engaged with EBCD/AEBCD, reporting it as a valuable improvement approach leading to increased activity opportunities. The structured EBCD/AEBCD approach was influential in enabling coherence and cognitive participation and legitimated staff involvement in the change process. Researcher facilitation of EBCD/AEBCD supported cognitive participation, collective action and reflexive monitoring; these were important in implementing and sustaining co-design activities. Observations and interviews post-EBCD/AEBCD cycles confirmed creation and use of new social spaces and increased activity opportunities in all units. EBCD/AEBCD facilitated engagement with wider hospital resources and local communities, further enhancing activity opportunities. However, outside of structured group activity, many individual staff–patient interactions remained task focused.ConclusionsEBCD/AEBCD facilitated the development and implementation of environmental changes and revisions to work routines which supported increased activity opportunities in stroke units providing post-acute and rehabilitation care. Former stroke patients and carers contributed to improvements. NPT’s generative mechanisms were instrumental in analysis and interpretation of facilitators and barriers at the individual, group and organisational level, and can help inform future implementations of similar approaches.

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Barriers to the use of trained interpreters in consultations with refugees in four resettlement countries: a qualitative analysis using normalisation process theory

BMC Family Practice ◽

10.1186/s12875-020-01314-7 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Anne MacFarlane ◽

Susann Huschke ◽

Kevin Pottie ◽

Fern R. Hauck ◽

Kim Griswold ◽

...

Keyword(s):

Primary Care ◽

Online Survey ◽

Routine Care ◽

Process Theory ◽

Normalisation Process Theory ◽

Cross Sectional ◽

Interpreter Use ◽

Funding Sources ◽

Barriers To Implementation ◽

Primary Care Practitioners

Abstract Background Increasing numbers of primary care practitioners in refugee resettlement countries are providing care to refugees. Access to trained interpreters is a priority for these practitioners, but there are many barriers to the implementation of interpreted consultations in routine care. There is a lack of international, theoretically informed research. The purpose of this paper is to understand barriers to interpreter use in primary care consultations in four resettlement countries using Normalisation Process Theory. Method We conducted a cross-sectional online survey with networks of primary care practitioners (PCPs) who care for refugees in Australia, Canada, Ireland and the US (n = 314). We analysed qualitative data from the survey about barriers to interpreter use (n = 178). We completed an inductive thematic analysis, iteratively developed a Normalisation Process Theory (NPT)-informed coding frame and then mapped the emergent findings onto the theory’s construct about enacting interpreted consultations. Results In all four countries, the use of an interpreter presented communication and interaction challenges between providers and patients, which can impede the goals of primary care consultations. Primary care practitioners did not always have confidence in interpreted consultations and described poor professional practice by some interpreters. There was variation across countries, and inconsistency within countries, in the availability of trained interpreters and funding sources. Conclusion There are shared and differential barriers to implementation of interpreted consultations in a consistent and sustained way in the four countries studied. These findings can be used to inform country-specific and international level policies and interventions focusing on improving skills and resources for interpreted consultations to improve implementation of interpreted primary care consultations.

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Development and usability testing of a very brief intervention for personalised cancer risk assessment to promote behaviour change in primary care using normalisation process theory

Primary Health Care Research & Development ◽

10.1017/s146342361900080x ◽

2020 ◽

Vol 21 ◽

Cited By ~ 1

Author(s):

Katie Mills ◽

Simon J. Griffin ◽

Stephen Sutton ◽

Juliet A. Usher-Smith

Keyword(s):

Primary Care ◽

Cancer Risk ◽

Focus Groups ◽

Behaviour Change ◽

Brief Intervention ◽

Risk Information ◽

Process Theory ◽

Normalisation Process Theory ◽

Health Checks ◽

Nhs Health Checks

Abstract Background: Cancer is the second leading cause of death worldwide. Lifestyle choices play an important role in the aetiology of cancer with up to 4 in 10 cases potentially preventable. Interventions delivered by healthcare professionals (HCPs) that incorporate risk information have the potential to promote behaviour change. Our aim was to develop a very brief intervention incorporating cancer risk, which could be implemented within primary care. Methods: Guided by normalisation process theory (NPT), we developed a prototype intervention using literature reviews, consultation with patient and public representatives and pilot work with patients and HCPs. We conducted focus groups and interviews with 65 HCPs involved in delivering prevention activities. Findings were used to refine the intervention before 22 HCPs completed an online usability test and provided further feedback via a questionnaire incorporating a modified version of the NoMAD checklist. Results: The intervention included a website where individuals could provide information on lifestyle risk factors view their estimated 10-year risk of developing one or more of the five most common preventable cancers and access lifestyle advice incorporating behaviour change techniques. Changes incorporated from feedback from the focus groups and interviews included signposting to local services and websites, simplified wording and labelling of risk information. In the usability testing, all participants felt it would be easy to collect the risk information. Ninety-one percent felt the intervention would enable discussion about cancer risk and believed it had potential to be easily integrated into National Health Service (NHS) Health Checks. However, only 36% agreed it could be delivered within 5 min. Conclusions: With the use of NPT, we developed a very brief intervention that is acceptable to HCPs in primary care and could be potentially integrated into NHS Health Checks. However, further work is needed to assess its feasibility and potential effectiveness.

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