Table 7 Unintended consequences: TDF and NPT in practice

For diabetes and blood pressure practices, the intervention failed to differentiate itself from routine work (NPT differentiation), and practice staff perceived themselves as already doing this work (TDF social and professional roles), lacking resources or capacity to do any more work (TDF environmental context and resources, beliefs about capabilities), and unlikely to achieve anything more by engaging with the intervention (NPT communal specification; TDF beliefs about consequences). Some staff perceived its value (NPT individual specification) but were unable to gain traction with other team members (NPT cognitive participation: enrolment and legitimation).

Delays in delivery of outreach and outreach support had the unintended consequence of delaying practice participation and access to trial resources (TDF social influences and environmental context and resources), reducing the likelihood that staff would have time to adopt changes in their work (NPT collective action: contextual integration) or enrol in the work (NPT cognitive participation: enrolment). Feedback reports had the unintended consequence of de-motivating staff as they failed to achieve change on the more ambitious indicators (TDF motivation and emotion) and staff reacted by reducing visibility of the intervention (TDF memory) or believing the intervention to be ineffective or not worth engaging in (TDF beliefs about consequences; NPT collective action: relational integration).