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Table 6 Overview, using NPM constructs, of promoting factors and potential threats to normalisation of the PITC intervention

From: Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model

  Promoting factors Potential threats and how these were addressed
Interactional workability
Congruence • The design of the intervention was congruent with both operational needs (too few lay counsellors) and STI clinical practice. • It is difficult to justify upwards task shifting (from lay counsellors to nurses) in a low resource setting, so the PITC intervention was adapted to minimise the increased workload on nurses.
Disposal • Nurses saw this as an opportunity to enhance the standard of STI care. • It was critical that nurses accepted the paradigm shift toward normalising HIV testing. The project champion achieved this by convincing nurses of the benefits and the feasibility of a shift in practice towards integrating HIV testing.
Relational integration
Accountability • There was a governance structure responsible for stakeholder involvement, planning and oversight. • The downside of this accountability structure and consultative planning was that it resulted in a long, protracted and fragmented planning phase that delayed the implementation date.
• Leadership by senior management promoted ownership. • There was a range of disagreements among stakeholders. The conflicts threatened the viability of the project. Conflict resolution involved a compromise: to extend the clinical guideline and shorten the training. Removal of these stumbling blocks was largely due to the conflict resolution skills of the project champion and because she had the seniority to make executive decisions.
• The project was provided with a dedicated project manager to support implementation and monitoring.
Confidence • Nurses were convinced of the utility and feasibility of new intervention, even though they were concerned about the additional workload. • Lay counsellors and trainers were less confident about the new PITC intervention (see ‘Skill-set workability’ below).
Skills-set workability
Allocation • The new tasks for nurses were in line with standard STI practice. • Lay counsellors were concerned about their reduced role in pre-test counselling and their job security. This concern was allayed because they were allocated an increased role in the post-test counselling of HIV-positive patients.
• All the parties agreed that the intervention required training.
• Training was well attended by nurses and their clinical supervisors.
• Lay counsellors and HIV trainers were concerned about the acceptability, ethics and feasibility of PITC intervention. They agreed to support the intervention only when the clinical guideline was adapted to focus more on assessing the patient’s test readiness. The adapted clinical guideline meant nurses had to include more questions and tasks, making the intervention longer and more difficult to integrate efficiently into the STI consultation.
  • Training focused on counselling skills and did not address the operational challenges of integrating the new HIV tasks within the clinical consultation.
Performance • The HIV offer was delivered to the majority of new STI patients in an ethical manner. • The HIV test was not offered to all new STI patients as intended, reducing the size of the impact.
• Levels of confidence and efficiency of delivering the intervention varied with gaps in clinical communication skills evident. • There was variation in the how efficiently individual nurses delivered the intervention and in how long it took. Although positive about the intervention, nurses remained concerned about the added time.
• Nurses persisted with intervention despite the challenges around how to balance the new tasks.  
Contextual integration
Execution • Receptive environment for a paradigm shift toward normalising HIV testing. • The feasibility of this intervention depended on management identifying extra capacity in terms of nurse time, which may be difficult to do in many similar PHC settings.
• Operational conditions promoted shift toward expanding HIV testing.
• Not all the variation in the HIV testing outcomes across intervention clinics could be fully explained, and some may be due to organisational factors.
Realisation • Organisational leadership and accountability in place. • Dedicated project management support may not be a sustainable component to up-scaling.
• Responsive resourcing of the intervention through dedicated project management. • No cost-effectiveness evaluation was conducted.
• Facility managers reinforced line management accountability.