Table 2 NPT framework
NPT construct | Component | Questions to consider | Organisation | Professional | Patient |
|---|---|---|---|---|---|
Coherence: sense-making work | Differentiation | Does the stakeholder (SH) recognise the WISE approach as different from their existing ways of working? | New type of grant for PCT—needed new skills/management/finance to embed | Difficulty differentiating WISE principles from those underpinning existing practice undermined the embedding of the intervention. SMS/WISE not seen as different to their perception of how they already work | Does not see benefit in getting SMS from health practitioners |
Does the SH understand the purpose of self-management support (SMS)? | SMS fits with the direction the PCT wants to move in | ||||
Communal specification | Does the SH recognise the steps s/he needs to take to assist in the integration of WISE? | Top/down initiative—needs to be embedded in 'right' part of the organisation | Limited communication within practices post-training stifled discussion surrounding WISE and its potential benefits | Not prepared to initiate SMS discussion with GP/nurse | |
Middle management not involved | |||||
Individual specification | Does the SH identify their personal role and responsibilities with the WISE approach? | Pretty clear roles for people—lack of ownership by middle managers | Marked variation existed in nurses' opinion as to the fit of the WISE tools in their current practice: the guidebooks fitted well and PRISMS did not | SM responsibility seen as outwith interactions with health service | |
Internalisation | Does the SH identify any benefit in adopting the WISE approach and for whom? | Recognition of PCT as innovative org—approach seen as beneficial to population | Familiarity with information and services provided by long-established, reputable sources undermined effort applied to identify the benefits and value of the WISE guidebooks. One nurse saw WISE as improving patient care and relationships | Guidebook useful—to compare with others | |
Cognitive participation: relational work | Initiation | To what extent does the SH appear to have been a supporter of the process to integrate WISE? | Champion SMS innovations for some time—WISE fits this—self-care team and EPP and tele care | Failure to engage in a practice-wide strategy discouraged individual commitment to adopt WISE. QOF is priority | Does not see point of engaging with HCP about SMS |
Enrolment | Has the SH made any adaptations to their personal routine or assisted in the reorganisation process leading to implementation? | Paid for dedicated trainers—supported practices to attend training | In most cases, no adaptations were made, but nurses who saw themselves as having autonomy were able to take up the WISE tools in individual practice | None—did not take PRISMS forms to GP | |
Legitimation | Does the SH believe that it is appropriate for them to be involved in integrating WISE? | Yes—a key aim for the PCT but doubts from some over cost benefit ratio. Evidence base not legitimate, not relevant to GPs—new elements Step up | Many nurses did not perceive their roles required adoption of the WISE approach. | No | |
Activation | Has the SH taken steps to sustain the use of WISE? | Implemented training within a self-care team in hopes of sustaining | Assessment and review of the processes involving the tools to sustain their use was afforded little priority, too many reasons not to use PRISMS and QOF the over-riding practice priority | No | |
Collective action: operational work | Interactional workability | What work does the SH describe as having taken place to operationalise the use of the WISE approach? | In terms of grant—needed to work on getting budget right. Managed through professional directorate NOT commissioning | Difficulty engaging patients in self-management practices limited enthusiasm to invest effort in new ways of working. PRISMS used (rarely) to open up consultation, but not to take the next step of supporting behaviour change | None, concerns around disrupting the status quo of relationships |
Trainers and SC team | |||||
Creation of online directory | |||||
Relational integration | To what extent does the integration of the WISE tools and resources help or impede people's work? | Needed management champion to ensure correct pathways—did not happen | The convenience and ready access to information in hard-copy format encouraged use of the guidebooks but PRISMS got in the way of existing tasks and priorities | Guidebook helped to consider SM choices in day to day life outwith HCP | |
PRISMS might be a prompt sheet | |||||
Skill-set workability | Who does the SH view as being best placed to make use of the WISE approach? | PCT had to get new skills in managing research budget. Trainers to support and spread the word; training skills facilitative and reflexive | Nurses delegated SMS by the GPs. But this work is hidden and not audited. Responsibilities as health educators promoted nurses' role as implementers of WISE's holistic approach to SMS. Books most compatible and accentuated patient-centred approach | SM skills still seen as individual responsibility and trial and error – hard to see where HCP fits in | |
How compatible is the WISE approach with their current tasks? | Needed to be in commissioning directorate to work | ||||
Contextual integration | Does the integration of WISE fit with the objectives of the organisation/individual? | Yes—innovative PCT at forefront of policies directed at deprived population | QOF is the priority of the practice and nurses happy to do the tasks but the tensions are with the skills they see themselves as having which are disregarded by the QOF process. QOF tick-box priority means no space for SMS work. The practice systems were not able to integrate PRISMS forms—so 'not to hand' | No | |
Reflexive monitoring: appraisal work | Systematisation | Has the SH taken practical steps to measure the influence of adopting the new techniques? | No and at a loss as to how to do this, see it as pilot. No outcomes to measure, not audited, GPs not accountable | Limited, informal gathering of feedback from patients regarding the accessibility and utility of the WISE guidebooks was recorded, suggesting that some use this resource as a prompt and practical means of disposal when responding to patient concerns | No |
Communal appraisal | Are there any joint efforts to appraise the impact of implementation? | Costly model (training individual practice)—seen as not viable | No—reflecting a silo-style working environment, few practitioners recorded engaging colleagues in discussion of their experience of using the tools | No | |
Individual Appraisal | Does the SH reflect personally on the impact of the WISE approach on his/her routine? | Trainers kept reflexive journal and communicated with research team | The limited take up of the tools and resources was reflected in the prevalent view that the training had produced little change in practice. In contrast, supporters of PRISMS noted the positive impact on patient engagement | No as no impact | |
Reconfiguration | Has the SH made attempts to modify the way the WISE approach is used as a result of experience? | Trainers worked with research team to adjust training content | For adopters of PRISMS, identifying how the process of using it could be adapted to fit in with existing practice such as by focussing on the most pressing concern rather than a range of issues was important to the sustainability of the tool | No |